I want to open this by saying that what follows is based on opinions, it is not representative of NHS policy at present. So please, bear this in mind when reading and replying.

I was sat in a meeting recently during which an accident and emergency consultant gave a presentation on a number of things of interest to GP practices. Towards the end of her piece she turned to the 'future' and presented an idea which whilst not new I'd be really interested to hear your views on.

It's used already in Australia amongst other places and it takes the form of some advanced care planning but has implications for us all.

The talk was on ceilings of care, a predetermined highest level of intervention by a medical team. It was presented as a grid which I'll struggle to replicate here but it had 4 categories on the x-axis and 4 on the y-axis.

On the y axis were 4 very broad definitions of levels of care:

1.Full invasive intervention and referral / transport to national centres of excellence. (Example is during the swine flu outbreak when some people were put on external ventilation to allow their lungs to recover)

2.Up to and including intensive care at the district general hospital.

3.Ward based care (but no further).

4.Care at home / residential or nursing home.

Onthe x axis were four very broad definitions of a person’s state of general health.

1.Normally very fit and well.

2.Some co-morbidity / chronic health conditions (COPD / diabetes / morbid obesityetc)

3.Generally poor health, multiple chronic illnesses and or co morbidities.

4.End of life / palliative care.

The plot showed how each level of care might be made available to people in each category and of course this would not be a decision taken lightly but in the presence of the patient / family / multi disciplinary team.

It's perhaps unsettling to think that a medical team will, based on your other conditions and general health predetermine at what point they're going to limit their intervention but it seems to be well backed up.

The crux of it was very simple: if, based on good science, your chances of meaningful survival with a good quality of life are high then the teams will move heaven and earth, however, if you were less likely to survive then you would be lower down the scale.

I'll endeavour to get the references for some of the information below when I'm not reliant only on my phone.

It's been shown recently that 63% of us will die in hospital, if you're male then that probability is even higher (females tend to live longer and are more likely to pass away in a residential home / nursing home etc). It's also been shown that for a chronically unwell elderly person, their chance of surviving a CPR attempt without brain damage is just under 2%. Compare that with an otherwise fit and well person whose long term survival chances are around 15% if the arrest is witnessed in a clinical setting and immediately resuscitated.

So, there's an opportunity for a decision to be made somewhere as to how far we want a medical team to go or, in fact, how far they should go in the knowledge of the above.

It's worth noting at this stage that CPR is violent, invasive and painful and not the sanitised process we see in films or on TV where after a few compressions the patient sits up, thanks the team for their help and goes about their day. Infact, the consultant likened her crash team to a 'pack of attack dogs' who pounce on a patient literally jumping on their chest so vigorously that cracking ribs isn’t unusual whilst others intubate, take arterial blood for gas analysis and so on. She asked if that was how the audience would like to spend their own last hour or indeed that of an elderly loved one. Would it not be better, more dignified perhaps, for that elderly relative to spend their final moments in the comfort of their own space maybe with their family nearby? If the discussion and decision had taken place before the crisis had occurred then would the family member know that the person didn't want an ambulance to be called and have two ambulance crew jumping on them followed by (and I use her words, not mine) a team of ED attack dogs?

People’s plans can and do change, especially in a crisis where the prospect of losing your own life or that of a loved one can have a significant impact on decision making ability; so, is having something like the chart I alluded to above in the open, for all to be aware of a bad thing?

Perhaps it is, or perhaps not? This is where I’m really interested to hear your views.

Noone knows how their future is going to play out, with regard to illness, accidents, heart attacks, strokes & so forth.

Yes there are those who do have a diagnosis, which come with a limited life span (as it were).

But it's not one that's set in stone, as it's usually a range of a time period.

Now I personally would like to think that those who work in Health Care, would do everything in their power to maintain a person's life.

I am sure we all to some degree or another have been in a position where a relative/friend is/has been seriously ill & you are looking to the Doctors to do whatever it takes to keep them alive.

I certainly would not like to think that just because (for instance) my Uncle Smith has chronic illnesses, he will only get given a certain amount of care, just because he was at the lower end of the scale, based on an axis of survival!

I personally feel, that no one has the right to be Judge & Jury over another's right to life & care.

