Month: March 2013

Disappearing doctors: the limits of medical debate on Twitter

My adoption of Twitter coincided with the Liverpool Care Pathway (LCP) controversy. Naturally, I ‘joined the conversation’. The compact exchanges that followed forced me to examine and re-evaluate my views. The links to press stories (in newspapers I would not normally read) and blogs helped me appreciate how broad the spectrum of opinion is. The cases described in the media are enough to open anyone’s eyes to the risks, but the additional voices on Twitter, their views expressed vehemently at times, reinforced the fact that many more have witnessed, or at least perceived, poor practice. I am happier now to accept that the Pathway has not been used well universally, and perhaps, even though the pathway is intrinsically helpful, it needs to be changed to ensure better application. Nevertheless, because I have seen the benefits of the pathway, I have argued forcefully in its favour.

Engaging in the argument demands patience and moderation, because Tweets can be provocative. Accusations of murder are common, and for some this forms the backbone of their case against the LCP. It soon becomes clear when your interlocutor’s mind cannot be changed. The intensity rises, the argument gets personal. In some cases it becomes clear that the individual in question had a relative who died in difficult circumstances. Trust in the medical profession and the way it manages end of life care was damaged, and when things go wrong so close to home that damage tends to be irrevocable. Whatever the evidence, however overwhelming the number of voices in favour of the pathway, you are unlikely to overturn the misgivings of someone who has vivid memories of a relative dying in hospital.

Nevertheless, it seems reasonable to continue to argue, for Twitter is a place that gives you time to compose your arguments, and time to digest the points made by others. But here the difficulties arise. As doctors we are trained to sympathise and empathise with the relatives. When we talk with a relative of a dying patient we try to inhabit their point of view and understand what they are saying. If they are angry, we absorb that emotion. If they accuse us, or the hospital, or the system, of making mistakes, we do not challenge them; it’s not the right time. These are universal qualities of course, not restricted to doctors, but they are qualities that we have actively developed as part of our vocation.

This is why I find it difficult to maintain opposition to someone whose views are so clearly coloured by personal experience. In trying to overturn their doubts I fear that I am actually belittling their memories of a loved one. So, just as I would never allow myself to become involved in an argument with a patient’s relative on the ward, however much I disagreed with them, I am increasingly reluctant to have arguments with those who wish to banish the pathway. The same applies to those affected by poor care at Mid-Staffordshire, or relatives touched by medical error elsewhere. Doctors seem wary of challenging the validity of HSMR statistitics, knowing perhaps that Tweets may be read by families involved. It seems impolite. Does this reticence lead to a stifled, incomplete debate?

Perhaps doctors are too ready to adopt a ‘customer is always right’ approach. We often find ourselves speaking with people, be they patients or relatives, who challenge us. But we absorb the emotion, the occasional animus, the very rare invective; we step back, give it space, let it mellow with time. You can’t do that on Twitter, it’s about the here and now. And it’s loud. When doctors find themselves losing their rag, raising their voice, making it up as they go along, they tend to remove themselves from the scene. They disappear.

cover to tweet


Not For this and Not For that: emphasising the positive in care for the elderly

It is a sad truth that we sometimes spend as much time deciding what not to do when treating elderly patients as we do determining what options are appropriate. The early part of each admission is straightforward enough – we take a history, perform an examination, form a list of possible diagnoses and initiate treatment of some sort. But as we walk away at the end of the day, part of our duty is to consider what will happen if the patient deteriorates. If, in the middle of the night, or over the weekend, they suffer some sort of collapse – what instructions should we leave?

In most cases we do not need to leave specific instructions, because the hospital is set up to deal with such emergencies. The patient’s worsening condition will be identified by a nurse, the on call team will be bleeped (perhaps a ‘MET’* call will be put out), resuscitative measures will be taken and they may even be transferred to the high dependency or intensive care unit. If their heart stops they will undergo cardio-pulmonary resuscitation (CPR). That is the default. For many though, such a sequence of events will prove disastrous.

The reasons why very elderly or already frail patients should not undergo resuscitation have been rehearsed on this blog before, but many of those arguments apply to ICU admission too. The potential benefits are so slight that the definite burdens (such as prolonged ventilation, tracheostomy insertion, connection to a dialysis machine via central venous catheters, critical care neuropathy) cannot be justified. So, it is necessary to determine in advance whether those options are offered.

This is reasonably straightforward if the patient is alert and understands the issues. Unfortunately, a large proportion of acutely unwell elderly patients do not have the capacity to engage in such a conversation when they arrive in hospital. We therefore turn to the family, and by combining what we learn about their pre-existing wishes with what we anticipate are the possible benefits of organ support, we set ‘ceilings of treatment’. We try to work out what the patient would want if they could talk to us clearly. We make an informed guess, then we write in the notes phrases such as:

Not for ICU

Not for MET

Not for escalation

Ward based care only

Not for filtration

Not for NG tube

Not for NIV**

Not for ventilation, for NIV only…

Not for this, not for that. A typical ward round or on-call shift might require many such decisions, and it can feel overwhelmingly negative. Doctors are trained to treat actively, but increasingly, as the population ages and more and more patients are admitted to hospital toward the end of the expected human life span, they have to be protect them from the full gamut of invasive medical procedures. And the less information they have about the patient’s preferences, the greater the weight of responsibilty in setting those ‘ceilings’.

