Tag Archives: Hospital

Those who go; those who stay

A large proportion of my life is spent within the walls of the hospitals of North East London. But when I’m not at work, I can often be found in one of London’s fantastic art galleries. Art is essential for my personal wellbeing, and a great way to dissociate myself from the trials and tribulations of being a doctor.

But every so often these two worlds collide.

Those who go

A few years ago I went to an exhibition at the Tate Modern on Futurism. It was a fantastic exhibition, highlighting a brief but incredibly influential period of modern art. I was profoundly struck by a specific piece: a tryptych by Umberto Boccioni entitled “Farewells; Those who go; Those who stay,” now on view at the Museum of Modern Art in New York. Not only is it beautiful, but the artist effectively captures the emotions inherent in farewells. It has stayed with me ever since. I was reminded of this piece recently after a particularly emotional on call shift.

I was having a long overdue cup of tea and updating the patient list when the screech of the arrest bleep demanded my attention. I rushed to the appropriate ward and arrived in time to see the patient lose output. The team got to work quickly switching from BLS to ALS, and we attached the defibrillator to see what no arrest team wants to see: PEA, a non-shockable rhythm. After a rapid intubation and several cycles of good quality continuous chest compressions with appropriate drugs given, the rhythm remained PEA. The arterial blood gas showed no reversible causes and several poor prognostic indicators. From the information we had available we concluded the patient had died and was not coming back and we stopped attempting to resuscitate them.

There is always a strange moment at the end of an unsuccessful resuscitation as the cohesive, united team, at one within the all-consuming emergency, shifts; and becomes, once again, a group of individuals. Each one takes a deep breath, psychologically removes themselves from the situation and walks away to continue with their shift.

As I took my own deep breath and stepped outside the curtains, I became aware of the patients and relatives in the bay. I had been preparing myself to speak to the patient’s own family and explain what had happened, but I had not considered the effect on those who had just witnessed the death of a fellow patient, behind the mysterious veil of the blue curtain.

Those who stay

Those who stay

Whilst we acknowledge the loss of “Those who go” I wonder if we provide enough support for ‘Those who stay’. On this occasion, after talking to the family directly affected by the death I went to speak to each patient and relative in the bay and tried to offer some comfort and reassurance. They had many questions, and I was not able to answer them all due to confidentiality. But it did open up the opportunity to talk about life and death. It led to a particular patient expressing his worries about his own diagnosis, and the opportunity for me to clarify the information we had available on his prognosis.

Talking to the patients and relatives who witness a cardiac arrest is not my usual routine, and it is unlikely I will always have enough time to do so. I know that nurses often fulfil this role but I wonder whether as clinicians we are guilty of relinquishing our responsibilities and not providing effective holistic care. I searched for evidence of the impact on hospital inpatients of witnessing death, and interventions to support them. I found very little. One study looked at hospice patients, and another patients with schizophrenia: quite specific and different populations. My knowledge in this area thus remains in the realms of anecdote.

In the 1912 catalogue of the Futurists, they claimed ‘We thus create a sort of emotive ambience, seeking by intuition the sympathies and the links which exist between the exterior (concrete) scene and the interior (abstract) emotion.’ This seems particularly apt as we try to navigate the emotions provoked by witnessing death and grief, and maintain control over the concrete scene of the hospital ward.

As doctors we should all aim to provide holistic care, but must consider what this really means. Holistic care extends beyond the acute illness; beyond the individual patient; to all those affected by illness: patients, relatives, colleagues and ourselves.

When the lights go out

Most people I know have never watched a person die. Even those that have been to funerals and therefore have seen and been in physical proximity to a body, have rarely been present at the moment of death. The moment when in the eyes of the dying person the lights go out.

I have been there, in the moment, a number of times and remember every time with eerie clarity. Sometimes I have known the patient well; other times I have only met them in their last minutes or seconds. Sometimes it has been almost ethereally peaceful. Other times it has been frantic, chaotic or distressing despite our best efforts to treat end of life symptoms. Most often it has just happened.

Jean* had been admitted from her nursing home with end-stage dementia and multi-organ failure and was clearly in the last hours of life when she arrived in the emergency department. I admitted her in the morning and was passing through the medical assessment unit a few hours later and felt the need to pop in and make sure she was comfortable. There was a stillness in her room that felt anticipatory. I offered to stay whilst the healthcare assistant went to attend to another patient and so happened to be sat by Jean’s bed when she died. She was calm and comfortable. When the moment came it felt like the world paused for a moment and held its breath, while she held hers, then exhaled as she breathed her last breath.

And then the world continued on, with one less person in it.