That ultimately lies with the person, who if they so wish can write a DNR.

In the cases where the person can not communicate their needs/requirements, then yes the decision to continue giving care lies with their family. (A Doctor/s opinion is also considered here, but only so the family has all information to hand).

Which may or may not of been discussed beforehand with the person concerned, esp if the person was previously diagnosed with a life limiting illness, or as I said above, noone can predict if A person will have an accident/become ill & so forth.

It's not something anyone plans for.

I did have one of my Grandads (my Mums Dad) give up on his life after my Nan had died. We watched him over the following year turn in on himself & no amount of talking or coaxing would bring him back. It was not so nice to see & his last few weeks were spent in a Hospital where he curled himself into a ball & waited to die.

Now he was not actually ill, he had no diagnosis of any kind. It simply was his choice to give up & join his wife. Everyone concerned in his care did everything to maintain his life.

But it ultimately was his choice. He died 16 days after being in Hospital & nearly 1 year to the day my Nan died the year before.

Everyone treated him with respect & his care was no different to any other patients. As the Nurses would chat away to him as they changed his drips, cleaned him & changed his bedding. They were wonderful & were always on hand to talk to us & support us through my Grandads time with them.

He passed away peacefully with us by his side.

I then had my Dad's Mum become very seriously ill with intussusception at 75+ years old. It literally happened overnight & she had to have emergency surgery & was then placed in Intensive Care.

We were all called to come to the Hospital as she was not expected to live through the night.

The Doctors at this time stated that due to her age & the seriousness of her illness that they expected her to pass away.

Over 48 hours later, with us family members alternating being with her. My Nan was still alive. The Doctors spoke about infection (due to the bowel bursting contents inside her body) & quality of life. We listened but we decided as long as my Nan was breathing then there was no choice to make..

7 weeks later my Nan walked out of Hospital alive & very well. She continued to get well & she is now looking to her 88th Birthday on Christmas Eve. She suffered no ill effects or is even ill despite her age!!

My Nan is remarkable, although a bit crabby & she now has 2 great, great grandchildren.

Again her care was second to none & even though she was not expected to live, everyone involved maintained her life & treated her with respect.

Which is what I would expect with every person, no matter where on the axis given above they were.

As we do not know how one can survive a very serious incident but another does not. Although the level of care given can play a huge part. (esp where my Nan was concerned).

But isnt Everyone entitled to the same level of care & help no matter what?

I indeed say yes in my book, despite what any axis may say!

This is just my opinion based entirely on my own experiences so far....

Rainbow, it's great to read about your Nan, however crabby she might be!

Thank you for replying and thanks for raising the points you have, all of them are absolutely valid. So much of this crosses the line between personal beliefs and preferences about the importance of being alive.

Separating the science from the people is always challenging, the people we talk about are just that and have lives, families and others dependant upon them.

I agree, everyone is entitled to the same level of care, I think the consultant was really alluding to survivability and some people's preference to only be alive in relatively good health. We recently had two deaths in our family, my grandfather who eventually died from sepsis and a ischemic changes in the brain as a result of this that rendered him in an almost vegetative state. The decision was made amongst the family and medical team not to attempt resuscitation should he pass and, within a matter of days he did. A couple of weeks later we lost our daughter as an almost full-term still birth, again we had to look at this in the terms of how her life would have been had she survived. Horrible, difficult decisions for anyone to make but nontheless absolutely necessary.

The DNACPR form is a challenging issue but bear in mind that these are often clinical decisions, the family will of course be involved and their wishes considered.

I picked up on one thing you wrote: "It's not something anyone plans for."

That really interests me, it's the only inevitable thing about life and as the population ages I think it is something we should discuss, if only with our nearest and dearest. We're bombarded with adverts with Parkinson talking about 'Life Cover' for the over 50's and any funeral home will set up a plan for you but each of them, perhaps wilfully, avoids talking about the bit in the middle - actually dying. Having those around us aware of our own beliefs and preferences is absolutely key in my opinion - I know what my preferences are, if I'm that bad, let me go...

What you describe ThinkaboutIt has, in my jaundiced view, already been informally adopted by clinicians. They are already playing God, making decisions without consulting patient or family.

