Risk and Responsibility
Friday 9 November 2018
The Friday before last saw Barry and I enjoying a bite of lunch together, reviewing a successful morning at the ranch. There are aspects of that sentence that might not ring true with colleagues: the fact that we had found time to eat, yet alone together, and what’s all this about a ‘successful morning’? Admittedly, it hadn’t looked promising earlier; the carer of a chair-bound 94-year old lady had requested a visit to sort out what sounded like potentially serious ‘undercarriage’ issues, never the easiest in a cramped and cluttered front room, in the dazzling glare of a flickery and distant 25 watt bulb. I phoned the community nursing hub, who arranged for two of their finest to meet me at the house, and the excellent carer came back in her own time to provide moral support for the patient. Duly historised and examined, with a nurse on either wing and suitable lighting, I discussed the options with the patient and her advising throng, even managing to get advice from a friendly gynaecologist via the Consultant Connect app whilst I was still in the patient’s house. Gosh.
I went back to base and met Barry, who’d found time and space enough to wade through the inbound electronic mail without interruption. I used Senior Partner clout to send him out to get my lunch, and we sat together at my desk reminiscing that ours can be an immensely satisfying job, as long as everything runs as advertised and we have enough headroom to get on with it. We discussed our frailest palliative care patient, a delightful lady who lived with her husband just a stone’s throw from where we were sitting. She had dementia and wasn’t recovering from a prolonged chest infection. Several of the GPs had visited and had the appropriate discussions with her relatives and carers: she was for palliative care, ‘just-in-case’ medication was in the house, and a TEP form stating that she was to be cared for at home was metaphorically stapled to her chest. What could possibly go wrong?
Something did. When I logged onto EMIS after the weekend, I saw two documents added to her record, the second of which was a communication from Musgrove to say that she had died in a side-room at the hospital. I felt awful- what had we missed? What could have happened to foil our best-laid plans for our patient? I went back to the first document, an ‘out of hours’ (OOH) record, expecting to find my answer, but no- it told of a visit by the OOH GP at the carer’s request; they’d assessed the situation, recorded their examination findings clearly, noted the TEP and the directive that she should not be admitted, reassured the relatives that she was comfortable and her condition was as would be expected, and left. So what had happened?
After surgery, I visited her husband, a true ‘gentle’ man who I’ve known and looked after for 30 years, for the majority of which he had been the frailer half of the relationship. I’m there principally for a bereavement visit but also seeking answers. He told me that after the OOH visit, one of the carers was worried that she ‘didn’t look so well’ (!), and called her supervisor. The supervisor called her manager, who called 111, who dispatched an ambulance. The ambulance crew gave her oxygen and commented that she looked a little better, and they ought to take her to hospital. At this stage of the story, I’m chewing on a knuckle and trying hard not to scream. I gently probe my poor bereaved patient as to whether the paramedics saw the TEP form? He can’t be sure, but added: “you don’t argue with those people”. Hmm. I’m trying to see it from his point of view and have considerable sympathy. It can be intimidating for anxious and frightened elderly folk to have flashing blue lights outside the front door, and their kitchen buzzing with the paramilitary wing of SWAST, and he’s not the sort to make a fuss.
My enquiries continue. I can’t believe they didn’t see the TEP form, but how else to explain our patient being admitted other than the paramedics not feeling able or prepared to accept that the patient was dying? It’s a similar mentality to the notion that by default, everybody, of whatever age or frailty, should be actively and aggressively resuscitated, unless there is a valid DNAR form prominently displayed that meets everybody’s criteria and satisfaction. I’m not sure how we’ve got to where we are now, but it seems that nobody is allowed to die peacefully and with dignity, unless we/they have agreed and certified somewhere that this can be the case. Front-line clinicians are all well aware that cardiopulmonary resuscitation resulting in a successful outcome and a neurologically intact patient is rare enough under the best of conditions. If cardiac arrest is the first thing to happen, then by all means have a bash, but if it’s the last event, consequent on other vital systems having given up due to overwhelming disease or old age, the patient hasn’t ‘arrested’- they’ve died. There are signs, I hope and believe, that the pendulum is swinging back towards allowing more people to die with dignity, and our palliative care colleagues have been vocal in making sure that ‘End of Life’ is considered in all of the workstreams arising from the Health and Care Strategy Review.
