Observations Life and Death

Do not sit on the bed

BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c1478 (Published 17 March 2010) Cite this as: BMJ 2010;340:c1478
  1. Iona Heath, general practitioner, London
  1. iona.heath22{at}yahoo.co.uk

    Rules that mostly diminish rather than enhance the joys of life have no place in hospitals, where joy is too often in short supply

    Still trying to come to terms with the widespread banning of flowers from hospital wards (BMJ 2009;339:b5406, doi:10.1136/bmj.b5406), I learnt recently from senior nursing colleagues that sitting on a patient’s bed, by either visitors or clinicians, is now also prohibited, apparently in the interests of infection control. A quick internet search of “sitting on the bed” and “infection control” produces a huge list of leaflets from a variety of hospital trusts across the country, from Northumberland to Cornwall, each reinforcing the prohibition. My immediate reaction is to thank all my lucky stars that I have been able to spend my career in general practice, where flowers are still welcome and sitting on the patient’s bed positively encouraged.

    Doctors should never be discouraged from sitting, because patients consistently estimate that they have been given more time when the doctor sits down rather than stands. Standing makes the conversation seem hurried even when it is not; and, in the hospital setting, sitting on the chair does not seem to work nearly as well, because the levels are somehow all wrong. Some of the most intimate and effective interactions between doctor and patient that I have either witnessed or experienced have occurred while the doctor has been sitting on the patient’s bed. Such interactions are precious and should be made easier rather than more difficult.

    This ban on sitting on the bed seems to be imposed without exception even for patients who are known to be dying. How and why has this happened? Infection control is clearly a subset of “health and safety” but needs to guard against taking on too much of its rhetoric and public face, which is increasingly characterised by its lack of humanity, common sense, and even humour. I can find no mention of either flowers or sitting on beds in the “epic2” national guidelines on preventing healthcare associated infections in hospitals in England, so the default presumption must be that there is no hard evidence for either of these demeaning prohibitions. There seems to be something very strange going on. Is it all in the interests of being seen to be doing something very noticeable about the worrying levels of hospital based infections, however ineffective and otherwise disruptive? Is this some sort of virtual cleanliness—an illusion of activity with no substance? What is the framework of pressures and constraints under which infection control staff have to work?

    Too many patients report that the technological care in hospital is excellent but that the human dimension of care is often lacking. There is much talk about bringing care closer to home in the design of health services, and this is intended to keep patients away from hospitals as much as possible, which will always be a good thing because they are both expensive and dangerous places. But providing hospital treatments at home and even arranging outpatient functions in local clinics are likely to prove at least as expensive as existing services. The ever increasing subspecialisation of expertise, with a progressive narrowing of the range of skills and with performance being related to the numbers of procedures performed across this narrow range, means that the trend to centralisation seems set to continue despite the good intention of trying to reverse it. And whatever the eventual outcome of this policy paradox, many people still need the levels of care and skill and technological intervention that only hospitals can provide—and so perhaps we need to be looking at bringing care closer to home in a different sense, by bringing back elements of home into hospitals and by enforcing rules only when clear evidence exists to justify the erosion of any sense of homeliness that results.

    Home means familiarity of both surroundings and people. Patients could be encouraged to bring tokens of home into hospital rather than actively discouraged. In his great poem “The Building,” Philip Larkin describes a hospital as being “curiously neutral” with “homes and names suddenly in abeyance.” What can we do to make this less true? In the same poem Larkin found hospital flowers “wasteful, weak, propitiatory,” but I am certain that he would not have thought their prohibition an advance. Familiar faces are an essential element of home, and yet continuity of the familiar is less and less evident on hospital wards as staff are distributed on the basis of maximising efficiency at the expense of any other virtue. One of my patients lost the will to live over a long bank holiday weekend, when each new shift brought new faces, each of whom required him to recount his frightening story all over again. Such an experience is the very opposite of home and is dehumanising not only for patients but also for staff.

    So can we not campaign for home within hospital and encourage flowers and sitting on the bed and every other informality, unless there is robust evidence to deter us? “Do not sit on the bed” and “No flowers” are injunctions that are all too similar to “Do not walk on the grass” and “No ball games” rules that mostly diminish the joys of life rather than enhance them, and such rules, unless absolutely necessary, have no place in hospitals, where joy is too often in short supply.

    Notes

    Cite this as: BMJ 2010;340:c1478