Tuesday, 23 August 2011

The rise in NHS bureaucracy even stops you dying at your anointed time.

We are sure that a few of our fellow GPs and district nursing colleagues will have noticed the emergence of the DNR form. DNR form? Well it stands for Do Not Resuscitate form which has made its appearance as an additional passport now needed by the dying patient from NHS bureaucrats to speed up their navigation on their final NHS journey.

Imagine as the on call doctor in your average NHS GP’s consulting room you are happily practising a few putts on your golf simulator with your three 96 inch plasma screen 3Ds displays and surround sound when there is a knock on your door that distracts you from winning the last US Masters with your expert putt after years of practice while on call.

In walks 37 stone of experienced cream cake eating and work avoiding district nurse commissar Kristina Brinklocova whose proud boast is that she always puts paperwork first. This former Eastern European chocolate putter then thrusts a DNR form in front of your face and drawing herself up to her full 4 foot 6 inches of honed work avoiding lard while making her once every 3 monthly appearance at ND Central as a new modern matron of remotely hosted district nursing service says sign this.

Not that we are easily intimidated here at ND Central but when your only defence between being crushed to death is a golf putter then discretion is sometimes the better part of valour (thanks Dr Z).

You then read the mountain of paperwork that is a DNR form and see that Ernest Thistlewaite age 65 who your friendly local oncologist has given odds of he will not last to the end of the month as most of his lungs and body organs have been replaced by small cell lung cancer and was, and is still, a 60 a day smoker whose sole nutritional support is alcohol is, until you sign otherwise, to be resuscitated in the event of any preterminal cardio-respiratory arrest.

He is being given the privileged of going AWOL from death and avoiding CPR even though death is seriously on his case despite the nurse commissar whose response time in the event of a code blue would be hours, just to assume a vertical posture from lying down.

The DNR is yet another sign of the paperwork generating NHS for unless one is signed, given to the district nurses, relatives of the patient, Police, Ambulance and Fire services, local boy scouts and local girl guides together with the local Women’s Institutes then anyone unfortunate enough to be on a very short haul flight to meet the Grim Reaper may have their stay in the departure lounge extended by all of the above jumping up and down on their chest for no useful purpose other than protocol.

Not so long ago GPs and district nurses worked together. They knew and discussed patients together and with their relatives and if a patient was about to die we discussed the issue of dying and CPR and if appropriate we agreed when we would/would not. The out of hours services were also informed so instead of dispatching life saving paramedics a death confirming doctor would be sent.

We would call this death with dignity. No unnecessary heroics just an unassuming passage into the after life with minimal bureaucracy in the here and now.

For reasons better known to those with less experience than us it appears that all punters are for resuscitation at all costs unless a DNR is signed. An interesting point that isn’t it? Patients have by implication given their consent to CPR even if they are dying from incurable diseases and have NEVER been asked? Remember "no descision about me without me"?

Who is worthy of resuscitation? Well as all comrades are equal in the NHS then obviously everyone is regardless of their physical condition even Ernest whose body is being painfully eaten away by a cancer that no-one can do anything for. If Ernest stops breathing or loses a pulse should all the stops be pulled out to resuscitate Ernest back to life so that he can continue to live out his remaining life in pain with no hope of remission unless the parole board give him a DNR?

Well over the years we have worked with doctors who would happily gone into a graveyard to dig up corpses to practice resuscitation on. This is an example where common sense used to prevail but not now the bureaucrats have taken over. It is now “policy” dictated by “protocol” that means that regardless of any patient’s medical condition being assessed individually people should be resuscitated by NHS corporate policy. You cannot die with NHS care although you may often die because of it.

The thought that the application of military triage principles be applied clearly frightens some. After all who would be able in today’s NHS to fathom out those who will not survive, those that will survive with treatment and those that need no immediate treatment? An article in this week’s BMJ highlighted the default position being that of resuscitate without any thought except in certain instances such as “rigor mortis, decapitation, decomposition or dependant lividity”.

We like that last one how many UK sixth formers doing General Studies A level grade U or E- or below soon to be next week’s elite NHS managers would know what “dependant lividity” meant? Is it an Excel Word or on Facebook thingy? Perhaps some others like doubly incontinent, demented, not moved for years after multiple stokes with pressure sores or dying of something incurable should be added to the list? And can it get worse?

