Month: July 2013

The eyes and the ears: why Adam blew the whistle

Previously I wrote a dialogue between two junior doctors. They discussed why Michael would not report, to some higher authority, the dangerous incompetence of a consultant. In this second dialogue, Adam explains to his friend why he phoned the GMC to report dangerous staffing levels. This dialogue seeks to illustrate why a doctor might feel compelled to act, rather than just watch, shake their head and move on.

This is imaginary, obviously. It is intended to describe the thoughts that a whistle blower might have.

Adam and his friend sit in a beer garden. Adam occasionally looks over his shoulder to check who has taken the adjacent table.

“Was it you?” asks Adam’s friend.

“What?”

“Who called the GMC.”

“What did you hear?”

“That someone blew the whistle on A and E.”

“What else did you hear?”

“That it was about staffing levels, lack of support…it was you wasn’t it?”

“Why do you think it was me?”

“Because you’ve been going on about it for ages.”

“That’s the point I guess. I wasn’t seeing any changes at all. I was out of ideas.”

“So did you actually complain first, officially…through proper channels?”

“I told the clinical lead that I thought we were too thin on the ground. Several times.”

“And what did she say?”

“That it ‘will get better’. That ‘when the deanery send us more juniors we’ll be fine’. Mañana, mañana.”

“Did you have examples, of poor staffing leading to bad outcomes?”

“How can you get that evidence? We’re working on the ground, struggling, we work our arses off to keep the ship afloat, some people die, most don’t, how do I know if any particular death is directly related to not enough staff? How do I know if our department has got more deaths or delayed diagnoses that average? I don’t have that overview.”

“So how can you justify blowing the whistle? You don’t know that the department was actually under-performing.”

“If you follow that line of reasoning, no-one would ever stand up and say anything, they would have no confidence in their own opinion. ‘I’m just a cog in a machine, I’m not driving the machine’. To justify NOT saying anything you have to have complete faith in the driver. Do I have faith in the driver? I don’t know, I don’t know the people who run the hospital . All I know is that sometimes it’s hell in that department and patients are falling off their chairs in the waiting room.”

“And despite not knowing, you made the call. Where did you develop that confidence in yourself?”

“It’s not confidence. It didn’t come easy. I waited for months and months before making that phone call. Nearly a year in fact. But nothing was changing.”

“It has now.”

“I know.”

“You should feel proud.”

“I don’t. I just feel sick when I walk through A and E. At least staff move through it so quickly the current set of juniors don’t recognize me as the troublemaker. The consultants do. But a few have told me that they are pleased I did it.”

“Weren’t they embarrassed?”

“No, I don’t think so. They thought the same as me. When someone actually does it…does something positive, everyone suddenly says ‘Yeah, I agree, it’s unacceptable…’. Like the emperor’s new clothes, everyone pretends it’s fine, they can manage, then someone pipes up and the truth becomes clear to all, undeniable. Weird psychology.”

“But why did it take your call? The Trust knew about the situation, the department was aware…not just from your comments…but it took the fear of a GMC investigation to do anything.”

“I honestly don’t know.”

“Has anyone from senior management spoken to you?”

“Yep.”

“And…?”

“It was all very reasonable, understanding, respectful in fact.”

“Fake?”

“Actually no. We got into a good discussion. He made me feel relaxed, and we went into it in some detail.”

“Such as?”

“The bigger picture. He allowed me to push him…to draw him out…to reveal HIS thoughts about whistleblowing. It wasn’t the greatest example of whisteblowing in history was it, really, more of an alert I think…so I don’t think he minded talking about it. So we got into the bigger picture. He encouraged me to think about scale, to think about the hospital as a unit, providing care to all of its patients and to the whole community. Elective and emergency. Babies, kids…not just the sort of patient I was seeing. Those in charge have to decide where to put the resources, where to place the staff…”

“So only they have the overview, and the knowledge…”

“Perhaps, but it went further. I said yeah, you have to make hard decisions, to ration basically, but you in turn are being rationed, by the government, who have demanded that you save x million this year as a share of the £20 billion of efficiency savings. He liked that.”

“He didn’t really agree to pass the buck onto the government did he?”

“Not as such. But perhaps he should have. I might have sympathised with him.”

“You can take the bigger picture further you know Adam.”

“How?”

“To society as a whole. Why does the government demand we save £20 billion?”

“Because the economy is screwed. Austerity.”