How then to change the emphasis and accentuate the positive, focus on what we can do, and not what we cannot?

It’s all about anticipation. I am always amazed when patients in their nineties, or their families, express surprise when I bring up the possibility that they might die. It seems never to have crossed their minds! This natural reluctance to consider death has been challenged. Dying Matters (a coalition led by the National Council for Palliative Care) highlights that,

81% of people have not written down any preferences around their own death

Nearly two thirds (63%) of us would prefer to die at home, yet of the 500,000 people who die each year in England, 53% die in hospital.

They request that people consider,

The type of care you would like towards the end of your life

Where you would like to die

Whether you have any particular worries you would like to discuss about being ill and dying

Whether you want to be resuscitated or not

‘It’s OK to die’, an organisation in the United States set up by Monica Williams Murphy MD, advocates a similar set questions. Imagine if every patient came into hospital with this information. No more guess work. No more stressed families trying to explain what their elderly relative would have wanted, feeling the weight of responsibility even when reassured that they are not being asked  to make ‘life or death decisions’.

Engaging in these questions may not be natural. Those with manifestly terminal conditions may be drawn into such discussions by their families, palliative care teams or general practitioners (GPs, family doctors), but those who are in their ninth and tenth decades without end stage disease are not necessarily going to dwell on their mortality. It falls to their GPs to initiate the discussion.

The concept of the Advance Care Plan (ACP) is well established, albeit in the context of life limiting conditions. The document ‘Advance Care Planning: A Guide for Health and Social Care Staff’ specifies that,

The difference between ACP and care planning more generally is that the process of ACP will usually take place in the context of an anticipated deterioration in the individual’s condition in the future, with attendant loss of capacity to make decisions and/or ability to communicate wishes to others.

It might seem then ACPs are not intended for people in a stable condition who are in no imminent danger of deteriorating. The document does however include this common, ‘non-terminal’ example scenario:

Mrs Carter – An 81 year old lady with COPD, heart failure, osteoarthritis and increasing forgetfulness, who lives alone. She fractured her hip after a fall, eats a poor diet and finds mobility difficult. She wishes to stay at home but is increasingly unable to cope alone and appears to be ‘skating on thin ice’.


Perhaps then it is not unreasonable to introduce the idea of an ACP to people with common cardio-respiratory problems that do not seem ‘life-limiting’ in the most obvious sense.

The same document is explicit that:

If an advance decision includes refusal of life sustaining treatment, it must be in writing, signed and witnessed and include the statement ‘even if life is at risk’

And warns that it,

Only comes in effect if the treatment and circumstances are those specifically identified in the advance decision

These stipulations make ACPs less workable in primary care or general medicine. How can a person be expected to anticipate specific circumstances? How will they know, in advance, what the burden of those life sustaining treatments will be, in relation to the possible benefits. Again, the emphasis is on the negative. Wouldn’t it be more helpful to know what they do want, what their ultimate goals are. For instance, ‘to be able to look after myself when I get home, feed myself, to interact with my grandchildren…’ These goals may preclude extended life preserving treatment that can be reliably predicted to result in chronic debilitation or loss of independence.  They may be better suited to a ‘Preferred Priorities of Care’ statement. In reality, I suspect the term ACP is used in a more general way than intended.

Do ACPs work? There is some evidence. A study by Karen M Detering et al (BMJ 2009) randomised 154 of 309 mentally competent octogenerian in-patients to the make an ACP, and found,

Of the 56 patients who died by six months, end of life wishes were much more likely to be known and followed in the intervention group (25/29, 86%) compared with the control group (8/27, 30%; P<0.001).

            In the intervention group, family members of patients who died had significantly less stress (intervention 5, control 15; P<0.001), anxiety (intervention 0, control 3; P=0.02), and depression (intervention 0, control 5; P=0.002) than those of the control patients.

A proactive approach to ACP (or equivalent) is not without risk. As part of the National End of Life Care Strategy GPs were encouraged to identify those under their care who were predicted to die in the next twelve months, and to make a list. Some parts of the press did not take this well;

Thousands of patients have already been placed on ‘death registers’ which single them out to be allowed to die in comfort rather than be given life-saving treatment in hospital, it emerged last night.

            Nearly 3,000 doctors have promised to draw up a list of patients they believe are likely to die within a year, Department of Health figures showed yesterday.

            As part of an unpublicised campaign endorsed by ministers, GPs have been encouraged to make lists – officially known as End of Life Care Registers – of people they believe are going to die soon and should be helped to do so in comfort. (Daily Mail, 18th October 2012)

The subject became entangled with the Liverpool Care Pathway controversy. I don’t know if the registers have continued to be compiled. The taboo of death remains strong. But the idea is sound. Dying Matters have promoted the ‘Find your 1%’ approach. They request that GPs ask themselves,

 “Would I be surprised if this person were to die in the next 12 months?”


  …this simple question is accurate seven times out of ten.

They emphasise some general indicators of likely death within 12 months:

– Limited self-care and interest in life: in bed or a chair more than 50% of their time.

– Breathless at rest or on minimal exertion

– Progressive weight loss (>10% over last six months).

– History of recurring or persistent infections and/or pressure ulcers.

