Why should relatives accept being treated as suspects if nurses are not ?
Why should relatives accept being treated as suspects if nurses are not ?
I sent a question to a GPs' organisation a few months ago, and I've just received a response. The response includes this, which I will comment on after showing it:
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'A colleague described a patient scenario around this recently - 93 yrs old lady, lives on her own. Family lives nearby. No pressing health issues. GP usually visits once a year, generally to give her a 'flu jab and general check-up'. Her daughter calls round each day. She is found dead in bed one Tuesday morning. The GP hadn't seen her for several months. The GP went out to see her to confirm death. There were no suspicious circumstances when the GP arrived. This was discussed with the coroner who agreed to issue a certificate with cause of death as old age.
This scenario could have gone many ways. The GP could have refused to issue a certificate and she would have been removed for a coroner's post mortem. If this was a weekend, then the Out Of Hours would have sent the Police around in lieu of the coroner's officer.
From the experience of our Senior Clinical Advisor in this area, the Police are often not best trained to handle these situations and their presence is often quite intimidating for relatives.'
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Now, I agree with all of that - but, I am more bothered by this variation of it:
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'A colleague described a patient scenario around this recently - 93 yrs old lady, who shares a home with her daughter. No pressing health issues. GP usually visits once a year, generally to give her a 'flu jab and general check-up'. Her daughter finds her dead in bed one Tuesday morning. The GP hadn't seen her for several months. The GP was not quickly available to attend the death.
This scenario could have gone many ways. The GP could have refused to issue a certificate (if the GP subsequently did attend) and she would have been removed for a coroner's post mortem. If this was a weekend, then the Out Of Hours would have sent the Police around in lieu of the coroner's officer.
From the experience of our Senior Clinical Advisor in this area, the Police are often not best trained to handle these situations and their presence is often quite intimidating for relatives.'
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In my scenario, there is not a GP to attend and to either phone the coroner to discuss the death, or to talk to any coroner's officer who attends (and it isn't necessarily attendance by police or a coroner's officer: my mother died on a Friday morning, and police and a coroner's officer turned up - but, crucially, not the GP who gone on holiday to Europe).
This 93 yrs old lady, has probably 'just died suddenly - quite a lot of old people do that'.
Once the police become involved, they definitely 'tend towards treating the death as suspicious, until certification is certain' - and certification cannot be certain, in my scenario.
This is what winds me up - as I pointed out recently to another doctor during an e-mail discussion:
If an elderly patient 'dies suddenly' at home, you tend to have police involvement, and the police tend to 'interrogate' the live-with relatives. This leads to worse, and stronger, memories of the death, for those relatives.
If a clinically identical elderly patient 'dies suddenly' in hospital, I feel sure that the police are not summoned to the hospital to 'interrogate' the nurses on the ward.
Neither death can be 'certified without some investigation [into its cause] and/or discussion with the coroner' - but the deaths are essentially identical.
SO HOW COME THE RELATIVES ARE TREATED AS SUSPECTS BUT THE NURSES ARE NOT ?
The GPs' organisation also suggested:
'The ultimate decision about what happens to someone's body when they die rests with the Coroner - this is perhaps where you could also take your points. However, we are sympathetic to your concerns.'
Well, I WOULD LOVE TO - but I've tried to discuss this with both my local coroner (who originally said I should discuss it with the NHS {disingenuous !} - subsequently, he changed to the simpler position of just refusing to discuss it with me) and 'nationally': CORONERS REFUSE TO DISCUSS IT (at least, they refuse to discuss it with me !). Most CCGs - if they reply - tend to say 'you need to discuss this with Community Services ['Community Services' in essence means 'with district nurses']' which is similarly unhelpful, because district nurses FOLLOW 'community death policies' but they do not DESIGN those policies (in so far as those policies are 'designed', it is the GPs and the local coroner who essentially control them).
And the GPs' organisation also told me:
'There is always a duty of care to the individual to consider i.e. ensuring that a willful act against the person has not taken place and we are not covering up wrongdoing.'
Well, 'duty' is interesting.
Suppose that my terminally-diagnosed father, with whom I am sharing a home, explains to me one evening that he definitely would not want resuscitation (CPR) to be attempted, if his heart stops beating. He has got a meeting scheduled at the GP's surgery the next afternoon, to discuss some test results, and we decide to 'sort out this refusal of future CPR' with the GP at that meeting.
What happens, if my dad collapses the following morning, before the meeting with the GP, and I suspect he has arrested (is 'in CPA') - SURELY I HAVE A DUTY TO PREVENT ATTEMPTED CPR ? But, I need to call 999 - I'm not a clinician, and my dad might be collapsed but not in arrest: if I don't call 999, and he recovers 'to continue living but with clinical damage which could have been prevented by treatment' neither he nor I would want that damage to have occurred - THIS IS A TOTAL MESS.
It isn't as simple as 'phone 999 and explain to them, what your dad explained to you' - see below !!!
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I sent a survey to various NHS Trusts ca 2010, and the answers I received (I only got 8 replies) are not exactly consistent with patient autonomy being the top-ranking principle - in particular, the answer from the GP of 'He should do what his father asked him to do' is the one I agree with, whereas the answers from nurses 1 and 4 'are reflective of the problem I have with current mindsets/behaviour'.