Medicine is a science, but not an exact one. I have good reason to doubt the ability, competence, honesty and integrity of the medics at my local hospital. Increasing pressure on beds, budgets and time (as if it isn't bad enough already) will just encourage even poorer decision making. To have this formally sanctioned using some kind of graph/scoring system just terrifies me.

Nobody has the right to judge another person's quality of life.

As always, it's about money - or lack of it.

I wonder how many people would sign up to this system (honestly explained) if it meant keeping the 'free at the point of need' service that we have now (sort of), against an insurance based one that promised no ceiling of care?

Surely this type of triage would be contradictory to the Hippocratic Oath ?

Surely this type of triage would be contradictory to the Hippocratic Oath ?

Show me a doctor who has sworn the Hippocratic Oath, then.

For the few that might have, do you expect them to comply with it fully?. If so, don't go to them with bladder stones .... Since part of the Hippocratic Oath is "I shall not cut for stone....."

Many Dr's will uphold the Declaration of Geneva (Physician's oath), even if not formally sworn, and in the UK a Registered Medical Practitioner has responsibilities as set out by the GMC, the foremost of which is "make the care of your patient the first concern".

Tell me, what percentage of emergency ITU admissions should survive?.

ITU beds are a limited resource. If 100% of emergent ITU admissions survive, they aren't taking sick enough patients, they are taking people too well many of whom would survive without ITU.

If 100% of emergent ITU admissions die : they are taking too many people who ITU can't help survive. Unless you are advocating a massive increase in staffed ITU beds there HAS to be some limiting of the precious resource to where it is appropriate.

If you say "well, have more ITU beds!" : it isn't just a matter of finance. If you want high quality care, those beds need ITU Drs and nurses, and it'll take time to train more, and more will be needed to open those extra ITU beds while maintaining quality of care.

So, in practical terms, ITU beds supply exceeds potential demand, and will do in the immediate future.

There is a scoring system called APACHE 2 : the 2nd version of the Acute Physiology and Chronic Health Evaluation scoring system that helps ITU Dr's decide : score too far at one end and it is unlikely even ITU will help you survive. Too far at the other end, and you'll likely survive regardless of if you go to ITU.

So, your relative is seriously ill. Do you want them to have that last ITU bed, or do you want it used on a fit and well 20 year old who doesn't really need it after their appendix operation?

Used on a 75-year old who never gets out of a chair, is on home oxygen because their lungs are so shot by chronic airways disease, and (who, if admitted to ITU will need to be on a ventilator), and will almost certainly if ventilated never get off the ventilator as this is part of the progression of their disease process?

I'm glad there are ITU Dr's who make the tough decisions, and both don't take people to ITU who dont need it, and decline people who ITU wouldn't help but would prolong their (and their families) suffering.

I don't think it is "playing God". The Almighty has chosen that those patients have the conditions they have, and the Dr's are trying to do the best they can, for the individuals and the population as a whole.

Suggesting that is against "The Hippocratic Oath" just makes me think you don't understand the situation, what those Dr's have to do to make best use of ITU, and what it means to "act in the patients best interest", which SOMETIMES means saying "no".

Whoops.. that's me told then !

Whoops.. that's me told then !

Well, you might disagree, and not want to explain why.

You might disagree and (want to, and) be able to explain why to the extent I "get told" and I change my viewpoint

Or, I might have persuaded you ........ hopefully by reasoned argument.

It is an emotive subject. Not everyone wants to make an 'advance directive', and sometimes families want "everything done" when that isn't what their relative would want or in their relative's best interest.

Equally there will be cases where against expectation people survive and a gloomy picture had been painted.

Even with APACHE2 and the like : it's not an exact science.

If the stats / evidence says "95% chance of death, even with full ITU care", that doesn't make someone 95% dead.

It just means that 100 ITU beds would be needed for 5 people to survive. It doesn't predict which 5 though!.

It doesn't tell you how many would survive without ITU (none? 1? 2?).

Do you use those 100 beds for people with a 5% chance of survival with ITU? 50% chance of survival with ITU?

What about the influence of the chances of survival without ITU.

