Sunday, 27 April 2014

Liverpool Care Pathway - The Dangling Conversation...

Studies have demonstrated death to be a key focus of the day to day business of hospitals...

The dangling conversation...
Yes, we speak of things that matter
With words that must be said:
"Can analysis be worthwhile?"
"Is the theater really dead?"
- Paul Simon
And do we speak in homonyms...?
The phone rings. It is 2am. It is a young voice, the voice of a man. He confirms who I am.
“We need to talk about resuscitation...”
He is talking about my brother...
“If anything happens, we’ll be jumping on him and all sorts of things; it wouldn’t be very nice.”
“As a medical person, you always do everything you can...”
“You want us to use CPR?”
The conversation peters out.
Jane Ellison responded to Mr Nicholas Brown at Question Time that permission is not required to slap a DNR on a patient’s file...
This is Hansard –
A decision not to attempt cardiopulmonary resuscitation (CPR), like other decisions not to attempt a particular form of medical treatment, does not require the patient's consent. However, as with all clinical decisions, healthcare staff are expected to be able to explain and defend their decisions to their employing authorities and their professional regulatory bodies.
They do not require our permission but they may want it.
The phone rings half-way through another busy working morning. It is a young voice, the voice of a woman. She confirms who I am.
“We need to talk about resuscitation...”
She is talking about my brother...
“Can you come in today to speak to the registrar? It is important you have a discussion about resuscitation.”
“It is important we have a discussion about the infection J*** has picked up.”
There is a space of silence.
In 2011/12, of the more than 32,000 discharges from Ontario’s long-term care facilities, almost half left in body bags. This is Palliative Care: Research and Treatment from Libertas Academia –

The average age of LTC residents in this study was 84.5 years, and about 70% were female residents. Results showed that residents admitted from home were less likely to have a DNR order on file during assessment and three months later. Residents whose families were responsible for care were more likely to have DNR orders when admitted, but this effect was not found at three-month follow-up.

When family members are responsible for care, it appears that a DNR order is more likely to be in place. What may we infer or construe from this...? This has implication and consequence.
The factors that influence whether residents have DNR orders on file upon admission depend on the presence of family members, whether the residents are designated as end-of-life cases (six months or less), older age, and health. Discussions about resuscitation are an important part of care plans.
Silence is a space, vacant, waiting to be filled...
“This is a hospital-acquired infection...”
Another space intervenes.
“J*** is in a side room. I have been told he’s been vomiting. I am required to don gloves and apron to go in the room. Have the results come back...?”
“If you  will come in...”
“When is J*** going back to the nursing home? The sooner he’s removed from the source of infection, the better.”
“My registrar has asked me to talk to you about resuscitation.”
“You just want to slap a DNR in J***’s file. I need to discuss how J*** has contracted this infection.”
There is another pause. “I don’t know...”
Thankfully, there is inconsistency in their stance and in their attitude to CPR and DNR orders. This is a clear indicator that the arrogant Death Cult which struts brashly through hospital ward, into care home and surgery consulting room, audacious, presumptuous and insolent, has not yet won the day. We are still only halfway there.

This is the Liverpool Echo –
A Liverpool nurse who failed to perform CPR on a nursing home resident who later died will have to be supervised while he works  for the next 12 months.
Joseph Imathiu was brought before the Nursing and Midwifery Council accused of misconduct over the incident which happened at Wavertree Nursing Home in March 2012.
Imathiu told the panel he was unable to complete CPR (cardiopulmonary resuscitation)  while he was on the bed as the bed was “sagging” and a hard surface was needed.
The hearing was told Imathiu asked two healthcare assistants (HCAs) to place him on the floor and as they were doing so left the room to call for an ambulance.
Imathiu told the panel he had intended to perform CPR when he came back but almost immediately after he had returned to the room the paramedics had arrived and were doing CPR.
Imathiu said one of the HCAs could not have called for the ambulance as they were “inexperienced”. After the paramedics had performed CPR unsuccessfully for 25 minutes the elderly man was pronounced dead.
Imathu, a nurse with 30 years experience under his belt, only had to present the ‘Lakhani Defence’ as just cause not to perform CPR.

In performing CPR, success is slim; Imathu was permitting this elderly gentleman “a naturally dignified death because he was a dignified person”. This is the 'Lakhani Defence'. Imathu was only following the Lakhani Recommendations.

And, clearly, the Nursing Home was being remiss in not putting Care Plans in place. Discussions about resuscitation are an important part of care plans.

The conversation dangled...
“You do know J**** has an infection?
“Then, I need to speak to someone who does know. You’re a member of your registrar’s team and you don’t know?”
“We need to discuss resuscitation. Will you be in today to speak to the registrar?”
“Yes, I’ll be in. Will you be there?”
“I may be...”
I am on the ward. There is no-one about. Outside the side room, I am ready to don apron and gloves. I look through the open door.There is an elderly patient in the room in J***’s place. She does not look up; she is preoccupied about some matter. I am becoming concerned.
I look in the next room. No, not there, either...
Here, Katie Morales raises some serious ethical issues in an article which discusses the Lazarus Phenomenon. This is...
the delayed return of spontaneous circulation (ROSC) after cessation of cardiopulmonary resuscitation (CPR). In other words, coming back to life after being pronounced dead. And it can be the root of an ethical issue in nursing.
Walter Williams, an elderly Mississippi man “died” at his home. His hospice nurse called the coroner, who arrived and declared him dead.

