Advanced directives needed. Choice in death and dying. Lord Darzi warns of “draconian rationing”. GPs need to be involved at the interface of oncology and palliative care.

I personally have made an advanced directive. (You can find it on this site) My family know what I would like, and it is clear. It is also clear who and how has to make the decisions in the absence of my wife. A friend and colleague was in his late 80s and an “event” happened leaving him incapacitated and in pain. He had multiple health problems, but his mind was sound. Full mental capacity entitled him to determine his own future, and he chose to stay at home, with pain relief, and without a diagnosis. He died 2 days later, and the death certificate reads “pneumonia” because that’s what happens when you lie still. The “old man’s friend” as it used to be called. Lord Darzi is right, and Lord Howard of Lympne commends him. I respect my friend’s decision, and laud his bravery. He died at home, surrounded by family, without prolonged distress, over investigation or overtreatment, and it was his choice. Even the “Non-terminally ill seek right to die” (Sarah-Kate Templeton and Becky Barrow in The Times 9th October 2016)

Apart from old age and multiple morbidity, one of the greatest areas for saving is at the interface between oncology and palliative care. Oncologists may hold onto patients too long, and it could help to have a GP attached to both teams and encourage appropriate transfers.

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A letter in the Times 3rd October expresses my friend’s feelings:

Sir, Lord Darzi’s article is timely. We octogenarians and nonagenarians should be given a choice, when we have such multiple chronic conditions and functional disabilities. Some may tolerate a form of highly restricted independent life, but many of us would rather be allowed to die with dignity, before our lives become an intolerable burden.

Gillian Chipperfield
London SE3

Lord Darzi in “We need to keep high-cost patients out of hospital” on the 30th September opines in the Times:

The NHS finds itself increasingly trapped between soaring demand and squeezed budgets. Health leaders warn of “draconian rationing”, chronic understaffing and hospitals on the brink of collapse. Savings must be made. But are we looking in the right place for them?

This week it was reported that some patients are facing waits of up to 15 months for cataract operations. Yet cataract surgery is cheap and highly effective.

A survey of 1,000 doctors last week found seven out of ten said they had witnessed restrictions on NHS treatments. They cited breast reduction, varicose vein removal, IVF, and the excision of benign lumps and bumps, but these account for a tiny proportion of spending.

When looking for savings, instead of restricting minor activities that yield little, it makes sense to focus on the costliest patients and the costliest treatments. Figures from the US show that 5 per cent of hospital patients account for 50 per cent of health spending. In the UK, a study in one NHS trust found that 3 per cent of patients accounted for 45 per cent of expenditure. David Blumenthal, president of the Commonwealth Fund, said in a lecture to the Institute of Global Health Innovation this week that these figures were likely to be true across the world.

These high-need, high-cost patients are typically older, with multiple chronic conditions and at least one functional disability, such as an inability to dress or feed themselves or manage their affairs. Patients with three chronic conditions and one functional disability cost 400 per cent more than the average. Their numbers are increasing as the population ages.

This is where we should be putting our efforts — designing high-quality, low-cost interventions to keep these patients out of hospital and living independently. One example is the “Call and Check” scheme in Jersey which uses postmen to deliver prescriptions and link elderly people with other services.

There are good humanitarian reasons for doing so, too. Given their frequent contact with the NHS and multiple treatments, these patients are much more vulnerable to things going wrong. Improving the performance of the NHS will require improving care for those who need it most, not those who need it least.


Lord Darzi is a surgeon and director of the Institute of Global Health Innovation at Imperial College London

An advanced directive or living will – It’s important to specify, especially lying flat. Good news if you take action.

Don’t get old and frail – if you can avoid it – in our covertly post-code rationed services

About time too – Doctors ponder ending ban on assisted dying

Live longer with dementia: Mr Hunt pillories the profession. Most doctors will be making “living wills” to avoid over-zealous care and prolonged demented lives…

Who will write the obituary for UK General Practice? Will you know the doctor looking after you when you die?

Do not resuscitate’ is doctors’ own choice for end-of-life care – but perish the thought to educate patients!

The Nursing home crisis is upon us. There is not enough space or money for everyone.

Dead people don’t vote… End-of-life care ‘deeply concerning’

Local government grants cut to charities which are health related – The pretence that there is no rationing has to be ended, before meaningful debate and cultural change can begin.

Death discussions ‘taboo’ for many in UK, survey finds

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This entry was posted in A Personal View, Rationing, Stories in the Media on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

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