I don't envy the people who have to make those decisions daily) & yes, I do know some of them)

I'm glad there are people who do make those decisions, and try their best to make the right decision based on the imprecise science.

I think the OP was trying to say "difficult subject, emotive topic, not everyone wants to talk about it", but that an open and honest discussion of the issues if people feel able to do so, is worthwhile.

It's not about survival rates in ITU, but that the medics should do everything possible to preserve life and heal. A percentage will die. That we accept (especially in ITU). A policy with ceilings of care suggests to me that they will decide on just how hard they'll work depending on the body in the bed. Too fat? Too bad!

You say it is not all about money Bazzas, but yet that is the axis on which everything turns. Beds, doctors, nurses, training, equipment. All require money.

Yes, people would still die (we all will eventually) if the purse was bottomless, but not because the doctor decided you were not worth the effort.

I'm confused about why, in your example, we should need to decide who gets the ITU bed. I would ask why is the fit 20 year old in ITU? Surely, he should be on another ward altogether. Isn't this bed management?

You are glad there are ITU doctors playing God? I'm not. I do not want to mock religion but I cannot accept that any spiritual body chooses people to have certain conditions.

Only a patient decides if he's 'had enough.' A close relative of mine did this and we respected that decision. Sadly we learned how useless palliative care and pain management (and every related service) were afterwards. In the event of the patient being incapable, the patient's family need to be consulted. Another of my relatives died because the doctors 'gave up' only for a pm to uncover the ghastly truth that they died from an easily treatable condition. I'll let the doctors have full control when they've cracked resurrection.

How trusting of you to believe that doctors are always acting in the patients' best interests.

Personally, I have asked my family to lob me off Beachy Head rather than take me to the local hospital. However, I reserve the right to change my mind. My decision.

It's not about survival rates in ITU, but that the medics should do everything possible to preserve life and heal.

It isn't always appropriate to "do everything possible".

It should be "everything possible that is appropriate"

A percentage will die. That we accept (especially in ITU). A policy with ceilings of care suggests to me that they will decide on just how hard they'll work depending on the body in the bed. Too fat? Too bad!

Why is the fat person being turned down then?

When does "so fat that they'll need to be ventilated, and never wean off the ventilator" become unacceptable : it is unacceptable when it is based on prejudice, rather than outcome. Look at smoking : there are some heart opd not given to smokers : not because of "let's punish the smokers" but because "there is no point, their health & survival isn't changed by the operation if they are still smoking".

If it is based on outcomes rather than personal prejudice : why is that wrong?

You say it is not all about money Bazzas, but yet that is the axis on which everything turns. Beds, doctors, nurses, training, equipment. All require money.

Yes, people would still die (we all will eventually) if the purse was bottomless, but not because the doctor decided you were not worth the effort.

There are still only so many beds (for your "effort" read "beds/ resources). It is about money : and you are right, it could be a bottomless pit.

Because unless spending is increased, more ITU beds means less of something else. So increase spending (more of those pesky "playing God" Dr's, eh?), but who is providing the care for those beds ; you can't "knit" new fully trained staff : it isn't as simple as "just open more beds".

I'm confused about why, in your example, we should need to decide who gets the ITU bed. I would ask why is the fit 20 year old in ITU? Surely, he should be on another ward altogether. Isn't this bed management?

Absolutely is bed management.

But you seem to be saying it is acceptable to refuse to take someone to ITU on the basis of "an ITU bed won't be of benefit to them, they are too well" but not acceptable to say "it won't be of benefit to them, they are too ill". Surely if one is acceptable so is the other?

You are glad there are ITU doctors playing God? I'm not. I do not want to mock religion but I cannot accept that any spiritual body chooses people to have certain conditions.

I never accepted that ITU Dr's are "playing God". Others believe so, but I was trying to show that they are humans making difficult decisions, not "playing God" (hence my use of quotation marks)

Only a patient decides if he's 'had enough.' A close relative of mine did this and we respected that decision. Sadly we learned how useless palliative care and pain management (and every related service) were afterwards.

Then improve those services too. However, that is a topic independent of "how to decide who gets an ITU bed"

In the event of the patient being incapable, the patient's family need to be consulted.