“Yes, that’s the environment we live in. But within that environment the government has decided to squeeze the health service because it has a duty to maintain other parts of the state at the same time. Defence, social security, prisons…so in their eyes, the bigger picture demands that Trusts feel the pain. That’s the price of austerity, of long term economic stability. We don’t have that overview, the really big overview.”

“You really believe that? No wonder you didn’t make that call. You’ve intellectualised it to death.”

“Perhaps.”

“I said I sympathized with the big picture, but ultimately it doesn’t cut it. Because it’s not our business to care about the bigger picture, don’t you see? Resources are be sent down according to the best judgements or intentions of our political masters, or moved around the Trust by our senior managers, but we must concern ourselves with what the effect of those decisions is at ground level.”

“Humour me a minute Adam, I’m not criticising you…but why whinge about those decisions? We live in the big picture. We are citizens in a democracy, we, as a society, voted for austerity and hardship. We ARE cogs. That’s the state we’re in, we should just do our best within it. ”

“It doesn’t matter. We, as doctors, work in a small world, the hospital…and we are there to make patients better. We are the ones with the eyes and the ears to tell the ones who move those resources around that their decisions are proving destructive. We are the ones who must tell them if minimum acceptable standards are not being maintained. Who else is going to spot that? If not us, who?”

“But doesn’t everyone think that their little domain is under resourced, straining to maintain minimum standards? We can’t have all of them ringing the GMC helpline.”

“I agree. And that’s why it took me a year. I challenged myself over and over again, told myself it was just me, just a bad run of shifts, that my seniors had recognised the problem and were dealing with it…but nothing happened! So I did it. I reassured myself that it was up to me to tell them that here, in this case, the balance wasn’t right.”

“Eyes and ears.”

“Yep. That’s what Francis said.”

“And mouths too.”

 

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The cusp: ethics of the learning curve

learningcurve

 

There is a moment in medical training when you think you are ready to go it alone. The difficulty is deciding when that moment has arrived. Independence, working without supervision, is a watershed moment.

Imagine this situation. A gastroenterology registrar who believes that she is ready to deal with bleeding ulcers receives a phone call. A patient is bleeding in the ER. She makes arrangements to bring the patient to the endoscopy unit. She decides not to call her consultant because he has said on a number of occasions that she is ready. He has ‘signed her off’. The patient now awaits her; she takes the endoscope and passes it into his mouth. She finds the ulcer quickly and knows what to do. But it is bleeding rapidly, and the views that she obtains are not very clear. She knows what to do. She washes the ulcer, tries to clean the blood away, but still it bleeds. She begins to feel nervous…even more nervous. She asks for a needle with which to inject adrenaline, hoping that this will slow the bleeding down. Then she might see enough to apply some definitive therapy, a clip or thermal coagulation.

She waits for the endoscopy nurse to get things ready, and watches the patient. The elderly man is sedated, but his pulse rate continues to climb despite the blood transfusion. The registrar knows that she would rather her supervisor was here. But then she reflects – this is what independence is about. Coming out of your comfort zone, absorbing the stress, dealing with the situation, making the decisions, …enlarging that zone… making yourself better so you can treat the next patient with even greater confidence and skill. But what if that process involves putting this frail man at risk? She readies herself for the next part of the procedure. She knows that if this goes well she will emerge from that room a better doctor.

The scenario can now go one of two ways…

A. She injects the adrenaline and as she had hoped it has a constricting effect on the blood vessels, causing the flow to slow down. Now when she washes the blood away it takes longer to ooze back, and she can see the culprit in the middle. A raw artery that has been eroded by acid. She chooses to use the heater probe and asks the nurse to make it ready. She passes it down the channel of the endoscope until she can see it emerge on the screen. With one hand she controls the wheels on the endoscope to optimise the position, and with the other she presses the heater probe onto the vessel. Then, with her right foot she presses a pedal on the floor and sends electricity into the probe, creating a tiny zone of intense heat until the vessel is ‘cooked’. Thinking that she has sealed artery she pulls the probe away. But the bleeding is even worse now. She must have torn the wall away. Quickly she calls for a clip and the nurse passes her the kit. The registrar pulls out the heater probe and quickly, calmly, replaces it with the clip delivery device. Soon she sees the metal jaws, grossly magnified, floating around the field of scarlet on the TV screen, and although the view is flooding with blood again she can still glimpse the artery. Before the window of opportunity has passed she pushes the clip onto the artery and asks the nurse to deploy. The clip closes down on the artery and stops the bleeding immediately. The field clears and she places two more clips above and below. The patient is stable.

