The care of Doctors, and their ability and time to care needs to improve. So does continuity of care…. This is not the work of one leader, or one health minister, although it is tempting to allocate blame.
Iona Heath (Back to the future – Iona Heath BMJ 2018.writes a seminal and thoughtful essay:
Her last paragraph is worth reproducing, but before this she regrets the ending of continuity, and acknowledges the relative inefficiency of new pharma and technologies, Private Finance Initiatives, the conflict between the needs of society (populations) and individuals, and the need to reinstate teams that care for their patients, and for each other. She indirectly challenges the “free at the point of access” philosophy, pointing out that prescription charges and other co-payments are already in place (In England). She avoids talking about the merging of heath (free) and social care (means tested) and co-payments. She also fails to look at other systems, but her intent is clear. Look again at what we used to do well – before it’s too late.
….Things that should change
We all, professionals, patients, citizens and policymakers, need much more recognition of the limits of medicine and the intrinsic uncertainties of its practice. Applying general scientific truths to individuals will always have unpredictable results and, however sophisticated (and expensive) our technology becomes, all of us will sooner or later get sick and die. There is far too much false certainty in our simplistic descriptions of cause and effect and, when things go wrong, this makes it much easier to blame clinicians struggling to do their best at the frontline of care.
The longstanding democratic deficit within the planning, organisation, and regulation of the NHS needs to be acknowledged and tackled, perhaps through a system of elected regional government, in parallel with the devolved national governments. The deficit is in no way resolved by the current system of appointing the great and the good to the boards of NHS bodies and creating patient participation groups, however dedicated and worthy, because none of the participants are in any way accountable to a wider electorate.
So, let’s hold onto the best, change with more caution and care, and celebrate the NHS at 70.
Adrian O’ Dowd reports: Doctors need to improve their conversations with dying patients, says RCP – BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4330 (Published 19 October 2018) Cite this as: BMJ 2018;363:k4330
Doctors need to speak to patients with terminal illnesses in a timelier way and handle conversations with greater compassion and confidence, says a report from the Royal College of Physicians.1
The report, which examined why clinicians find it difficult to talk to patients about death, found that some doctors thought that death could be perceived as a failure and that modern medicine was expected to cure all ailments. However, evidence from patients and carers indicated that many people wanted to talk about death and that planning helped them feel more empowered about their care and decision making.
Almost half of all deaths in the UK are estimated to occur in hospital, and many patients admitted to hospital are in their last year of life. The college said it believed it was essential for doctors and other professionals to have the knowledge and skills to undertake sensitive conversations at an appropriate time when patients were ready.
The report was based on conversations with doctors at all levels, patients and carers, and medical organisations.
A range of clinicians from medical students to consultants said that they were uncomfortable about initiating conversations about the future with patients. Students and junior doctors had little practice with real patients and said that training did not prioritise the “soft” skills they needed.
Other barriers to talking about death included confusion over whether hospital doctors or GPs should be having the conversation, workforce pressures, lack of privacy, lack of prioritised time for conversations, and the need to be sensitive to different cultural and religious beliefs.
One key issue identified by the report was that healthcare professionals needed to begin conversations about planning for care at the end of life care nearer to when patients are given a terminal diagnosis. Early conversations give patients more choice and control over the remainder of their lives.
The evidence showed that patients who had these conversations and had care plans put in place had a better experience than those for whom the conversations came in the final days or hours of life.
The authors offer solutions and resources to help build clinicians’ compassion and confidence in this area of care and detail four case studies of hospitals that lead the way in supporting conversations about care at the end of life. The report highlighted the University Hospitals Bristol supportive and palliative care team for its Poor Prognosis Letter Project, a scheme that has enabled local GPs to identify patients approaching death more easily and earlier, so they can start discussing end of life care.
The Royal College of Physicians’ president, Andrew Goddard, said, “This report is a big step forward in helping patients, relatives, and doctors to talk honestly about death and dying.
“We must minimise the barriers in our systems and culture that prevent this happening. This is not just about palliative care in the final days but about having a series of conversations much earlier after a terminal diagnosis.”