The GMC too recognises the importance of being forward about end of life care planning. Its End of Life Care booklet includes this:

If a patient in your care has a condition that will impair their capacity as it progresses, or is otherwise facing a situation in which loss or impairment of capacity is a foreseeable possibility, you should encourage them to think about what they might want for themselves should this happen, and to discuss their wishes and concerns with you and the healthcare team.


Areas for discussion include:

            –  the patient’s wishes, preferences or fears in relation to their future treatment and care

            – interventions which may be considered or undertaken in an emergency, such as cardiopulmonary resuscitation (CPR), when it may be helpful to make decisions in advance

            – the patient’s preferred place of care (and how this may affect the treatment options available)


These initiatives and guidelines are fine, but harder to achieve than they are to promote. Talking about death is never easy (for families or doctors), and it is still more common than not for patients to be admitted with no evidence, verbal or written, of their fears, priorities or goals. It falls on doctors and nurses whom the patients have never met to introduce the subject and explore those issues…or, when mental capacity has been lost, to gather clues from the family who may not have had those conversation either. Until this changes it will remain a sad part of our role to gauge how far each patient should be escalated, hoping always that our judgment is correct.


* MET score – medical emergency team; most hospitals now have an ‘early warning’ system for deteriorating patients, whereby nurses can summon the on-call team if there are dangerous blood pressure, pulse rate or respiratory changes.

** NIV = non-invasive ventilation; a tight mask is applied to the face to improve lung function, effective but often quite unpleasant as the patient is awake

Derailed: how the LCP controversy has changed family discussions

The Liverpool Care Pathway (LCP) debate has brought the public’s attention to the possibility that patients are being deprived of life, their death hastened, when medical teams decide that their time has come. The elements of the pathway that were intended to reduce the burden of treatment, such as not inserting new intravenous lines or passing feeding tubes, have been portrayed as withdrawals of care.

The end result, at one level, has been helpful. Doctors and nurses are now more careful and explicit in describing what the pathway entails and what its effects might be. It is undeniable that in some cases, the LCP was started without families being aware of it. Most in the medical profession feel stongly that the LCP does not itself bring about death, but it has become necessary to consider this possibilty when discussing it with relatives. But I now wonder whether this need for clarity has altered the tone of end of life care discussions adversely.

To put it simply, there is a danger that we end up discussing the philosophy and application of LCP itself more than the needs of the individual patient.

This may be because we are nervous. I can only speak for myself of course, but I have found myself introducing the term ‘Liverpool Care Pathway’ with a degree of hesitancy, because I know it may have baggage attached. I do not know how the relatives that face me will interpret those words, because I do not know how they have reacted to the media coverage. Will they assume that I am trying to enforce some form of euthanasia? Will they read into my words some malign motivation, the need to clear a bed, to unburden the Trust of their ailing loved one? Or will they have listened to the debates and read the articles without developing scepticism towards doctors? It is necessary to gauge the family’s reaction before moving on to the next part of the discussion. And this carries with it the danger of the derailing the whole interaction. There is a danger that focus on the patients needs and previously expressed goals is lost, while the conversation segues into a cursory review of recent news stories and media reports.

You have no idea what the reaction will be until you mention it, but because the LCP is now ‘controversial’, you have to make emotional room and physical time to manage it. The tone is altered. If there is scepticism or fear (and who could blame a Daily Mail or Telegraph reader for having doubts after the numerous reports?) it remains for the doctors or nurses to overcome this, to gently persuade and reassure. Their skills and knowledge are diverted into justifyng a mode of care that they continue to have faith in, rather than concentrating on the individual aspects of the patient’s treatment.

One option would be to carry on regardless, to have the same discussion that one would have had before the controversy took fire. But that approach risks ignoring any concerns that the family might have but are too shocked or nervous to voice. There is a danger that a day or two later the import of the Pathway’s initiation will sink in and the situation could be challenged. The bottom line is that permission is needed to start the pathway. Indeed, Jeremy Hunt (Secretary of State for Health) has suggested that it may become a legal requirement. This contrasts with resuscitation, which remains a ‘medical’ decision*.

So, what to most doctors and nurses was merely a way of organising and formalising established methods of terminal care has now become a ‘treatment’ in itself, one that demands a separate exploration of risks and benefits. I would question whether this is the right kind of conversation to be having with the family of the patient who is clearly dying. Is it really appropriate to introduce new ideas and new decisions at this moment? The medical journey has almost reached an end. The burdens and benefits of various therapies (chemotherapy, antibiotics, surgery, ventilators…) will have been discussed at length, but they will not have proved successful, and that is why the patient is now dying. As the patient moves into their final few days, the relatives are presented with yet another decision…one which, most believe, is not a true decision at all.

Critics of the LCP argue that doctors are not good at predicting death. This forms the foundation of Professor Pullicino’s case against the Pathway. To a family member who has taken an interest in the controversy one of the first questions they might ask is, ‘How can you be sure they are dying? I’ve read that it’s a completely inexact science…’ To the doctor or nurse who is trying to talk through end of life care options, this is hugely undermining. How can they introduce the concept of the LCP, designed to alleviate discomfort at the end of life, while simultaneously fielding doubts that are raised about the diagnosis of dying? The honest answer would be, ‘We can never be a hundred percent certain sure…’, while the unvoiced thought runs through their mind – ‘I’ve seen hundreds of patients die, and I can tell you with a great deal of certainty, your mother is dying…’

Medical professionals can deal with all of this. Part of our role is to explain what is happening to families. We don’t mind…but I do find it regretful that the very term LCP has become a potential stumbling block in a journey that should be smooth. Doctors, nurses and families should not have to be skirting around the issue of ‘that death pathway they’re always talking about…’ when the minds of all involved should be focused on the needs of one person – the patient.