Yes it can! For any DNR order now has a review date, an excellent increase in totally pointless bureaucracy and multiple form signing.

So let us return to Ernest whose life has got even shorter since we last mentioned his name by a disease over which we have no power to defeat. If you were a thinking person and were asked to complete the DNR for him you would think that the review date is postponed indefinitely but oh no Matron will not allow more than a few days grace in case something changes. If it does and he gets cured we promise we will ring the Pope but a review date get real?

At this point anyone with intelligence will have lost the will to live or be suffering a cerebral haemorrhage of some description as a result of repeated banging of a head against a wall. Can it get worse? Yes it can for before these worthless pieces of paper came along we were sent letters saying how much “effort” had gone into devising these pieces of soiled lavatory paper. Lots of words like “consultation”, “partners” “co-operation” “inter agency working” but how come no-one told, or asked, the grunts on the ground?

Praise be the Party whose concern to provide first world medicine for patients is always trumped by its desire to add more paperwork in order to evidence its patient centred activity. When Ernest dies there will not just be a death certificate and a hopefully dignified pain free death to justify his well taxed self abusing life style there will also be a DNR audit and quality care paper trial available to justify Matron’s huge girth.

Why make things simple that work when you can have NHS care? The morons are well and truly in charge. We must away to read the next protocol and avoid patient care as a result.

And no doubt Matron will get through some chockys and cake while doing more essential DNR forms and ignoring the morphine. One involves meaningless paperwork the other involves hands on patient care. Which is most important?


Doctor Zorro said...

Excellent post. Once upon a time not only did you and your district nurses talk to each other, you would also have known some of your consultant colleagues in the hospital.

JW said...

From an ambulance service perspective, the presence of a DNR is extremely helpful. You must remember that relatives panic and dial 999 when someone dies, even if it is expected - and often no one has told then death is imminent despite the various professionals involved knowing it to be so.

So an ambulance turns up and discovers Ernest in arrest. We know nothing about Ernest and his wife doesn't know much either about his history. We may well suspect it is futile to resus him, but what would you have us do? Say "well he's a bit of a fatty/clearly smokes too much/drinks too much, let's not bother"? We can't do that, from the Coroner downwards that's not a defensible position.

So a DNR properly written and logged with Ambulance Control is in the best interests of the patient. it may seem silly to you, but you're not u one trying to decide whether to resus someone you have never met, on your own, at 3 am surrounded by screaming relatives.

HyperCRYPTICal said...

This is indeed a complex issue.

Several years ago I contacted my (long deceased) mums GP as I wished that she not be resuscitated in the event of her natural death in the throes of end-stage dementia. As she had not completed a ‘living will’ I was informed that this could not be so and that her life retained some ‘quality’ – it didn’t – but I did understand that the GPs hands were tied, so to speak.

As a nurse it is my duty to perform CPR – for if I don’t I will be struck off – on those that cease breathing in the care home I work in if a DNR is not in place. Oh how I hate the thought of this (CPR) as for some as I regard it as an assault on the dead. Why oh why should Mrs. Miggins not be allowed to die naturally, when it is her time?

That said who am I to decide who lives or dies? Who am I to decide whose life retains ‘quality’ and thus should be (at least) attempted to save? I don’t know. I can make a judgement based on my knowledge of a patient – but do I have a right to make this judgement? I do not wish to be the final arbiter, yet at the same time do not wish to crack Mrs. Miggins ribs in a futile gesture.

I also hate how death is being neatly packaged up in protocols, tick box exercises in an effort to save NHS cash. Why is it acceptable (in these tick box exercises) for forty-five yr old Fred with dementia who is deemed as lacking capacity to be suddenly deemed to have capacity in signing a DNR, thus tying up loose strings? Fred does not understand that he is signing his own death warrant.

This Pulse article explains the dilemma to all. Soon, to meet cash saving protocols, Mrs. Tettly – the tea lady will be able to approve a DNR.

As far as I am aware, dying at your anointed time as always been a bone of contention and placing a DNR is a method of tying up loose ends – yet I find it worrying. Death is being so neatly being packaged up and there is no get out clause.

Anna :o]

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