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VIEWS & REVIEWS: Paula Newton A good death—but no thanks to the NHS BMJ 2007; 334: 536 [Full text]

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A good death - but no thanks to the NHS

Sarah K Corlett   (9 March 2007)

A good death: we only have the one chance to get this right!

Ghislaine C Young   (10 March 2007)

There can be a better way

Andrew Thorns   (10 March 2007)

The nurse's bad day

Diane-Marie Campbell   (13 March 2007)

Communication is the key

Shyamali Griffiths, Anoushka Chelvendra   (14 March 2007)

Tariffs versus humanity in the NHS?

Martin G Duerden   (14 March 2007)

Let nurses work

Phillip J. Colquitt   (15 March 2007)

A good death - but no thanks to the NHS 9 March 2007
Sarah K Corlett, Consultant in Public Health Lambeth PCT SE1 7NT Send response to journal: Re: A good death - but no thanks to the NHS	My heart went out to Paula and her family on reading her personal view (1). Fortunately my 80 year old mother survived her brush with the NHS this time last year but it was a frightening experience especially for her, but also for me. Despite thinking I was fairly sanguine about the human frailty of NHS staff and sympathetic about their (our) working conditions which aren't exactly conducive to providing whole person care, I was shocked at what I perceived to be the low level of engagement by staff in bringing together sound clinical judgment and an understanding of individual needs. We the family felt fobbed off although I thought I went out of my way to emphasise I was acting as daughter not doctor in my enquiries and my parents, who thankfully retain all their marbles, were in my view reduced to the status of "crumble" with my mother reluctant to make a fuss incase she "blotted her copybook". Similar to Paula's father my mother's hospital discharge was initially delayed for several days because of a low sodium of indeterminate cause, then she had a secondary haemorrhage into a fracture which was only picked up after a further two days because of a falling haemoglobin, although the bruising and consequent oedema were perfectly visible to my mother and her visitors within hours. I will say that nurses were kindly and the communication skills of the junior doctors I met were to die for and I wish them well but mostly at the time I wanted them to be able to take a history and examine a patient fully and record and communicate their findings accurately to seniors. And I wanted seniors to be scrupulous about checking what their juniors were doing, to demonstrate to them how to integrate the clinical and human issues in the interests of the patient, particularly how to listen and treat them and their relatives as useful sources of intelligence in planning treatment and care, and then to exercise their influence in making things happen when there are blocks in the system (for instance in getting people home). Too much to ask perhaps? 1. Newton P. BMJ 2007; 334:536 Competing interests: None declared
A good death: we only have the one chance to get this right! 10 March 2007
Ghislaine C Young, Nurse Practitioner BD183EE Send response to journal: Re: A good death: we only have the one chance to get this right!	I was very sad to read Dr Newton's account of her father's death. Good nursing care should be the right of every patient and certainly not be something that is only provided in private hospitals! I have heard many such distressing tales- from friends as well as colleagues, and they are hard to erase from one's mind even when does hear of happier experiences. There is no excuse for a lack of care and compassion: neither "having a bad day", nor lack of time. All it takes is a willingness to be in the present with the patient, to recognise their humanity and to imagine how our loved ones would like to be treated in this situation. I don't undertand how staff can become brutalised to the pain and suffering of others. We need good leaders in both nursing and medicine to act as role models and to set and insist upon the very highest standards of care. I found an ancient booklet the other day on nursing care at the Middlesex Hospital where I trained a few decades ago. Written in the mid 1940s it gave an account of a patient brought into casualty and then admitted to a ward, where he thought he must be the only patient there, such was the individualised care he received. He commented that the nursing was "something beyond efficiency" and he left hospital feeling that his wellbeing had really mattered to the staff caring for him. Sadly the Middlesex is now closed but surely its spirit lives on in the hearts and minds of our new generations of nurses who enter the profession with high ideals. If nursing reflects the society it serves then maybe we need to change society and teach our youngsters to treat each other with courtesy and consideration. There is so much in society that is divisive: politics, class, religion. However what we should all reflect upon is our shared humanity and that what unites us is far more powerful than what separates us. Competing interests: I am a nurse currently working in the NHS
There can be a better way 10 March 2007