Note: this article is written with an emphasis on non-capacitous patients, rather than those who are able to engage in a full discussion before the terminal phase of their illness.

*best practice always involves explaining the resuscitation decision, and ideally obtaining agreement from the family. This occurs in the vast majority of circumstances.

When paternalism = bravery: a ‘slow code’ dilemma

What are doctors supposed to do if a patient’s relatives fail to agree with a Do Not Resuscitate order, even when the doctor knows that such resuscitation would be completely futile? One solution to this, described in literature coming out of the United States, is the ‘slow code’. This is when a deliberately ineffectual resuscitation attempt is made to satisfy relatives, but also to ensure that on no account will a patient’s  heart be restarted.  ‘Code’ is the American term for a crash call. A 2011 paper in the American Journal of Bioethics (£) defended this  practice, albeit in the arena of neonatology where the positive psychological effect on parents who need to know that ‘everything was done’ may be more important.

                “A leading textbook calls slow codes ‘dishonest, crass dissimulation, and unethical.’ A medical sociologist describes them as ‘deplorable, dishonest and inconsistent with established ethical principles.’ Nevertheless, we believe that slow codes may be appropriate and ethically defensible in situations in which cardiopulmonary resuscitation (CPR) is likely to be ineffective, the family decision makers understand and accept that death is inevitable, and those family members cannot bring themselves to consent or even assent to a do-not-resuscitate (DNR) order.”

Another paper, based on interviews with critical care practitioners (“Slow” Code: Perspectives of a Physician and Critical Care Nurse, Critical Care Nursing Quarterly 1999) [free access] included this powerful passage:

                “I remember a specific case involving a 30-year-old patient with a particularly virulent strain of pneumonia. Blood was sent to NIH to rule out hanta virus. It was a case that was frightening but also very enlightening and interesting. She developed full-blown ARDS so severe that only bilateral lung transplants would have saved her.

                “Routine turning caused her to desaturate because she was that unstable. I can understand that, because she was 30 years old, the family wanted everything done. No matter what we said to them, they didn’t hear that there were no alternatives. Of course, this was an extreme case, one in which I can understand the family’s wishes.

                “If I didn’t have the medical knowledge about ARDS and someone told me that my 30-year-old sister was going to die, I would have wanted everything done. The family thought we could do lung transplants right there in the room. They had to be very gently wooed into the idea of a DNR status. She coded before a DNR status could be obtained. In this case, the family was very much opposed to a DNR status and a “slow” code was performed to satisfy their needs.”

In acute general medicine similar but less dramatic dilemmas are encountered on a daily basis. Although it is rare for disagreements between relatives and doctors to arise, it is common for there to be a delay of several days while families engage in conversations about the benefits, and burdens, of resuscitation. During that hiatus, anything could happen. Many patients therefore remain For Resuscitation, by default, while doctors attempt to achieve consensus.

Consider this scenario. A 91 year old lady is admitted to hospital with symptoms of urinary tract infection and significant kidney dysfunction.  She is confused, temporarily, by the sepsis. She has been living alone but depending on the help of relatives and neighbours, nothing major. The consultant agrees with the junior doctor’s initial diagnosis and confirms that the antibiotic and fluid prescriptions are correct.  There is no sign of cardiac instability, but he decides to take the relatives (a son and a daughter, in their late 50’s or 60’s) to one side. He begins to explore the subject of unexpected complications, and the possibility of sudden cardiac arrest.

‘I’d like to discuss with you on the issue of resuscitation. Your mother doesn’t appear to be in any danger, but we must consider that during any illness there is a risk of sudden deterioration. We should anticipate what we should do, and what she would want us to do, if heart were to stop.’

‘She’s very strong. She was ill four years with pneumonia but she pulled through, she’s a fighter.’

‘I can see she is, but if the worst were to happen, and the heart were to stop, then however strong she seems now it would be very difficult for her to recover.’

‘So what are you saying?’

‘My feeling is that the chances of her coming round, of surviving, even if we did cardiac compressions and gave electric shocks with the defibrillator, the chances would be very small. I think she would have a lot of damage to the heart and possibly the brain, and would be unlikely to leave hospital.’

‘We haven’t really thought about this before. No one has ever said this before. ’

‘I’m not asking you to decide, certainly not. It’s just important that you understand why we make these decisions, and important that we know how your mother would feel.’

‘What would your advice be?’

‘I definitely would not advise that she has resuscitation. I would be very uncomfortable letting that happen given her physical frailty.’

The doctor recognises a steely look in the two relative’s eyes. He senses that his introduction of the subject of dying has caused a reaction. They exchange glances, and the son replies,

‘Well we really do have to go away and talk about that. I mean, as I say, she would want everything possible done to get her through this. She really is a fighter. She had a cancer operation five years ago, and they said she couldn’t have that…but she did.’
‘OK. I don’t think we have to reach a final decision at this precise time. Perhaps it’s good that we’ve talked about this now…you can think about it with the family overnight. But my opinion would be that resuscitation would not be right for her. Perhaps tomorrow or the next day we can talk again…I really would like there to be something in her notes so that any other medical teams called to see her know what to do if…she goes downhill.’

