Monday, November 19, 2007

Blood On The Tracks

Common sense...

I think we do our best to frighten people out of it. Or are people just afraid of being responsible for their own decisions?

I think a lot depends on the back up they expect to get from their colleagues, or professional body. Or how used they are to making independent decisions. Thus, I expect doctors to be able to make, and justify, their own decisions, even if these run contrary to "usual practice", or "protocol", or "guidelines".

Nurses and Ambos are reluctant to do so. Because they can't? I'm not sure; I'm certain their training is less about the synthesis of a plan based on the available info, than about responding in a set way to pre-defined parameters, but I'm also pretty sure they get bugger all support if they step out of line, even if it's to do the 'right thing'.

An example, which also goes to my post about dignity.

An elderly lady is discovered collapsed in bed at her nursing home. She appears to have had a stroke. She had been physically disabled by a previous stroke, but her mental faculties were in fine fettle. She had previously expressed a firm desire not to be resuscitated in the event of physical deterioration; in fact she had left written instructions expressing her desire not to go to hospital in such an event. These instructions had been communicated to her daughter, who was in complete agreement.

So, when she is found, what happens? An ambulance is called, obviously. Was this right? Was it wrong? Could the GP not have come out?

Either way, when the Ambulance arrives the situation is made clear to them. But, the written request for non-transport is not countersigned. The patient's daughter is present, and re-iterates her mother's wishes.

This is apparently not enough, so into hospital she comes

My assessment was of an intra-cranial catastrophe of such magnitude as to be unsurvivable; intervention might preserve life, but not in a way she would have wanted, as far as I can see. I discussed this with her daughter, and the home. We agreed she would want to be in familiar surroundings, and arranged for transfer back there, priming her GP as to what had happened.

Was I wrong? I can't be certain of my diagnosis, but I can be pretty sure. This was not a response to something easily correctable, the resolution of which would have returned her to her old self.

Should she have come to hospital? I don't think so. The primary reason she did was to cover the Ambos. Is this their fault then? Of course not. If their organisation does not support free thinking, they have no choice.

Is it anyone's fault? I'm not sure. The system failed, despite all this patient's best efforts, she almost did not get the end she wanted.

Now, I know that the whole area around resuscitation, and 'living wills' is hugely contentious, but surely there's still a bit of room for us to use our common sense? Or are we to become so afriad of criticism, of litigation, that medicine will become a series of giant algorithms, with no room for indepndent thought?

Medicine is an art, and art is sometimes ambiguous.


Chrysalis Angel said...

I didn't know you were back. It's so good to see you posting again!

These situations are awful. All I know get all those papers in order, have a power of attorney in place, and have paper work to pass to the ambulance personnel. I don't know as that's even enough.

I'm so glad you were able to let her go home, where she wanted to be.

RoseAG said...

I am glad your lady got her wish. Hospitals aren't such great places.

If you see her say hello she might be in Tangier
She left here last early spring is living there I hear
Say for me that I'm all right though things get kind of slow
She might think that I've forgotten her don't tell her it isn't so.