One aspect of the brave new world of neighbourhoods and collaborative working that doesn’t get enough attention is the management of risk. It was a question that I asked at the recent NHS England study day in Exeter about developing GP networks, and I didn’t get much reassurance. GPs are trained to manage risk, and in recent years many of us feel that we’ve been lugging too much of it around ourselves. There has to be willingness elsewhere to cope with the uncertain, and we have to find a way so that GPs aren’t the only mugs still there at 6:29pm when the patient falls through an unforeseen hole in the system. This should be an aspect that we address as we start to develop the pilot Urgent Treatment Centres (UTCs).
Can anything be done to stem the ridiculous demands and requests that arrive to spoil our day? Just last week, a message arrived from a nursing home (quote): “the doctor needs to give permission for patient X to have his fentanyl patch applied in the afternoon, rather than the morning, as the supply was late arriving”. The previous afternoon, the same home had requested that we fax an urgent “VOD” form (me neither- they meant “verification of death”) to them as they suspected one of their patients (who I didn’t know) was about to die, and they needed me to say that the registered nurse, who I’ve never met, but who I’m told has had extensive further training to recognise death, should be certified as able to do so in this specific case. I think we’ve largely nailed this particular brand of nonsense in the community, but many nursing homes are still a law unto themselves. In the event the patient beat us all to it, and so I had to call in to confirm death after I’d finished at the surgery.
On Tuesday this week, the (same) nursing home sent no fewer than seven faxes regarding our patients, all addressed to me as (presumably) I’m first in the alphabet/longest standing partner/general sucker. Take a fax, any fax.....this one’s a cracker: “Siopel cream- instructions say ‘apply as required’. This is insufficient for CQC. Where are we meant to be putting it?”. Are you kidding me? You asked for it, so I rather assumed you had a vague idea where to put it. I phone and speak to a nurse, but it’s clear that I’ll have to alter the prescription. In retrospect I accept that my amended instructions might be a bit, er, graphic, and the pharmacist might struggle to get them all onto a 50g pack of Siopel. Most of the other faxes are to inform me that elderly patients are losing weight, telling me their MUST scores and asking me to prescribe supplements, probably not on the formulary, in a variety of flavours. Why am I doing this? Why can’t dieticians have limited prescribing rights to take this nightmare on? For the record, when my time comes, I’m not having any of that muck: give me bowls of Raspberry Ripple mixed with clotted cream, and possibly garnished with a Flake, depending on the state of my gums.
My brain is starting to melt when I become aware of our HCA lurking in the doorway. She has a sheaf of Patient Specific Directive (PSD) forms for people she is going to give flu jabs to for me to sign. So what’s the logic of this? I know she’s had a heap more instruction on giving injections than I ever had. Presumably I’m meant to look at each one in turn, stroke my chin thoughtfully, consult the record, and consider the risks involved and the suitability of each patient for her tender mercies, and whether any need the added benefit of immunisation backed with full registration of the Nursing and Midwifery Council. I’ve got it down to a fine art and it takes about three seconds for the lot.
I’m sorry that I won’t be even in the right hemisphere for the joint LMC/CEPN (Community Education Provider Network) study day at the racecourse on the 13th November, which will focus on ‘Neighbourhood’ development and transformation. Dr Chandler and I, along with Dr Fathers and ‘Chicken George’ (blogs passim), will be on a long-planned boy’s adventure, and at about the same time that Jill’s Weekly LMC Update lands on your desktop on Friday, I’ll be touching down 6000 miles to the south. It’s only fair, as Mrs. Chair has planned a long weekend at Center Parcs with her sister and the girls. Will discovered that the most cost-effective way for our equipment to travel with us was for us all to sign-up to become members of the ‘Virgin Swingers League’. I’m now fully affiliated, but then we need to print out our profile pages complete with mugshots from the website. Naturally, I was extremely careful a) to pick the correct ‘Virgin Swingers’ option offered to me by Google, and b) to use Barry’s computer in the LMC office to do so.
I was once asked in an interview how many golf balls it would take to fill all the oceans. I see this as a deferred practical, and we’re starting with the Indian Ocean. The LMC provides support in many ways, including sporting advice. I was serenaded by the team yesterday as I left the office in an emotional rendition of that stirring sporting spiritual, “Swing slow, sweet Chairman Nick, shouting “FORE!” to every-one....”
More, possibly, next time, when we’ll be in London for the English LMC’s conference.