‘Fine. But we need to talk about this as a family.’

The junior doctor, who was present throughout, asks,

‘But isn’t it a medical decision?’

‘Yes it is. You’re quite right. But do you want to tell them that, at the moment? They are shocked by the idea that their mother might die. I think it’s a step too far tonight to write a Do Not Resuscitate form until they have expressed their agreement.’

‘But if she does arrest you’ve said she won’t survive. As it stands she’ll be resuscitated if she arrests.’

‘My assessment is that the risk is low. If she was showing signs of instability I would probably have to force the issue tonight, and perhaps write out a DNAR form without their agreement. But it’s going to take a lot of talking to lead them to understand the reasons why we don’t want to resuscitate.’

So the form goes unwritten. The consultant leaves in the hope that nothing untoward will happen. Has he done the right thing?

Here are some potential futures.

 – Outcome [1] –

The patient has cardiac arrest at 2 o’clock in the morning. The crash team is called and begins to work on her. While the anaesthetist prepares to intubate another doctor performs cardiac compressions, and the nurse attaches defibrillator pads to her chest. The medical registrar, standing at the end of the bed, reads through the notes. There is very little to read, only the admission clerking and the post take ward round entry. There are no major co-morbidities, but the patient’s advanced age and her evident physical frailty are inescapable. The second bolus of adrenaline is just about to be given when the registrar puts her hand up and says, ‘I don’t think this is right. The consultant was hoping to make her Not For Resus but the patient but the family didn’t agree. He wrote that it’s to be reviewed tomorrow. Clearly he thought she shouldn’t be For. There’s no way she’s going to survive this.  We should probably stop. Does everybody agree?’

The anaesthetist nods, the nurse running the ward nods. There is agreement… and the attempt is stopped.

What harm was done here?

The patient died and was not aware of anything. There was a genuine attempt to revive her, but, as soon as the registrar became aware of the circumstances she stopped it. Not a slow code, but a short code; almost an accidental code.

So, although the patient remained For Resuscitation, according to the paperwork, she was Not For Resuscitation, in spirit. The intention of the consultant who could not bring himself to actually fill out the form was in fact carried through by the crash team, although the patient still suffered (unconsciously) the indignity of three minutes of full-on advanced cardiac life support.

This strikes me as duplicitous. The decision not to resuscitate, very likely correct, had been made but had not been enacted or formalised for fear of resistance from the family. It is reasonable in this case that the form was not filled out because the consultant thought there was only a low risk of the patient dying over the next 24 hours, but…but, patients in their 90s do sadly die without warning. So the sensible precaution not to resuscitate was not in place. The reason? The consultant did not want to find himself at odds with the family, or the subject of a complaint. Because another scenario is as follows,

– Outcome [2] –

As the consultant departed from the ward round he had second thoughts. His junior’s question had got to him. So he went back, explained his reasons in the notes and completed the Do Not Resuscitate form. He felt that this was the right thing to for the patient. The patient arrested at 2 o’clock in the morning. The nurses had been informed of the DNAR decision and the crash team were not called. The patient died quite suddenly but quite peacefully. The family were called, after death, given its unexpected nature. They arrived, asked about the circumstances, and learned that no attempt had been made to revive her. They were upset; voices were raised.  Three weeks later and  formal complaint was made.

The consultant had unilaterally made the patient Not For Resuscitation, in opposition to the families interpretation of their mother’s desires, desires that she might have able to articulate had she had not been temporarily confused by the infection.

Without going over the top here, I am tempted to portray the consultant’s actions in Outcome [2] as brave. In order to protect his patient from the risk of a futile resuscitation attempt he signed the form, did the ‘right thing’ (according to his analysis of the situation), but took a risk. He knew that there was a chance of generating a complaint, of being accused of paternalism, arrogance and playing God.

What would you do?


i) GMC guidelines for DNAR decisions in patients who lack capacity to be involved in the decision emphasise the desirability of involving the healthcare team and those close to the patient, in order to understand as much as possible about the patient, and their known attitudes. However, as regards family agreement,

“In particular, you should be clear about the role that others are being asked to take in the decision-making process. If they do not have legal authority to make the decision, you should be clear that their role is to advise you and the healthcare team about the patient. You must not give them the impression that it is their responsibility to decide whether CPR will be of overall benefit to the patient.

ii) Why not try to resuscitate a 91 year old lady? The literature suggests that very few patients in this age range survive to discharge. Although age in isolation is never used to decide on treatment, the fact remains that overall fragility and organ function is likely to be impaired at this stage of life. For specific citations on this subject see a previous blog, ‘A form of words: honesty, kindness, coercion and early resuscitation discussions.’

iii) Most physicians I know would not fill out the DNAR form in this scenario.

Fatal error: a doctor deals with the harm she did

Junior doctors make mistakes, and how they deal with those mistakes is of crucial importance. In this dialogue I explore the psychological reaction and coping mechanisms of a Foundation Year doctor who has made a drug error, contributing to the death of a patient. She speaks with her registrar, who has been though a similar experience. As usual, it is fictional, but based on my observations of myself and others since qualifying.