Consulted? Yes, if possible.

But the family can only assent, not consent.

Their wishes should be considered but aren't binding.

You also seem to believe families will have one opinion : what happens when one older brother says "must do everything", while the other says "they'd not want to be put through all that on ITU"?

You also seem to be saying "Dr's bad, family good", but families may have ulterior motives....

What of the family who want Gran gone, for her legacy?

What if the family who want "everything done" only because they can't accept the inevitable, so Grandpa dies an unnecessary slow lingering death?

Another of my relatives died because the doctors 'gave up' only for a pm to uncover the ghastly truth that they died from an easily treatable condition. I'll let the doctors have full control when they've cracked resurrection.

1) I don't think Dr's have "full control". Part of the OP's point is to suggest people discuss these issues before the emergency occurs, precisely so people's wishes can be considered / respected

2) I don't think Dr's "play God". At least, any that do are likely to be reported (at least, by those Dr's I know who make those decisions!)

Part of being human is fallability : so mistakes will be made.

That isn't the same as saying "mistakes should be TOLERATED" : I'm not saying that.

However, mistakes will happen

How trusting of you to believe that doctors are always acting in the patients' best interests.

I don't. I just don't believe that all Dr's are charlatans who always have an ulterior motive.

Root out the incompetent and uncaring.

There will still be a majority left who are doing the best they can for their patients.

Personally, I have asked my family to lob me off Beachy Head rather than take me to the local hospital. However, I reserve the right to change my mind. My decision.

Due to my own experiences, I believe Care giving or maintaining A person's life should not be based on costs, statistics or survival rates!

It should be entirely based on needs at the given time. If A B C are required to keep someone alive then do it.

Which is what exactly happened to my Nan. She was rushed into Hospital as an emergency case due to intussusception. Due to her age & her bowel bursting open she would have been placed at the lowest end of a survival axis. (If one was being used).

No one expected her to survive this serious illness, let alone the operation.

But she did.

We were told she wouldn't last the night in ICU, which is why we all went up to say our goodbyes.

But she did.

As I stated previously she walked out of there 7 weeks later with no ill effects.

We thought of it as a miracle at the time, as the Dr's repeatedly told us "she would not survive" due to her age & the intussusception being as serious as it was.

They did in fact speak to us about turning the machines off, that helped keep her alive & even gave a time frame for doing so.

But my Nan was still breathing on her own, it was the only thing she could do for herself.

Don't get me wrong her internal organs were packing up & she had to have intensive, intrusive treatment & she had so many machines around her, we hadn't a clue what was doing what for her.

So we as a family agreed that as long as she carried on breathing for herself, we would not be making "the call" as it were.

No one we spoke to on the ICU dept expected her to live.

But she did!

Due to my own experiences, I fully agree that A person's life should be saved each & every time, as no one can say 100% definitively what the out come will be.

No Dr could explain why my Nan survived, but others that had gone before her hadn't.

Sure it had a lot to do with the treatment & care they gave my Nan. As without it she would have died.

My Nan is nearly 88 & she has 5 generations of her family around her. Sure she's crabby & can be demanding but that's okay, as she's still with us today.

That for us as a family means more than anything, as it would to any family who has gone through such a critical illness & came out the other end.

Saving a life should not be based on costs, statistics or a survival axis.

Neither should it be based on age or health conditions.

As no one has the right to say who can or can't survive.

But let's look at the other side where costs, statistics & survival rates are taken into consideration.

In an Hospital A&E dept; (An example of which there are many, many countless others).

person A age 80 & person B age 12 have both come in critically ill.

Both are in urgent need of an operation & an ICU bed to help them survive.

The Dr's by using their "axis" state that person B has a higher survival rate, the costs involved will be cheaper & statistics say person B has better odds than person A.

The Dr's wouldn't know anything about either persons life & their call is based on their survivability/costs axis.

Yet their families do, as we all have our own unique life experiences & they do count for them.

So why should the 80 year old who say fought for their country during the War, led a meaningful life & paid his NI & taxes be left to die?

Or why should Drs favour a 12 year old who as yet is too young to have made their mark on the world & had an meaningful life yet?