“Well done,” says the nurse “that wasn’t easy. You could tackle anything now.”

B. She continues to wash away the blood, but the view is terrible. She injects adrenaline and it slows things down, improving the view. Now the time is right to use the heater probe. She places its tip on the ulcer, right on the vessel that is spurting blood, and presses the pedal. The heat dissipates into the pool of blood, and makes little difference. She knows that a clip is the next best thing, but she needs a better view. She readies the clip, and through the other channel of the endoscope she squirts more water. The view improves and when the time is right she deploys the clip. For a while she thinks that the job is done, she sighs in relief and smiles at the nurse, but 30 seconds later the bleeding erupts again and all views are lost. She takes out the camera, bleeps another member of staff to come and help look after the patient, and rings a surgeon. He arrives quickly, but argues that the patient is too frail to undergo an operation. The registrar argues back, saying that she can do no more within the scope. They debate the pros and cons of various other treatments, and in the end agree that surgery is the only hope. The patient is anaesthetised and in the operating theatre 40 minutes later. The ulcer is located and sealed. But he does badly after the operation, and develops a chest infection. He remains on a ventilator, and in the end, seven days later, dies.

The registrar describes all this to her consultant. From the description he can see no reason for her to blame herself.

“You did fine.” he says, “You knew when to give up, that’s half the skill.” He doubts that his presence would have made much of a difference. But the registrar knows that the patient’s greatest chance of survival would have been afforded if he had not had to have an operation, if the most experienced person had been there to treat the ulcer…if she had not proceeded on her own.

*

As a trainee approaches the top of a learning curve the moment comes when they have to decide if it is safe to go it alone – the cusp. The patient who comes into hospital on that day will have no idea that they represent a significant moment in the career of the doctor who is called to perform their procedure. They will have no idea where they lie on that learning curve, or that they might form a stepping stone to independence and immaturity. This would not matter if their risk of harm was no greater than that of any other patient having the procedure. But it is the result of this risk analysis that forms a perfect example of how we balance individual risks versus societal benefits in medicine.

The concept of the learning curve was introduced to many members of the public in a horribly vivid way during the Bristol Heart scandal. One of the paediatric heart surgeons involved said,

“I believe that the reality of the learning curve may be illustrated by the evolution of surgery for transposition of the Great Arteries in this country … in the late 80s and the very early 90s it was generally understood and accepted that when a unit introduced the Arterial Switch operation for neonates there would initially be a period of disappointing results.”

I am not concerned with such extreme examples here, but the essence pertains. In order to achieve complete expertise it is necessary to accept a degree of ‘trial and error’. Or is it?

*

A thorough enquiry into this subject was undertaken by a US paper, the Dallas News, following controversial reports coming out of Parkland Memorial Hospital, the primary teaching institution of University of Texas Southwestern Medical school. This hospital seemed to take a liberal attitude to the surgical training, crediting its juniors with autonomy to proceed with many operations unsupervised.

One faculty supervisor who quit in protest said the mainly poor, minority patients of Dallas County’s only public hospital had effectively become “clinical fodder.”

Apparently,

The head of UT Southwestern’s general surgery residency program once said it was “OK for residents to make mistakes” on patients “even if they could have been avoided with better faculty supervision,” according to notes taken by a faculty surgeon and later included in court records. Tim Doke, UT Southwestern’s spokesman, challenged the accuracy of that account. But Anderson has testified that some faculty believed “that’s how people learn,” though he said he disagreed with the philosophy.

In this case (and the newspaper report makes excellent reading, as does this graphic summarising mortality), one supervisor became uncomfortable, and complained after he was called into a gall bladder operation too later, after a irreversible damage had been done to the bile duct.

This controversy crystallises an ethical dilemma in medical training. As the journalists put it, “There’s good for the patient, and there’s a societal good. We can’t exist as a society without physicians learning on the ground.”

A questionnaire study published in the BMJ found that 86% of surgical trainees or young consultants had performed procedures for the first time without direct supervision. This appears to be the reality of medical education. Attempts have been made to resolve the dilemma, another BMJ paper seeking to lay out a framework based on respect for the individual, beneficence and non-maleficence. In their introduction Jagsi and Lehmann explain that…

The burdens of medical education are not currently distributed fairly. In one US study, students saw disproportionately high numbers of non-white patients and patients with Medicaid (public insurance for the indigent).Another study found that children of doctor parents were less likely to be seen by trainees than were other children.