Andrew Thorns, Consultant in Palliative Medicine Pilgrims Hospice, Margate, Kent CT9 4AD Send response to journal: Re: There can be a better way	The story of Paula Newton's father is shocking and needs to be listened too and acted on (1). Within the NHS there are examples of wonderful practice at the end of people's lives. Too often they result from individuals who demonstrate the vital skills of compassion, understanding and practical wisdom rather than from the system in which they work. I have little doubt the NHS can provide a good death. The parent of one of our hospice nurses died in the local hospital and she felt the hospice could not have done any better. But it comes down to us as the professionals to look beyond the reflex reactions so sadly demonstrated in this case and put thought into the patient's needs and appropriate care. How different it all could have been. Perhaps a referral to a palliative care service, perhaps an agreed advance treatment plan, perhaps a GP or hospital doctor who could understand a patient's autonomous decision not to undergo further hospital "treatment" and instead to offer palliative measures at home as an effective alternative? 1.Newton P. A good death - but no thanks to the NHS. BMJ 2007;334:536 Competing interests: None declared
The nurse's bad day 13 March 2007
Diane-Marie Campbell, Emergency physician Itinerant Send response to journal: Re: The nurse's bad day	As a hospital patient last year - and unable to access some treatment modalities in the private sector - I experienced a number of the problems Dr Newton describes. Ms Young should not be so dismissive of the nurses' problems. Several times my bed was close to the nurses's station and I couldn't avoid overhearing conversations along the lines of "where's the afternoon shift?" "Two people off sick" "What are nursing admin doing?" ""What do you think?!" So on occasion there was lack of communication - because the handover time had been consumed by attempts to find someone available to work. It is greatly to the credit of the nurses that many would work unwanted "double" shifts rather than leave a ward dangerously understaffed. Sometimes the nurses had skipped lunch because the morning shift was busy, and they probably were hungry and tired before they even started the second shift, which would be busier than ever because they also missed the brief period of double staffing that usually enables the wards to catch up. That will be no solace to Dr Newton and to relatives in her position. But if this is the sort of problem behind the nurses' "bad day" then nothing but resourcing them properly is going to effect change. They are already giving more than we have any right to expect, the extra time and imagination Ms Young wants is not in unlimited supply. Even when the shift is normal, the nurse's time is needed by all the patients and from her point of view extra attention to one patient must come at the expense of less time with another; it is offensive and unreasonable to imply that all she needs is a "willingness" to provide more. Competing interests: None declared
Communication is the key 14 March 2007
Shyamali Griffiths, Medical SHO University Hospitals Coventry and Warwickshire NHS Trust, CV2 2DX, Anoushka Chelvendra Send response to journal: Re: Communication is the key	We read with interest the recent article in the BMJ – “A Good Death- but no thanks to the NHS” (1). We sympathise with Dr Newton regarding the care that her father received. We feel that there several ethical issues that need to be considered. Ethical principles feature heavily in undergraduate and junior doctors training. It is required that we as doctors acknowledge patient autonomy, beneficence, non-maleficence and equity (2). In doing so we endeavour to deliver the best possible care, whilst taking into account individual choice and respecting patients’ right to reach a decision about their treatment (3). In this way we aim to support and work in partnership with them. The remaining principles require that we reduce suffering, avoid doing harm and ensure that all patients are given the same consideration. However, we should appreciate that ethical values can sometimes conflict, producing a double effect with both positive and negative impact (4). As in this case admission for treatment of the abnormal potassium level was thought to be in the patients’ best interests (beneficence) but his initial wish to stay at home was not recognised (autonomy). In a report that analysed 16000 complaints sent to the commission of independent review over a two year period, 54% of grievances arose from issues regarding a dying relative. Contradictory or confusing information from different staff members was cited as a major issue (5). Good Medical Practice guidelines state that we must be considerate to relatives and others close to the patient. It is essential to be sensitive and responsive in providing information and support, including after a patient has died. It also states that good communication should include asking for and respecting patients’ views about their health, and responding to their concerns and preferences (3). In future, if these recommendations are considered before a “decision” to admit is made, then situations such as this may be avoided. REFERENCES 1.Paula Newton. A Good Death - but no thanks to the NHS. BMJ 2007;334:536 2.J. Woo & J Chan. Evidence-based medical practice: ethical considerations. HKMJ 1998:4:169-74 3.www.gmc-uk.org/guidance/good_medical_practice 4.Pierre Mallia. Biomedical Ethics : The basic principles. studentbmj.com/search/pdf/03/05/sbmj142.pdf 5.Susan Mayor. Care of dying patients and safety dominate report on NHS complaints. BMJ 2007;334:278 (10 February) Competing interests: None declared