Why would one life be worth saving, more than the other?

As both families will be looking to the Dr's to save their family member no matter what, as we all would do in their place.

It's not right for either to be left to die in favour of the other, as both could possibly survive IF the care & treatment is given to them both.

Will being fat, thin, smoker, non smoker, alcoholic, drug dependant, depressed, healthy, not healthy, male, female, young, old, right handed, left handed & so forth count for you or against you in a critical illness situation?

Are there any right/wrong answers?

Where do we draw the line?

Statistics at the end of the day are based on probabilities that cannot actually 100% predict the outcome of any critical life event.

Which is why I will always say no matter what, you treat everyone the same regardless. As noone can truly predict who will survive a critical illness/accident but another will not.

Sure we can listen as Drs hazard a guess or form an opinion, as the Dr's did with my Nan.

But they were wrong!

For that I am extremely happy!

Due to my own experiences, I believe Care giving or maintaining A person's life should not be based on costs, statistics or survival rates!

 

It should be entirely based on needs at the given time. If A B C are required to keep someone alive then do it.

 

Which is what exactly happened to my Nan. She was rushed into Hospital as an emergency case due to intussusception. Due to her age & her bowel bursting open she would have been placed at the lowest end of a survival axis. (If one was being used).

 

No one expected her to survive this serious illness, let alone the operation.

 

But she did.

 

We were told she wouldn't last the night in ICU, which is why we all went up to say our goodbyes.

 

But she did.

 

As I stated previously she walked out of there 7 weeks later with no ill effects.

 

We thought of it as a miracle at the time, as the Dr's repeatedly told us "she would not survive" due to her age & the intussusception being as serious as it was.

 

They did in fact speak to us about turning the machines off, that helped keep her alive & even gave a time frame for doing so.

 

But my Nan was still breathing on her own, it was the only thing she could do for herself.

 

Don't get me wrong her internal organs were packing up & she had to have intensive, intrusive treatment & she had so many machines around her, we hadn't a clue what was doing what for her.

 

So we as a family agreed that as long as she carried on breathing for herself, we would not be making "the call" as it were.

 

No one we spoke to on the ICU dept expected her to live.

 

But she did!

 

Due to my own experiences, I fully agree that A person's life should be saved each & every time, as no one can say 100% definitively what the out come will be.

 

No Dr could explain why my Nan survived, but others that had gone before her hadn't.

 

Sure it had a lot to do with the treatment & care they gave my Nan. As without it she would have died.

 

My Nan is nearly 88 & she has 5 generations of her family around her. Sure she's crabby & can be demanding but that's okay, as she's still with us today.

 

That for us as a family means more than anything, as it would to any family who has gone through such a critical illness & came out the other end.

 

Saving a life should not be based on costs, statistics or a survival axis.

 

Neither should it be based on age or health conditions.

 

As no one has the right to say who can or can't survive.

 

But let's look at the other side where costs, statistics & survival rates are taken into consideration.

 

In an Hospital A&E dept; (An example of which there are many, many countless others).

 

person A age 80 & person B age 12 have both come in critically ill.

 

Both are in urgent need of an operation & an ICU bed to help them survive.

 

The Dr's by using their "axis" state that person B has a higher survival rate, the costs involved will be cheaper & statistics say person B has better odds than person A.

 

The Dr's wouldn't know anything about either persons life & their call is based on their survivability/costs axis.

 

Yet their families do, as we all have our own unique life experiences & they do count for them.

 

So why should the 80 year old who say fought for their country during the War, led a meaningful life & paid his NI & taxes be left to die?

 

Or why should Drs favour a 12 year old who as yet is too young to have made their mark on the world & had an meaningful life yet?

 

Why would one life be worth saving, more than the other?

 

As both families will be looking to the Dr's to save their family member no matter what, as we all would do in their place.

 

It's not right for either to be left to die in favour of the other, as both could possibly survive IF the care & treatment is given to them both.

 

Will being fat, thin, smoker, non smoker, alcoholic, drug dependant, depressed, healthy, not healthy, male, female, young, old, right handed, left handed & so forth count for you or against you in a critical illness situation?

 

Are there any right/wrong answers?

 

Where do we draw the line?