Each time I have had this experience I have felt the same incredulity at the enormity of the moment. Whether I apply a philosophical or a religious framework, I struggle to grasp what happens when everything that makes up the person; their memories, actions, impact, emotions, beliefs are suddenly gone. The contrast between the significance of the event, and the undramatic way it often occurs, never fails to astound me.

When I know that one of my patients is dying I always feel an urge to check on them rather more often than is clinically necessary. Somehow I feel a responsibility to make sure they are not alone for the final moment. I know that many nurses share this feeling, but I sometimes wonder who we are really there for. Are we fulfilling an unwritten societal contract that means we must ensure no individual has to face the abyss alone; or are we, the living, reasserting our own vitality by forcing ourselves into close proximity with death?  I know many nurses who, whether religious or not, still insist on opening the window after a patient has died to “let the soul out,” as part of a ritual ingrained in them during their training. Even the confirmation of death by a doctor, which mandates checking pupil reactions, palpating for the pulse, and listening for heart and breath sounds, feels part of the ritual. In a busy shift this necessary pause feels appropriate to mark the fact that the world has lost another individual. The need for ritual at the end of live is pervasive across ages and cultures, but in an era of high expectations of healthcare we seem to struggle more with the inevitable than ever before.

“For the love of God,” Damian Hirst

We need a greater acceptance of the body’s physical frailty and a more realistic view of the limits of medical intervention. We need to find a more tangible connection with all stages of the circle of life, despite our sanitised and secularised society. We need to embrace the fact that the inevitability of our own mortality sets us free to live in the moment. As Wittgenstein noted “eternal life belongs to those who live in the present.”

I intend to make every day I have left count, before the lights go out.

Discharges in the dead of night

NHS Hospital discharges: thousands claimed to occur overnight

The news this week has been full of horror stories of patients being discharged from hospital in the dead of night. “Where is the compassion?” they cried, “How could they, the supposed caring profession?”  The stories began after The Times discovered, via Freedom of Information requests, that 100 NHS trusts sent 239,233 patients home last year between 11pm and 6am

The immediate response of the press was to paint a picture of an army of ambulance drivers booting out frail 90 year olds; dumping them at their front doors, alone in the dead of night. This dramatic depiction fuelled discussions on various forums and news programmes. The callers on Radio 4s “Any answers” actually made me turn the radio off.

My major concern is that this data was released without proper analysis. As usual in the reporting of science news, and particularly health-related news, the headlines were more important than the content. It took me two minutes to think of a list of possible contributing factors which may have led to these numbers of supposed patient discharges overnight:

  • Deaths are often coded as discharges. These may happen overnight.
  • Sometimes patients self-discharge, especially those admitted due to intoxication. On sobering up they may decide that at 5am they’d rather sleep off the rest of their hangover in their own bed. Good for them.
  • Many patients are offered the chance of discharge after a period of observation in a short-stay ward. Such patients are not really “admitted” in the traditional sense, merely held somewhere outside A+E due to the constraints of the 4hour rule, often awaiting test results.
  • Patients may leave the hospital hours before the discharge is “declared” by the ward. Sometimes this is due to the ward staff prioritising patient care over paperwork, and only getting around to logging the event later. Sometimes this is a more overt tactic to prevent more ward admissions when ward staff are under pressure. This may not be best practice, or good for patient flow, but is better than what has been imagined by reporters.

It is disappointing that those at The Times didn’t construct a similar list, and is part of a worrying trend of negative NHS stories despite high patient satisfaction. In my more cynical moments I wonder about influences on reporters and editors and links between media execs, politicians and those with interests in private healthcare.

“Patients should only be discharged when it’s clinically appropriate, safe and convenient for them and their families.” says Sir Bruce Keogh. Absolutely. I know no-one working in the NHS who does not “believe in the principles of holistic care – thinking about the patient as so much more than a bed filler and considering their lives outside the microcosm of the hospital.”

There may be a very small number of cases which fit the picture painted by The Times, and each of these is a failing of the system, which requires investigation and action. But please can we stop the media driven NHS-bashing? Those of us who work in public service endure long hours in difficult circumstances, but do so because we care. Nurses, doctors, occupational therapists, physiotherapists, pharmacists, discharge co-ordinators and matrons spend our working lives assessing patients to ensure that at the end of their medical investigations and treatment they are safe for home. When they are not we engage social services to put in place care to achieve a safe discharge. I worry that the profit motive, competition and privatisation will bring pressure to change this, but for now compassion remains at the heart of what we do, and no-one vulnerable and alone is going home at 3am on my watch.

BBC article: Overnight discharges from NHS hospitals to be examined

Sensible analysis by FullFact.org