220px-Immanuel_Kant_3

Immanuel Kant (image from Wikipedia)

However, the approach laid out in this paper does not really equip trainees with a practical method of making decisions on the spot. Another paper (Journal of Medical Ethics) approaches the problem by applying Immanuel Kant’s Second Formulation of the Categorical Imperative,

‘‘Act so that you use humanity, as much in your own person as in the person of every other, always at the same time as end and never merely as means”

In reality however,

This conflict arises because, at least presently, medical practitioners can only acquire certain skills and abilities by practising on live, human patients, and given the inevitability and ubiquity of learning curves, this learning requires some patients to be treated only as a means to this end….Accordingly, until a way is found to reconcile them, we conclude that the Kantian ideal is inconsistent with the reality of medical practice.

To resolve this conflict,

…supervisors might undertake to delegate only under conditions where they can be as sure as possible that the procedure would be done as well as they could do it themselves. If this assurance can truly be given by the supervising doctor, then the conflict is solved.’

 

This seems unrealistic. So are the patients who take their place on our learning curves nothing more than a means to an end? The paper begins with a quotation from Atul Gawande’s book Complications: a surgeon’s notes on an imperfect science

‘To fail to adopt new techniques would mean denying patients meaningful medical advances. Yet the perils of the learning curve are inescapable—no less in practice than in residency’

Le Morvan and Stock seek to challenge the perception that patients are guinae pigs in four ways;

1) Discontinuing unnecessary use of patients without consent – they suggest that we introduce a consent process where possible. The example of pelvic examinations by students on anaesthetised patients is one such example.

2) Continuing to develop medical simulation models

3) Enhancing supervision, but…”We are sceptical that such an approach, applied stringently, is practical for all procedures. It is hard to imagine—for example, that an experienced surgeon can honestly say that his trainee’s first liver biopsy will be performed just as well as he would perform it himself. Moving in this direction, toward a more conservative educational model, would, however, reduce the extent to which patients are used as means only.”

4) Changing expectations, or universalising the problem. If the involvement of trainees is taken into account when the statistical outcome from a procedure is calculated, patients waiting for that procedure are not actually being disadvantaged by having performed by a trainee. This argument does have a whiff of sophistry about it, but I have found myself using it before. As a patient and a parent I would want the hospital’s best qualified person to treat me or my children (although I am probably too polite to demand as much), but as a trainee I often muttered to myself, in response to a patient’s underwhelmed expression, “Look, either I do this procedure or it’s another five hour wait…what will it be?” As the authors conclude,

It does, however, offer a useful way of approximating this ideal in light of the constraints imposed by the reality of medical practice.

I don’t think there is a way of truly resolving the Kantian conflict unless our patients accept that it is not possible to always see the most qualified person in the institution. But the deal must be reciprocated by trainees – they must ensure that every single clinical interaction is approached not from the point of view of ‘polishing their resume’ (as the Dallas News article put it), but from the point of view of the patient. The trainee may well be on the cusp, there may be a theoretically increased risk, but if the skills are embedded, if the trainers have given their blessing, if they feel ready on that particular day or night…no more can be asked.

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An opaque code: the Liverpool Care Pathway and a gap in perception

The independent report into end of life care, ‘MORE CARE, LESS PATHWAY: A REVIEW OF THE LIVERPOOL CARE PATHWAY’ has been published. Eagerly awaited, following months of controversy (click on the category below for other posts) , the report contains a paragraph that at first sight seems somewhat trivial…but which I think holds a key to the whole problem,

The Review panel has reluctantly concluded that the term ‘Liverpool Care Pathway’ is most unhelpful: anxious and upset relatives cannot be expected to understand what an ‘integrated care pathway’ is, let alone what it has to do with Liverpool.

                A ‘pathway’ suggests to most people a road that leading somewhere. When someone is ‘put on’ a pathway, it sounds like, as one carer put it, they are being placed on “a conveyor belt to death”. In the context of the debate about assisted dying and euthanasia, some carers have formed the impression that “the pathway” represents a decision on the part of clinicians, in effect, to kill their dying patients, when that is clearly not the case.