SCENARIO: 'Father and Son'
A father is living at home, with only one family carer, who is his son. This is supposed to be an EoLC situation, so the father is expected to die within at most a year (determined, I assume, by divination). The father has been seeing his GP and is, therefore, 'sort of aware' of treatment options and outcomes.
The father has not refused CPR, and is not considered to be sufficiently 'near death' for his death to be considered 'expected', or for a 'clinical' (i.e. for CPR to be predicted to fail) DNAR order to be in place: so there cannot be a DNAR 'Instruction' in place. The expectations for a CPA could range from 'unlikely' to 'almost sufficiently likely, for the situation to be an 'expected death''. The father is in some sort of discomfort, which he considers to be severe. Either pain, or something else, such as struggling to breathe. This could be either continuous or episodic in nature.
One evening, the father initiates a conversation with 'Son, I'm really struggling here. I really can't put up with this. Would it upset you, if I'm just allowed to die, if you think I have stopped breathing?'. It could end with 'We'll sort this out with the GP tomorrow, but if I die before then, don't phone 999'.
Q1 What 'should' the son do, if he thinks his dad has stopped breathing, before anyone else has been told of the conversation?
Q2 As Q1, but with 'should' replaced with 'would' (in other words, Q1 is asking for your opinion of the 'theoretically and morally correct' behavior - by contrast, Q2 is asking you for an opinion, as to how you think 'sons' would actually behave in that situation).
COMMENT: this scenario leaves open the question of whether, if the son lets his dad die in peace and then afterwards calls out the GP, the GP would certify the death: but I can see no reason why patients and their relatives should be aware of post-mortem procedures.
Answers to Q1
GP: He should do what his father asked him to do.
Consultant Doctor: Wait and call GP later to certify the death
Paramedic no 1: Preferably make a quick note in care package AND/OR do not call 999.
Paramedic no 2: Respect father's wishes, in the event and contact and discuss with GP ASAP, call 999.
Nurse no 1: If an Advance Decision to Refuse Treatment (ADRT) has not been made and the father has not verbalized his wishes to a professional involved in his care then the son would have to call 999 as his conversation with his father has not been witnessed and not evidenced as "in his best interests"
Nurse no 2: respect his fathers wishes and not phone 999
Nurse no 3: Either ask his father to document his wishes in some form, or if possible contact the out of hours GP, and see if that would be an appropriate course of action
Nurse no 4: He should dial 999 as there is nothing formal that acknowledges his dads wishes. If he does nothing he will be in trouble as it will be classed as neglect also dad may have been having a bad day and if resuscitated may go on to live the rest of his life pain free, with dignity and in control by completing an advanced directive.
Answers to Q2
GP: I think some would and others wouldn't.
Consultant Doctor: As for 1.
Paramedic no 1: Most people will call GP/District Nurse/Macmillan Nurse for advice, and invariably be told to call 999.
Paramedic no 2: Respect his wishes, not call 999 but still contact GP for advice.
Nurse no 1: From my experience most would call 999 because of the moral and ethically duty not to let someone they loved die with an attempt to save their life. The son has to live the rest of their lives with the knowledge that if they didn't act "what if" and can severely affect their grief process unless they felt the action produced more good than harm (their father would be at peace rather than suffering).
Nurse no 2: As above.
Nurse no 3: He will probably ring 999, having recently done some teaching about end of life with the local ambulance service, this is a situation which arises on a regular basis
Nurse no 4: I think the son would dial 999 as he would want his dad to have every chance at life, also he may panic at seeing his dad die. This nurse also wrote the following, after my 'comment': 'You cannot assume that dad dies in peace, also there could be guilt at the "what if" as dad may be successfully resuscitated and have time to put his affairs in order and see family before he dies.'
Details of the Respondents
I1 Which PCT covers your working area?
I2 What is your role (District Nurse, GP, Paramedic etc)?
I3 How much experience do you have in your role?
I4 Have you undertaken any specialist training which is influencing your answers?
I5 Does your local PCT allow suitably trained nurses to verify 'expected' deaths?
GP: NHS Rotherham, GP, 24 years. 14 = yes, and 15 = yes.
Consultant Doctor: NHS Medway, Consultant in Palliative Medicine, 27 years. 14 = yes, 15 = Yes - after training and if expected death.
Paramedic no 1: Wirral, Paramedic, lots. 14 = no, 15 = no. (please see note below).
Paramedic no 2: Wirral, Paramedic, 19 years. 14 = no, 15 = no.
Nurse no 1: NHS Gloucestershire, EoLC Facilitator, 26 years of nursing (4 years Community Nursing (DN), 11 years Specialist Palliative Care, 5 years GSF/EoLC project work. 14 = Yes - palliative care degree, DN qualification, Masters module in health and social care, 15 = Yes as part of an EoLC Study Day.
Nurse no 2: NHS Gloucestershire, End of Life Care Education Facilitator, Medical nursing background, more recently in last 2 years specifically in end of life care education - care homes and community. 14 = diploma in palliative care, 15 = yes.
Nurse no 3: University Hospitals of Leicester. Palliative Care, Liverpool Care Pathway Facilitator/Macmillan Sister, 5 years. 14 = Completed the OU Death and Dying course, 15 = Not that I am aware of.
Nurse no 4: NHS Rotherham, Commissioning Manager (Registered Nurse), 28 years in NHS. 14 = yes, and 15 = yes.