At the funeral home, as workers were preparing to embalm him, he started to move. The very next day he was well enough to talk with his family.

This was in February of this year. Mr. Williams subsequently died in mid-March.

Katie Morales writes in Nurse Together -
The Mississippi man was a hospice patient. Many hospice patients are DNRs (do not resuscitate). This brings another curious wrinkle, a potential ethical issue in nursing. Was it even appropriate for the funeral home to call an ambulance?
Although not common, healthcare workers have been sued for wrongful life after successfully resuscitating patients with DNR orders in place. In 2011, a Colorado inmate sued the prison for performing life-saving measures. In 2013, a Florida woman sued a hospital and nursing home after medics successfully revived her mother despite a do not resuscitate order.
Another consideration is if patients with DNRs have implanted pacemakers/defibrillators in them, such as the Mississippi man. The device will fire when appropriate, despite physicians’ orders or patient’s wishes to the contrary.
In the case of the Mississippi man, if he had been without a pulse or oxygen for this period of time, he surely would have suffered brain damage. However, reports state that he was awake and talking.
Mr. Williams had been fitted with an internal defibrillator (ICD). This, of itself, raises ethical questions in the matter of withdrawing or denying treatment.

At Mid Cheshire, they have replaced their PIG (Prognostic Indicator Guide) with the EPAIGE (Electronic Prognostic Assessment & Information Guide for End of life care). Wee Bee Long and her dying people alliance might well learn a thing or three from these people. Great strides have been made since the days of the Barton Method aka The Surprise Question.

Modern ICDs act as pacemakers and defibrillators. Here is discussed deactivation of ICDs with the use of a magnet... 

If you require deactivation of an ICD urgently outside office hours, a magnet is available from Macclesfield CCU. This can be strapped to the chest using adhesive tape over the implant site.
 Further reading -
Liverpool Care Pathway - Catch Up EoLC

 Nurse Together continues -
Also, despite having an internal defibrillator, it is unlikely he went from an unshockable rhythm (asystole) to a shockable rhythm (ventricular tachycardia or ventricular fibrillation). This begs the following questions: 
  • Was this man ever really without a pulse and not breathing?
  • How did the hospice nurse determine the man was dead?
  • Did the nurse auscultate heart sounds or merely feel for a peripheral pulse?
At Mid Cheshire, thankfully, they can recognise when a patient is in the last days and hours of life. Otherwise disablement or deactivation of an Implantable cardioverter defibrillator (ICD) might be a death sentence.
I’m back at the nurses’ station. There is a lone nurse at the desk. “Can you tell me where J*** is please? He was in that room just there.” I indicate in the direction of the room.
She pauses, rifles through some documents. A puzzled look adorns her face.
“I think he is gone...”
Another nurse returns to the station from some duty which had kept her.
The first nurse looks up from her ponderings. “Do you know where J*** is?”
The second nurse muses. “J*** is gone I think.”
Neither nurse is certain. There appears no paperwork to paper chase J***’s whereabouts.
I am perplexed. “He’s gone back to the nursing home...? I spoke to a doctor on the phone just this morning.”
A face peeps out through a door. It is a young, fresh-faced man in a check shirt, seated in a chair. “I think he’s gone to G**** Ward, just next door.”
He acknowledges our confusion and beams with pleasure he is able to assist. “Yes, I wondered where he’d gone myself...”
Katie Morales writes -
Peripheral pulses can be hard to palpate in critical patients. As a Georgia nurse, I cannot legally pronounce patients dead. I can determine there is no pulse and respirations.
To accurately pronounce a patient dead, however, one must examine the patient. Following standard emergency assessment protocols, gently call the patient’s name as you rub the patient’s face or chest to determine unresponsiveness by trying to arouse the patient. Next, look, listen, and feel for the presence of a pulse and respirations. Auscultate heart sounds and palpate for a carotid pulse and check for pupillary light reflex.
The absence of all of these indicates the patient is dead. The time of the exam is noted as the time of death.
I have to believe these cases are rare. For it to be otherwise is simply unthinkable and reminiscent of a Robin Cook novel. We must never forget how fragile life is as we tend those entrusted to our care.
Life is fragile and life is precious.
“I understand J**** has been moved here from B***** Ward...?” I am on G***** Ward speaking to a nurse at her station. She directs me to Room 3.
J**** is in a larger room with none of the prior restrictions on entry. He is on a sodium lactate (Hartmann’s Solution) drip and oxygen. I notice he has a fluid restriction of 1500ml. There is no monitor, however. There is no-one about to ask about the infection.
A nurse appears outside with a dispensing trolley. She looks at the chart and obliges my request for information by telling me that J**** is still on antibiotics. These will continue for a few days. They will look for markers to see if these are taking effect. She knows nothing  of the phone call today.
Katie Morales concludes her article with a question: Do nurses have the right to pronounce a patient dead?

May doctors, likewise, pronounce a patient to be dying and then act upon that decision by withdrawing or withholding treatment that makes that end that more certain?

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