 

Statistics at the end of the day are based on probabilities that cannot actually 100% predict the outcome of any critical life event.

 

Which is why I will always say no matter what, you treat everyone the same regardless. As noone can truly predict who will survive a critical illness/accident but another will not.

 

Sure we can listen as Drs hazard a guess or form an opinion, as the Dr's did with my Nan.

 

But they were wrong!

 

For that I am extremely happy!

I don't disagree in theory with anything you have said.

It is just, until people pay way more to fund the NHS or the government's spending is dramatically changed : in real life those decisions have to be made, as resources are limited.

I don't disagree in theory with anything you have said.

 

It is just, until people pay way more to fund the NHS or the government's spending is dramatically changed : in real life those decisions have to be made, as resources are limited.

Is it more money that is required though ? Or just better management. I am not saying get loads more administrators/accountants, because that to me appears to be one of the problems.

Why hire on loads of agency staff at extortionate prices when they could have a bank of nurses who are more than happy to work either part time or whenever there is an extra need !

Drug wastage within the NHS is horrendous - how much could they save by not having a pill for every ill. Why not educate end users of the NHS that they don't just go to their GP or Accident and Emergency with a cough, cold or minor cut ?

If they are going to triage at the more serious end of the business, how come George Best was given a liver because he had abused his own. He then went on to abuse a gift that had been donated to him at the expense of someone who most likely would have appreciated it more.

Is it more money that is required though ? Or just better management. I am not saying get loads more administrators/accountants, because that to me appears to be one of the problems.

 

Why hire on loads of agency staff at extortionate prices when they could have a bank of nurses who are more than happy to work either part time or whenever there is an extra need !

 

Drug wastage within the NHS is horrendous - how much could they save by not having a pill for every ill. Why not educate end users of the NHS that they don't just go to their GP or Accident and Emergency with a cough, cold or minor cut ?

 

If they are going to triage at the more serious end of the business, how come George Best was given a liver because he had abused his own. He then went on to abuse a gift that had been donated to him at the expense of someone who most likely would have appreciated it more.

Years upon years of "efficiency savings" have taken their toll.

Why use agency staff/ locums?

Because the substantive posts have been whittled down to bare minimums, with no slack in the system.

Bank work is great for when the interest of the bank staff and hospital coincide, but when the staff give up the benefits of a substantive contract, some will need to replace that with the pay advantages of working as agency staff.

I agree re: drug wastage - but given the years of trying to cut down on wastage, it's not an easy fix.

Look at trying to educate people not to use A&E unless it is an emergency, and to educate people that the Ambulance services aren't taxi services ..... Same message over many years but still inappropriately used.

As for George Best : they shouldn't discriminate against people based on if their liver failure is due to "avoidable misuse" or "non-fault illness". However, I agree that transplant organs should be prioritised to those who won't abuse them.

No discrimination based on why the original disease occurred, but I don't see "decision based on predictable outcome" being discrimination .....

First of all, Bazzas, may I wish you a happy New Year.

Now back to business.

It isn't always appropriate to "do everything possible".

It should be "everything possible that is appropriate"

That's what troubles me. Who decides 'appropriate' and what is that decision based upon?

Why is the fat person being turned down then?

When does "so fat that they'll need to be ventilated, and never wean off the ventilator" become unacceptable : it is unacceptable when it is based on prejudice, rather than outcome. Look at smoking : there are some heart opd not given to smokers : not because of "let's punish the smokers" but because "there is no point, their health & survival isn't changed by the operation if they are still smoking".

Well, I think a fat person should be treated the same as any other person. How can you know beyond doubt that this sample patient will need to be ventilated and never weaned off that ventilator? If we were all seers and could forsee the outcome then that would be fine, but, as has been said, medicine is not an exact science and there is no such thing, in my opinion, as an expert.

If it is based on outcomes rather than personal prejudice : why is that wrong?

We are all prejudiced in some way; it is part of our make-up. My experience is that when groups of medics gather (and it will be the same in other professions) there is a tendency for confirmation bias. What is needed is more self-doubt, the confidence to express an opinion and the humility to listen to others (and that obviously includes the patient and their loved-ones).