It is worth considering how common drug errors are. Dean et al, in their BMJ paper ‘Prescribing errors in hospital inpatients: their incidence and clinical significance’ (2002) found during a 4 week period, which involved about 36,200 medication orders, that,

‘a prescribing error was identified in 1.5%. A potentially serious error occurred in 0.4%. Most of the errors (54%) were associated with choice of dose.’

Finlay and Ross, in a BMJ editorial ‘Medication errors caused by juniors’ (2008), wrote,

‘Preventable medication errors account for 10-20% of adverse events in patients admitted to hospital… The situation is similar in Australia and the US—medication errors occur in about 1-2% of patients admitted to hospital, resulting in around 7000 deaths a year in the US alone.’

The public are well aware of the potential for harm, not necessarily related to medications, with articles such as this in the Evening Standard (2002), which said:

‘Alarming failures in the education and training of junior doctors could be contributing to the thousands of medical errors, including hundreds of deaths, which occur in hospitals every year…’

The consequences of error are never underestimated by doctors. But the Francis report, in emphasising the duty of candour in admitting mistakes to patients and families, has focussed attention of the subject. It is vital that doctors who make mistakes can admit to them, but be supported while they work through the implications. If there is need for re-training, so be it. If errors seem to be repeated, or the doctor appears unable to accept a need to improve, then certainly their career choice will need to be reconsidered. For the majority of doctors who make a mistake however, it will be an isolated or very infrequent event. The way they deal with it requires some examination. This is how one such doctor deals with it.

Scene: a quiet corner in the doctors’ mess.

An FY1 (Foundation Year doctor, in her first year of employment since qualifying) and her registrar.

Registrar: What happened?

FY1: I made a mistake. A really bad one. Somebody died.

I heard about it. How are you doing?

Awful. I feel awful.

Are you worried? About your career?

Yes, well no, not about being in trouble so much. I know there will be an investigation, but one of my friends did something similar last year…

What happened to him?

He had to go on a course, pharmacology and prescribing, and he had to be observed doing drug charts for 6 weeks. But he got through it.

I can’t guarantee it’ll be that straightforward this time, but you’re right, I don’t see why you should be struck off or anything like that.  Not for a one off error. The irony is, however many courses you go on, after this you will never prescribe a drug again without being one hundred percent sure that the dose is right. You’ll be paranoid, but you’ll be safer than most of your mates.

I don’t want to prescribe anything again. I feel sick whenever I see a drug chart now. I’m avoiding writing any prescriptions.

That’s not good. We can’t have you not functioning properly. But it will get easier, I promise.

You’ve had this experience?

Every single doctor you ever meet will have had this experience. Any doctor working in acute medicine will know what it feel like to have done harm.

And how did you cope?

You have to find a way through it. You have to be able to see through it, to the other side. You know you’re going to be a doctor, working for years and years probably, so you have to put it into perspective. But at the same time you can’t ignore the importance of it.

That’s what’s worrying me. I can’t see myself doing this for ever. It’s too painful, having experiences like this. I know, when I think about it, that Mr _  would be alive, now, if I hadn’t written that prescription. Or if I had double checked the dose. He was due to go home in two days! I know that mistakes often have multiple reasons behind them, system errors, but in this case it was me, just me. I actually remember writing it, the word, the number.  I can’t handle that, not again.

You are handling it now, in a way. You’re here, at work, not at home sick, you’re talking about it. You’re finding a way through it.

But I don’t want to be here. You know what I want? I want to be home with my Mum and Dad.

That’s natural. It’s a need for security, for comfort. It’s a response to acute stress.

And I keep thinking about dropping out. I have this fantasy of running a book shop, just sitting there, no stress. I walked past one of the cleaners this morning, and I was jealous. I wanted to do her job. No stress. No complications. Simple tasks…

I know what you’re saying, but it’s not real. That cleaner probably has more stress in her life, more persistently, than you do. You are lucky, you have an amazingly satisfying job. You will always be needed, there will always be patients that need to see you. You have been trained to do that job, and I know that fundamentally you enjoy it! I’ve seen you at work remember. You are enthusiastic and genuinely interested. I’ve got no doubt that you’ll be fine.

They won’t be coming to see me! If I’m not there, there will be another doctor in my place. I’m not indispensible.

Of course. Nobody is. But you have the potential to be very good and to be important to your patients, and to the doctors that you in turn will train. The way I think is this, and I know it sounds harsh – but you have a responsibility to get over this setback.

Mr_ isn’t going to get over this setback, is he?

That’s not the way to think about it.

Why? Is my career more important than him?

Of course not. And his death will receive it’s due attention, we will all look at ourselves. Did we train you properly? Was the system for checking prescriptions working? Were the side effects recognised? His death will not just go unremarked. We will, we have, apologised to his family. The coroner will undoubtedly examine the sequence of events. It’s not going to trivialised or brushed under the carpet. But is it right that the mistake should result in a potentially excellent doctor leaving medicine? No, it isn’t. There would be no doctors left!

I feel really uncomfortable with this. It does feel as though we are belittling his memory, focussing on my future.

When I was in your position, years ago, I just kept it all in, didn’t talk about it. Perhaps there’s something to be said for that.

I’m a talker I’m afraid. I have to talk. Do you mind?