[page 17]

The LCP controversy has highlighted many things, not least the prevalence of poor communication at the end of life, but the importance of the ‘perception gap’ between doctors and patients has not received much attention. The two are of course connected. The paragraph reproduced above is all about perception, and I will use it as a springboard from which to explore this aspect of the LCP.

When the LCP was first adopted I found it quite a challenge. This was because its implementation required work. Before the LCP a patient’s final days would, in many cases, just happen. That is not to say that we were passive, lazy or negligent…just reactive. Doctors and nurses responded to symptoms and altered the care that was given appropriately. Families reported that their loved ones were in pain, we prescribed some morphine or a sedative.  Often, because our minds had not been focussed on the possible burden or futility of ongoing medical treatments (such as antibiotics, infusions or tubes) they would continue by default. The LCP ensured that these factors were anticipated, so the patient did not have to wait for pain killers or go through unnecessary interventions.

But the LCP was a ‘thing’ to be ‘implemented’. And, like any new or different form of treatment, it required discussion. So I found myself sitting down with families who were often bleary eyed with tears or outright fatigue, to introduce a whole new concept. It felt uncomfortable – describing it, justifying it, ‘selling’ it, this Pathway, when the family were under the impression that their loved one’s journey was nearly over. Another pathway, another plan, another change…

My initial thoughts about the LCP were, ‘Why? We’re doing it already. This just turns dying into another booklet…’ But its benefits became clear, and I will not describe all of them here. Because I saw those benefits I concluded that the work of describing and explaining it to families was worthwhile. It put them in the picture. It ensured that the ground was prepared for the adjustments that might be made around the bedside; the drip that might come down without being replaced, the blocked cannula that might be removed without being re-inserted, the feeding tube that might become coiled in mouth and taken away without being re-passed. Before the LCP such changes or omissions would have been discussed, of course, but now the philosophy of care, of minimising burden, was out in the open. But the work had to be done.

The work was complex. It was nothing less than a crash course in the pathophysiology of dying, the concept of treatment burden, the ’double effect’ of opiates… all the while remaining sensitive to individual circumstances. Doctors are used to such conversations, but now there was another step…to encapsulate those principles of palliative care and present them in a new package, the LCP. Here it is. Strange words. As that paragraph from the report suggests…Liverpool – why?, Care – that’s easy, Pathway – what? Well it’s just a name…it means nothing. The important thing is what it means for your relative.

The acronym became familiar to doctors and nurses. In fact it became a shorthand for ‘final days of life’. He’s on the LCP. She’s for the LCP. Don’t you think it’s time for the LCP doctor? Such phrases were not signs of a callous attitude, but instances of medical shorthand. Our conversations teem with them. And overnight, when junior doctors were called to see dying patients, it became common for that shorthand to become manifest. The LCP could be ‘started’ at 3am, unknown to the family. All it meant was, the patient is dying. It formalised the clinical impression. But was it too easy? It is quite possible that such automaticity led us to underestimate the gap in perception between us and our patients’ families. What became shorthand for us became an impenetrable code to families. Codes suggest secrecy, sacerdotalism, an imbalance of power, decisions made without discussion.

But if we did the work, made the time to talk families through it, there was no problem. So what happened? It would seem that on numerous occasions the work of talking was squeezed out, while the implementation – all those adjustments, all those omissions – remained. The ground was not prepared. The code was applied, but the explanation was not given. Thus, as described on page 22 of the report,

As if caught in the midst of a perfect storm, relatives and carers would discover that a previously sentient person was now semi-comatose. They were told that, following an overnight decision by a relatively junior clinician, this patient had been ‘placed on the pathway.’

 

This is the gap in perception. I, a doctor who is well used to seeing patients die, would interpret such a change in conscious level as the natural progression in a patient’s terminal illness, and the LCP as being no more than a corollary to this, a way of organising his care… but in the eyes of his family there has been a deterioration COINCIDENT IN TIME with a NEW TREATMENT. How could any reasonable lay person not assume that the LCP had led to the deterioration? Without the work of explanation the LCP is therefore at best opaque and at worst, to some who feel vulnerable or poorly served by the very hospital in which their loved one failed to recover following an acute admission, outright sinister.