There are still only so many beds (for your "effort" read "beds/ resources). It is about money : and you are right, it could be a bottomless pit.

Because unless spending is increased, more ITU beds means less of something else. So increase spending (more of those pesky "playing God" Dr's, eh?), but who is providing the care for those beds ; you can't "knit" new fully trained staff : it isn't as simple as "just open more beds".

Well, although I do believe the axis is money, I do not think that we should continually throw cash at the NHS. It is inefficient, like so many public bodies. The politicians do not have the guts to tackle the problem and the culture within the NHS (and elsewhere) is implacable. All of us will oppose change where we are not in control of it unless, of course, it is skillfully 'sold' to us. I have said for a long time now that we need to train our own doctors and nurses (which I appreciate takes a long time and much money) rather than bringing them in from abroad - but I would 'lock' them into the NHS for a long time.

Absolutely is bed management.

But you seem to be saying it is acceptable to refuse to take someone to ITU on the basis of "an ITU bed won't be of benefit to them, they are too well" but not acceptable to say "it won't be of benefit to them, they are too ill". Surely if one is acceptable so is the other?

Your response here continues to confuse me. If somebody is extremely ill and requires intensive treatment then they should be in ITU. If they are not and are recuperating after an operation, presumably doing well, why are they taking up a bed in ITU? I'm not suggesting we move the patient to the car-park. I'm hoping that there are other wards in the hospital that are capable of monitoring a patient and have the wit to spot if he's deteriorating.

I never accepted that ITU Dr's are "playing God". Others believe so, but I was trying to show that they are humans making difficult decisions, not "playing God" (hence my use of quotation marks)

My issue was with your comment "The Almighty has chosen that those patients have the conditions they have..." This may be your view, but it is not mine.

Consulted? Yes, if possible.

But the family can only assent, not consent.

Their wishes should be considered but aren't binding.

I translate this as the medics will accept your wishes as long as it chimes with theirs.

You also seem to believe families will have one opinion : what happens when one older brother says "must do everything", while the other says "they'd not want to be put through all that on ITU"?

 

You also seem to be saying "Dr's bad, family good", but families may have ulterior motives....

What of the family who want Gran gone, for her legacy?

What if the family who want "everything done" only because they can't accept the inevitable, so Grandpa dies an unnecessary slow lingering death?

Good point. However, if the objective is to preserve life and heal, this should never be an issue. If other services (like palliative care) were effective in this country then nobody need suffer a lingering death.

I haven't approached this topic as only being about ITU, but about care in general. Patients die on all wards.

1) I don't think Dr's have "full control". Part of the OP's point is to suggest people discuss these issues before the emergency occurs, precisely so people's wishes can be considered / respected

2) I don't think Dr's "play God". At least, any that do are likely to be reported (at least, by those Dr's I know who make those decisions!)

Part of being human is fallability : so mistakes will be made.

That isn't the same as saying "mistakes should be TOLERATED" : I'm not saying that.

However, mistakes will happen

I recall a long time ago listening to a radio program about a person (a woman, I think) who had some kind of crippling arthritis that left her increasingly immobile and in constant, worsening pain. She wrote a living will stating her wish, if circumstances presented, not to be resuscitated. Her situation deteriorated and she took an overdose and was taken to hospital. My memory is a bit vague, but the doctors did save her even though they were made aware of the living will via a family member. Some time later, back home and now given effective pain management, she was glad that the medics had ignored her wishes. She changed her mind. I suppose what I am trying to say is that we all think we know what we want or how we'll react in theory, but the practice can be quite different.

I accept mistakes can occur, but if a group of people (a medical team) are collaborating in making those mistakes I would question their skill, competenence and judgement. There doesn't seem to be a will to confront errors or poor care, but more a circle the wagons approach. Transparency and routing out the bad apples seems to be beyond the hospitals or regulatory bodies. And so it repeats.

I don't. I just don't believe that all Dr's are charlatans who always have an ulterior motive.

Root out the incompetent and uncaring.

There will still be a majority left who are doing the best they can for their patients.

Charlatans is a little strong. Clearly the quacks are in the minority. However, I go back to my earlier comment about humility. Arrogance kills. I know it.