Tim,
I think your last sentence, your "PS" is the most important. My get out of
jail card is always to the relatives: "if Margeret could tell us what she
wanted would she want to be comfortable in her nursing home or would she
want us to investigate her in the hospital for the cause of her 'collapse',
'dizziness', 'vomiting' etc whatever. Most relatives confidently and
reliably advocate appropriately.
What we need is an openess in advance as Tim has declared:
"Welcome to St Overthehills, we hope you will be very happy happy here and
we will do our very best to look after all your needs and wishes. Now, we
would like to check a few things with you:
Do you like milk in your tea ?
What type of music do you like ?
If you collapse do you want to go to hospital ?
Would you like visitors at any time ?
Where would you like to die if you have a terminal illness ?
Are there any videos you would like us to show frequently ?
Can you eat meat ?
etc etc
Its not exactly a self directed DNR or an advanced directive but it helps
people make decisions. In the presence of; spoken about and declared
wishes, wouldnt it be easier for the nursing home nurse to nurse a patient
with a termnal event instead of exposing him/her to the 'must do something'
junior doctor in and after an ED ?
Cant you imagine the ocnversation between Margaret and Frank:
"Frank is that you darling ? you look great" "Margaret what took you so
long I've been waiting 30 years for you up here, how was it down there ?"
Well dear it was'n to bad actually. Well, not until the last bloody 2
weeks. You know Barbara and James coud'nt cope with my collapses and funny
ways so they put me in this lovely place "St Overthehills". Quite nice
actually, you may remembe it. They built it on the old Tudor estate. I had
my own room, comfortable bed, hell they even played the Beatles and the Bee
Gees, remembwr our facourite song ? Well about 2 weeks ago they plucked me
from my bed because I had a temperature and quite frankly I didnt want to be
disturbed and didnt feel like eating. Of course for the last 2 years since
my last stroke I havent been able to tell them anything. Well they called
an ambulance. Jesus, this bloke was the first chap to stick needles in me,
three in all and then they took me to 'A&E', did you know they call it the
'ED' now ? Some kid younger than Nicola, oh you never met her, another
grand daughter, stuck more needles in me. They left me on this hard trolley
for hours. I was soaked. They never changed me. I could go on but darling
it was the most miserable 2 weeks of my life. I wont go on about the final
few days, it would only disturb you, suffice to say its so good to see you
again. But if I could only go back and tell them how to do it
differently............
Think of it when the next ambulance rolls around the corner.........
John Ryan
----- Original Message -----
From: "Coats Tim - Professor of Emergency Medicine"
<[log in to unmask]>
To: <[log in to unmask]>
Sent: Friday, June 14, 2013 3:16 PM
Subject: Re: Attendances and GPs
With estimates ranging from 0% to 50% responses to my question show very
different impressions about how many admitted patients could be looked after
in the community. I wonder if the explanation is that there is more
variation between our ED patient populations than might be obvious. Some
Departments seem to see lots of elderly patients who are sick and need
admission, whereas others seem to see lots of elderly patients who are not
sick and could be dealt with in the community. As they will all just be
classified as 'majors' there may be an important variation in case mix that
we are not at present capturing.
I also sense that there is also a difference in views on the desirability of
higher level medical intervention in elderly patients - should we be
admitting an elderly, dementia suffering, bed bound, nursing home patient
with pneumonia for iv fluids / antibiotics, or should we be aiming to
deliver a 'good death' in the community. 'Appropriateness' of hospital
admission will depend on our belief about best care of the patient. This is
a social rather than a medical decision, but society is not having the
debate.
This has been a useful conversation for me - I don't think that I had really
appreciated the variation in case mix between EDs. It may be that we need
several solutions rather than one!
Tim.
PS. If any of the younger members of the list end up treating me when I am
elderly, demented, bed bound and have pneumonia - please don't give me the
iv fluids and antibiotics.
------------------------------------
Prof. Timothy Coats
Professor of Emergency Medicine,
University of Leicester, UK
0116 252 3263
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Matthew Dunn
Sent: 13 June 2013 13:59
To: [log in to unmask]
Subject: Re: Attendances and GPs
> I profoundly disagree that most elderly patients need ED management. We
> might THINK they do, but that doesn't make it true. There is certainly
> a place for easy access OPD assessment, but ED???
>
I think the problem is that you have elderly patients who are at high risk
of dying within the next few weeks and that risk of dying within the next
few weeks can be reduced substantially by medical intervention. That doesn't
mean you'll necessarily be prolonging their life by more than a few months.
However, these are high risk patients who by a particular endpoint stand to
benefit from ED treatment. The question is whether that endpoint is
appropriate, but to an extent that is a decision for the patient.
>
> Here's the mindset of an experienced GP (or enlightened younger GP):
> "This person has chronic unwellness, or worried wellness, or advanced
> age. Based on my clinical impression, emergency secondary care is
> unlikely to find a cause or cure, even though they might make me, the
> patient and the family feel something is being done. Now, how can I
> help with your symptoms?"
>
That is indeed the input that GPs can have: assess the patient's chronic
condition; discuss matters with the patient; give them an open and honest
view of their likely prognosis and how this may or may not be modified by
medical intervention; and in discussion with the patient decide on what is
appropriate care in the event of deterioration or new acute illness.
However, the time for that assessment and discussion is not when the patient
has deteriorated or developed that new acute illness; it is while the
patient is relatively stable.
Matt
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