No, of course not. Look, this is how it goes. Or how it went for me. I made a mistake, it doesn’t matter what exactly. A patient died. I hated medicine. I didn’t want to come in. I avoided similar situations, just like you have been doing. And then, you know what happened?


Life happened, that’s what. By which I mean, the sun rose and the sun set, shifts came and went, patients arrived that needed to be seen, and they kept coming, and I had to see them and treat them. There was no option. And three weeks later I looked back, and thought – shit, I’ve seen hundreds of patients since I made that mistake, and nothing bad has happened. I felt safe again, in myself. I felt like a safe doctor. That’s how it went for me.

Riding a bike.

Kind of. You have the skills and the knowledge. You have identified something about yourself through this error…the fact that your memory for drug doses is not perfect, and you have learnt from it. Depending on the policy of this trust, which I don’t know, you may have to do some ‘remedial’ course or programme, and if that’s the case, fine, accept it. Penance. But in three weeks, I promise you, the pain you feel now will be a mental bruise. You’ll never forget it, but it will fade.

Easy as that.

Not easy. Because it will happen again. You can’t have a career in medicine, especially a practical specialty, or surgery, if you’re that way inclined, and not cause harm occasionally. Every invasive procedure has a complication rate, by their very nature. The chance that you will be the one who never has a complication is infinitesimal. So you have to find a way to deal with it. It’s going to happen. This is your first time. Your colleagues may experience it this year, next year, in three years time. Perhaps it’s good to go through it now, I don’t know. How are you feeling?

Just as bad.

I can’t change that. But time will.

cover to tweet

Meaning it: acting, (in)sincerity and compassion on the wards

A consultant and her junior sit opposite the daughter of a dying patient. They have entered the relatives’ room following an assessment of the patient on the ward round. The elderly lady is clearly succumbing to pneumonia, and the consultant wants to explain why continued efforts to ventilate non-invasively through a mask and monitor intensely in the high dependency unit are probably not the right things to do. The conversation lasts 15 minutes, for the patient’s daughter finds it hard to understand why such aggressive approaches to treatment should not continue. But already it has been going on for four days, and the situation is only got worse.

‘I’m sorry Mrs Davis, I really think it’s time for us to be honest with you, honest with the patient and with ourselves, and to admit that everything we have done, the antibiotics, the blood tests, the mask, have not made a difference. She’s getting anxious and distressed, and the truth that we must accept that this pneumonia is too much for her.’

‘But she has got through this type of illness before.’

‘I think this really is worse. And that was five years ago…her heart and lungs have grown weaker since then. We really are just keeping her going, keeping her alive, artificially really. The chances of her improving are next to zero now.’

‘But she improved at the beginning…’

‘She did. She tried, we tried, if there was a chance she would have taken it by now. I’m glad we tried as hard as we did, even if there was a 2, 3, 5 percent chance, it was worth it. But now it has become clear…I’m sorry.’

The relative begins to cry.  The junior doctor watches as his consultant reaches to the desk for a box of tissues. She puts a hand on the relative’s hand, where it rests on the edge of her seat, and she offers one of the tissues. She takes her time, gives enough space for the daughter to gather herself, but then carries on, without being brutal. The relative seems to understand, and agrees. It’s not a case of bulldozing her, just allowing her to take in the truth of the situation. The junior doctor watches in some awe, impressed by his consultant’s skill, her ability to empathise, to adjust her tone, to choose just the right words. He decides to emulate her, and to develop the skills that he was observed.

They leave relatives’ room. The patient’s daughter remains there, teary eyed, fiddling with her mobile phone. Consultant and junior walk back to the nurses’ station, where the patient’s notes lay open.

‘You couldn’t get me a continuation sheet could you? I need to write it all down, the usual essay! God…the poor thing never had a chance, I don’t know why we’ve carried on so long. Ten years ago she wouldn’t have even been offered non-invasive ventilation…we probably use it too much to be honest…’

Her junior is shocked. He gets the paper, places it into the notes, and watches as his boss writes a version of the discussion down. All those fine words…

What has happened here? Did the consultant actually mean what she said. Was she lying? Is she completely two-faced? Or was she just acting – playing the part? And playing it so well! Was she compassionate? Yes, it looks as though she was. So was she lying and practising compassionately at the same time? It seems so.

Ups and downs

Any non-medically trained person following a typical ward round in an acute hospital would be shocked at the range of emotions that is displayed and experienced. A ward round involves giving good news to those who are recovering, and the worst imaginable to those diagnosed with terminal disease. There are conversations with relatives regarding end of life care, and delicate explorations of what patients would have wanted in the final days and weeks of life.

The doctors involved engage all of their interpersonal skills, including empathy, delicacy, subtlety and sometimes assertiveness. Additionally they maintain an awareness of how the team is working. There will be teaching, cold facts and figures provided by their warm blooded patients providing the raw material, and there will be humour, which promotes good feeling between colleagues. When the mood turns jocular the dark cloud that hovered above them (following, say, a discussion with a patient about their cancer diagnosis), dissipates in an instant.

So many juxtapositions. Such inconsistency. Do we mean any of it?

The ability to be emotionally nimble is crucial in medicine. That’s because the typical day wil involve numerous human situations, to which the doctor must adapt quickly. She must sense the timing of the situation and change their demeanour, their behaviour and the choice of words accordingly. It is not somuch the need to be a comedian as to absorb, reflect and then take the lead according to the feelings that have been experienced. For, in critical or emotionally demanding situations, all will be looking to the doctor for their contributions and their judgement as to how to proceed.