This excerpt crystallises another gap in perception, in the area of consent;

                ‘No one explained anything to us about what would take place once the Pathway was implemented, or what would happen otherwise. We weren’t given anything to read and, as far as I can remember, the issue was raised so tentatively by the doctor and nurse that at the time we were simply unaware that we had taken such an important decision.’ [page 24]

 

The concern is echoed in one of the panel’s conclusions,

From the submissions of evidence that the Review panel has received, it is clear that one of the central issues causing difficulty seems to be some misunderstanding and uncertainty over whether deciding to implement the LCP is a treatment decision that requires the patient’s consent (if the person has capacity) or requires the decision to be taken in the patient’s best interests (if the person lacks capacity). [page 23]

Decision. The leather-skinned, busy, functional doctor in me reacts to this. Decision? I know that the LCP was designed with nothing more than comfort and dignity in mind, elements of care that should not require shared decisions or consent. But the empathetic, reflective doctor in me accepts that because the LCP appears to represent a change in treatment, every effort must be made to carry the family along in complete and explicit agreement. There is no point harping on about whether consent or assent are legally required. If the conversation is had, if the work is done, the gap in perception will be filled with words and mutual understanding. But the work has to be done.

Why do I use the term ‘work’ so much? It sounds churlish and reluctant. I use it because I think we need to prioritise the role of the conversation, rather than let this seemingly soft side of medicine give way to the never-ending, ever more urgent  list of hard tasks that our doctors, junior and senior, must accomplish in an average day. As the flow of acute admissions increases, as our patients’ degree of frailty increases with the average age of the population, we have to come up with better ways of organising that ‘work’.  The report’s introduction concludes with this entirely appropriate comment,

We feel strongly that if acute hospitals are to deal with dying patients – and they will – whether or not they are using the LCP – they need to treat patients, their relatives and carers with more respect. Hospitals and other institutions need to make more time available to them at any hour of the day or any day of the week. We know that hospitals are often short staffed, and that senior staff may often not be present at night, over weekends, and on Bank Holidays. This is perceived by many as one major cause of poor levels of care and communication. In order that everyone dying in the acute sector can do so with dignity, the present situation has to change.

Unless we can find the time to talk, at length, gaps in perception will persist, and our good intentions will continue to be misconstrued.

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5 days: a tale of escalation creep

escalation

Day 1 A 90 year old lady, Mrs V, is admitted to hospital with symptoms of pneumonia. She was managing at home 6 months ago but has become increasingly dependent on her family; the plan was to employ or arrange carers soon. She always said she never wanted strangers around – the words ‘fiercely independent’ are used a lot. She saw her husband die on an intensive care five years ago – it was very unpleasant, and her son makes it clear from the outset that she would never want to be put on a ventilator. Treatment begins, and her son actively engages the consultant in a DNAR conversation during the post-take ward round. All are agreed she should not be subjected to it should her heart stop. But the consultant explains that the pneumonia is not that severe, and says she is optimistic that Mrs V will improve. The son was due to go on a business trip for three days – he asks if that is wise. The consultant says,

“Well, nothing is ever certain, but her oxygen levels are not too bad, and she has no other illnesses. I can’t tell you what you should do, but she doesn’t seem to be in imminent danger.”

He leaves.

Day 2: Mrs V appears confused to the registrar who does the daily ward round. He notes that her oxygen level is borderline. The oxygen flow is turned up, the level improves. But later that day it dips again (saturation 83% on an oxygen mask). The registrar calls the consultant,

“I was thinking about some non-invasive ventilation on the medical HDU.”

“That would be reasonable. Her son was keen not to medicalise too much…”

“I think she just needs a couple of days of support.”

“I agree. She was pretty good before, the antibiotics haven’t really kicked in yet. Any positive microbiology?”

“Streptococcal antigen positive.”

“Ah. Well at least we know. But it could be aggressive. I’m happy for you to arrange transfer.”

Day 3: Mrs V has spent the night on a tight fitting mask which allows oxygen to enter the lungs under pressure. She struggles with the mask periodically, but settles eventually. Her oxygen levels are better, but she is still confused. The team put this down to delirium, an acute confusional state. A blood sample is drawn from the wrist, and it shows that her carbon dioxide levels have risen. The HDU nurse asks if the team could arrange an arterial line, a cannula inserted into the radial (wrist) artery, to allow more frequent blood sampling. This will avoid repeated needles. The registrar agrees, the SHO volunteers. He can feel the artery easily, and is confident. The ward round moves on and the SHO stays behind, but 40 minutes later he calls the registrar.

“I couldn’t get it in.”

“How many attempts?”

“Just three…but it bled and she has a big bruise.”

“Leave it for now. I’ll do it.”