Tariffs versus humanity in the NHS? 14 March 2007
Martin G Duerden, General Practitioner Meddygfa Gyffin, Conwy, North Wales, LL32 8LT Send response to journal: Re: Tariffs versus humanity in the NHS?	I have considerable sympathy for Paula Newton and a similar story to tell about the death of my father last year. My father was 78 years old and for more than 20 of the last years of his life had seen his mobility, and independence slowly eroded by multiple sclerosis (MS), but not his dignity. In the years prior to his admission he was largely bed bound, being barely able to stand and relying on carers for all aspects of everyday living. He developed a chest infection over Christmas but had strongly protested his desire to stay at home; this became impossible as pressure sores developed and even with intensive nursing support his condition deteriorated. Reluctantly he went into hospital. The first eleven weeks were spent in an acute medical ward. The doctors actively treated him with intravenous antibiotics, insulin infusions for diabetes and a nasogastric tube. Things got worse and he had ‘long-lines’ put into his deep veins as the veins on his arms became ulcerated; he had a chest drain inserted through his chest wall to treat his worsening chest infection. The emphasis was on ‘getting him better’ so he continued to receive unpleasant active intervention despite my remonstrations that palliative care was much more appropriate. His complex illness improved but he could not eat or look after himself: the ward was busy and he was in the wrong place. He became withdrawn and unresponsive, curled up in the foetal position. He could not eat and rejected the nasogastric tube so a percutaneous gastrostomy was performed. His pressure sores continued to get worse and he became confused. The last seven weeks were spent in a hospital which specialised in helping people with long-term debilitating illness. Here the staff actively treated him as a person not as a complex medical puzzle. He was washed and shaved caringly every day, he had a haircut and had his nails trimmed. He had a room which looked out over a garden and saw spring turn to summer. He was patiently given the type of food he was fond of. The staff sat with him and talked about his and their lives and his confusion lifted. His pressure sores started to heal. On Fathers Day many of his family visited him and he took a knowledgeable and active interest in the career development of his grandchildren. We cherish this memory as the next day he had a stroke and he died without regaining consciousness over the next four days. The staff let us stay with him while he was dying and looked after us. Both hospitals treated my father well but met different needs. The hospital which treats people with complex nursing and medical problems, and supports their carers, is now threatened with closure because funding is not available, and it is not a priority. We need a mix of medical models in the NHS but should not dispense with this type of care because targets and tariffs concentrate funding on the acute sector. Has the NHS lost its humanity? Competing interests: None declared
Let nurses work 15 March 2007
Phillip J. Colquitt, Technician/RN Independent Comment Send response to journal: Re: Let nurses work	Editor, The general reader of your journal may not be aware of procedures which may act to delay analgesia in a busy acute ward, in a way relevant to the account given by Newton[1]. Most of these very effective analgesics are narcotics and/or regulated as to their dispensing on wards, such that regardless how busy an individual RN might be, a second RN must countersign the log book to ensure that all doses are accounted for. These are drugs of abuse. Anyone can become addicted. Even staff. That is the idea operating behind the regulations. These checking procedures are often projected one step further by various employing institutions, by requiring each of the two RNs going to the bedside and ensuring the correct drug is given to the correct patient, and so on. This second step consumes time and resources, delays analgesia, is often ineffective at preventing errors, may actually promote error, and in my long experience the step reflects a crèche mentality wherein the older nurse “nurtures” the novice by pretending to be a novice herself[most nurses are “herselfs”] often. Why it is that normal individual adult responsibility which has dramatic safety implications such as that entailed in driving a car to work, can be achieved by nurses, yet when they enter the hospital grounds, they are required to regress to an earlier stage of development? Let nurses work. Let them do what they are capable of doing, and stop treating them like babies. [1] Newton P. A good death—but no thanks to the NHS. BMJ 2007;334:536 (10 March), doi:10.1136/bmj.39127.437998.59 Competing interests: None declared