So this leads onto the question, are doctors the supreme actors? And are they professionally insincere?

This article is, of course, written from the point of view of a health care practitioner. One could argue that this is the wrong way round, and that sincerity needs to be confirmed from the patient’s point of view. Certainly, if a doctor fails in making an accurate assessment of an emotionally charged situation, and adopts the wrong tone, they will come across as insincere. He will fail. The successful doctor will always appear sincere, but the question is –  does it really matter if they believe, and feel, what they are saying? After all, surely it is the end result, and the effect that the words have on a patient or family, that really matters, not the true quality of emotions within.

Two kinds of acting

Raj Persaud wrote a brief and entertaining article for BMJ Careers  – ‘Faking it’. He explained that…

Psychologists use the term “surface level emotional labour” to capture the fact that a large part of dealing with people at work is basically “faking it” or displaying emotions we don’t actually feel, like feigning interest, sympathy, or understanding.

One of his references is an internet accessible paper by C´eleste Brotheridge and Alicia Grandey, ‘Emotional Labor and Burnout: Comparing Two Perspectives of “People Work”’ (2002). In this, the relationship between those types of acting (be they voluntary or involuntary) are related to the preservation of mental wellbeing in people who work in ‘service industries’. Medicine features prominently in it. They explain acting in more detail:

(NB – for ‘customers’ read ‘patients’!)

‘Surface acting’

In surface acting, employees modify and control their emotional expressions. For example, employees may enhance or fake a smile when in a bad mood or interacting with a difficult customer. The inauthenticity of this surface-level process, showing expressions discrepant from feelings, is related to stress outcomes due to the internal tension and the physiological effort of suppressing true feelings.

                …inauthentic [acting] over time may result in feeling detached not only from one’s true feelings but also from other people’s feelings, suggesting a relationship with the dimension of depersonalization. Feeling diminished personal accomplishment is also likely if the employee believes that the displays were not efficacious or were met with annoyance by customers. Thus, surface acting is expected to relate to all three dimensions of burnout.

‘Deep acting’

Deep acting is the process of controlling internal thoughts and feelings to meet the mandated display rules. Emotions involve physiological arousal and cognitions, and deep acting works on modifying arousal or cognitions through a variety of techniques.

                …doing “emotion work” was a way of decreasing a state of emotional dissonance and may also result in a feeling of accomplishment if the performance is effective. Thus, deep acting might not relate to emotional exhaustion because it minimizes the tension of dissonance.

Another accessible article, ‘Reassessing the concept of emotional labour in student nurse education: role of link lecturers and mentors in a time of change’ by Pam Smith and Benjamin Gray (Nursing Education Today, 2000), explores these specifically in relation to healthcare. They cite Arlie Hochschild, author of ‘The Managed Heart’ (University of California Press, Berkeley, 1983), which seems to form the basis of most studies into how we modulate our emotions in the workplace.

Defining emotional labour Hochschild suggests that emotional labour involves the induction or suppression of feeling in order to sustain an outward appearance that produces in others a sense of being cared for in a convivial safe place.

The idea of ‘emotional labour’ really does chime, for most healthcare professionals would agree that emotional exhaustion precedes physical exhaustion during a busy shift. Just the other day I said to a colleague, ‘I’ve had three DNAR discussions on this ward round, I don’t think I can manage another right now.’ But, just as superficial acting is associated with ‘burnout’ (a paradoxical and counterintuitive findings one might think), deep acting appears to lead to true ‘job satisfaction’. This also rings true. You really feel you’ve done some good when you dip into a person’s difficult life, make a significant intervention, and then leave them. That is medicine. The satisfaction negates the exhaustion. It is ‘dissonance’ that wears you down.

Smith and Gray also note,

 By brushing over the emotional labour of nurses as an essential skill that does not require development, because it is so ‘basic’, the techniques of nurses’ emotional labour go unappreciated and are not developed as resources for the National Health Service (NHS) to draw upon.

This is a valuable comment. What seems like an ‘obvious’ element of compassionate healthcare is in fact a resource, one that is not infinite. A highly relevant point in the current climate of criticism.

An emotional continuum

We act. I think we can accept that as a given. It’s part of our professional skill set. I am more interested in how this affects our ability to provide compassionate care. My suggestion, and I would love to know what others think about this, is that rather than flipping between a mere two levels of acting and involvement, we move steadily along a continuum, like whales plumbing the ocean depths, responding to our perception of how emotionally complex and ethically demanding each situation is.  I can only speak for myself, but I think the ‘emotional work’ that I commit to is in direct proportion to those quotients. The expression of compassion is, in turn, directly related to that commitment, the words and actions being fuelled by a rarer and more precious fuel. The rewards however, are all the greater, as noted above. To put it simply, ‘you get out what you put in’… but it is unrealistic to put in your all during every interaction.

A warning

So, what of our consultant, the one who said all the right things and then displayed a streak of cynicism to her junior a minute later? I think I understand her. She had become too nimble, too smooth, too adept at making the quick change in emotional depth. She, the consummate actor, found it too easy to flit between compassionate caregiver and amusing educator. However sincere her words to the patient’s daughter, the rapid alteration in tone belied her.