Day 4: The consultant does a ward round in the morning.

“How come she’s got a nasogastric tube?” she asks of the charge nurse.

“She was sick overnight. Her stomach filled with gas because of the positive pressure. She’s a lot more comfortable now.”

“Is she eating?”

“Not much. She has some sips during breaks off the mask.”

The team look at the arterial blood sample results. Gradually, with the eye of faith, the respiratory failure is improving. Mrs V cries out. She has pleurisy, intense pain at the edge of the lungs. Simple pain killers are not enough, and she is prescribed morphine. As the consultant walks away she notices the urinary catheter bag hanging from a stand.

“Why the catheter?” she asks. The charge nurse replies,

“She couldn’t manage with the commode, not on the mask. She’s high risk for pressure sores. We put it in yesterday.”

Day 5: Mrs V deteriorates. A repeat x-ray shows that the pneumonia has spread further through the right lung. The registrar calls the consultant.

“I’ve got quite a bad feeling about her now. I think her age is beginning to tell, I know she didn’t have any other illnesses but…”

“You’re right. Once things begin to go downhill it’s hard to see her getting better.”

“I understand her son didn’t want her to go to intensive care.”

“I don’t think they would take her to be honest. But yes, he told me that she wouldn’t want that. In fact he needs to know what’s going on. He’s supposed to be coming back today.”

“The nurse called him this morning. He arrived back in the country in the early hours apparently. He’s on his way in.”

“I’ll speak to him. We need to discuss de-escalation.”

At 2pm her son arrives on the ward. He finds his mother lying on her bed, barely conscious now. She is muttering words but he cannot understand them. A monitor pings and alarms insistently above her head. Trailing from her body are a urinary catheter, an arterial line transducer, two intravenous infusion lines and the wide oxygen tube attached to the mask at her face. The air and oxygen in the mask whistles. Cardiac monitoring leads trail out of her gown into the machine that is alarming. He sees the bruise on her forearm that has now developed into a 4-inch haematoma that sits proud to the skin. He pushes the curtain aside, tears in his eyes, storms out of the cubicle and shouts in the direction of the nurses’ station,

WHO DID THIS? SHE NEVER WANTED THIS!”

She dies later in the day, the mask having been removed and the monitor having been turned off. Six weeks later her son writes to complain about the inappropriate, overly intensive treatment to which she was subjected during her final illness.

What happened here?

*

I wrote this to explain how, as the cliché goes, the ‘road to hell is paved with good intentions’. Looking back, Mrs V’s treatment seems misguided. How could her consultant have allowed a frail 90 year old lady with (what proved to be) severe pneumonia undergo multiple, potentially painful and distressing procedures to no avail? Didn’t she hear the son when he explained how Mrs V had witnessed her husband undergo a similar ordeal? Why didn’t she put a brake on the system and stop the medical rollercoaster in its tracks?

But then, let’s go back to beginning and follow these events step by step. The infection didn’t look that bad at the beginning, there was little reason to expect Mrs V’s death. So, when Mrs V’s oxygen levels fell, a judgment was made that a short period of assisted ventilation would help. But then, to avoid repeated blood tests, an arterial line was required – a procedure that proved harder than it looked. The gastric tube had to be passed, the nurses couldn’t just stand by as her stomach filled with gas. The catheter was routine. Every step was justified.

How could this have been avoided? Well, if the son had been there every day he may have called a halt to things, but I’m not sure he would have felt able to question each procedure in the face of enthusiasm and almost routine pattern following on the part of junior doctors and nurses. So to stop this we need to go back further…to the initial conversation. It needed to focus on the ‘ceiling of care’.

Perhaps the consultant should have made a decision, in discussion with the son, that whatever happened Mrs V would remain on the basic medical ward…even if she deteriorated. In that way there would be no danger of being prescribed the mask, and no danger of having to endure the paraphernalia that can goes with it. The son would have returned (perhaps a day or too earlier if he had been contacted about the deterioration) to find his mother being treated on the original ward, in relative comfort. Knowing how things turned out in the end, that decision would have been right. But no-one knew how things were going to go. The consultant thought there was a chance of survival. She decided that the burden of treatment was reasonable in this case, despite the caution that the patient’s son had expressed. She made the wrong call.

I have no right answer here. I wish only to highlight that, as Soren Kierkegaard said, ‘Life can only be understood backwards; but it must be lived forwards.’

The case description is entirely fictional.

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