Saturday, October 27, 2007

Nurses to make end of life decisions

As a normal member of the public you would think that the title 'consultant clinician' would refer to an experienced doctor with years of training and a proper medical degree. You would be sadly wrong; as nurses with no other training than nursing training are now called 'consultant clinicians', and they have now been empowered to make decisions about you or your loved ones resuscitation or lack of it when critically ill.

Recent scandals concerning Hospital Acquired Infections have outlined how basic nursing is simply not being done, meaning that patients are routinely left wallowing in their own faeces. Good old fashioned nursing is no longer valued, as nurses are handed more and more power without any extra training.

One would imagine that doctors with doctor training should do the doctoring, while nurses with nursing training should do the nursing. One would also think that empowering nurses with only nursing training to do doctoring would be rather lethal. The BMA and the government do not seem to think so, using their logic I am sure experienced cleaning staff will soon be making important clinical decisions.

The dumbing down gathers apace, proper education and training continue to be seen as completely unimportant. Whether it be in the form of nurse consultants, police community support officers or classroom assistants; this government is presiding over a lethal empowerment of the ignorant and is in the process guaranteeing the public are delivered a truly substandard service.

53 comments:

the a&e charge nurse said...

The "dumbing down" jibe's a bit rich coming from a profession that until relatively recently used to write DNR orders in the notes without EVER discussing it with the patient first [which of course rather upset one or two of them when they found out about it] - how on earth can nurses do any worse than that ?

Dr De'Ath said...

"When a decision not to attempt CPR is made on these clear
clinical grounds, it is not appropriate to ask the patient’s
wishes about CPR, but careful consideration should be given
as to whether to inform the patient of the DNAR decision"

(From the guidelines)

A and E charge nurse, I suggest you go back to the drawing board.

It is frequently not appropriate to discuss a DNAR order with the patient.

The fault in the case you mention may lie with whoever chose to tell the patient of the decision.

Hence your point is quite frankly no point at all.

Nurses could do very much worse, seeing as you ask.

The number of nurses that push for making patients DNAR just to avoid doing some work is rather too frequent for many a doctor's liking.

The number of times that nurses assume DNAR means not for any active treatment is also rather appalling.

Resuscitation decisions are often poorly managed, however empowering the ignorant is no way to remedy this situation.

Maybe some of you just don't like to listen to the truth, and would rather live in denial.

Clovis Sangrail said...

Dangerous though it is to get in the middle of a professional turf war, I just want to point out that Dr De`ath seems to have come up with the definitive slogan for New Labour: `empowering the ignorant since 1997'.

the a&e charge nurse said...

Dr De'ath - as an ALS and APLS provider I am well aware of policy that governs conditions when a doctor is unable to discuss a DNR order.

But that's not what I'm alluding to, and well you know it.

I would not like to be in the position of trying to defend the frequency of COVERT DNRs that where entered into the notes all to frequently by doctors [at least up until relatively recently].

There are countless examples of this on the net try; http://www.healthdemocracy.org.uk
Look at the items on "compulsory euthanasia", particularly Dr Rita Pals experiences of being pressurised by her consultant to inject diamorphine into a patient with pneumonia [presumably at higher doses than standard titrated doses associated with LVF, for example].

Are you seriously claiming that nurses prefer to bump off patients rather than do a bit more work ?

I'm sure you are fully aware of the MANDATORY requirement to report such outrageous breeches of trust - if these potential murderers are still plying their unscrupulous trade on your watch then you are guilty, or at least partly culpabale [if you hold prior knowledge] by association.
How many of them have you actually reported ?

For what it's worth I think nurses would extremely foolish to get involved in making unilateral DNR desicions - trust/dialogue amongst the TEAM, and with the patient whenever possible is the gold standard in my experience.

I know it can be difficult for some people to avoid stereotypes but amazingly there might be one or two nurses out there who might have just a little bit more experience than you, both in the hospital and in life in general - if it where my nearest and dearest job title alone might not always be the most important criteria when comes to end of life decisions, especially when there is little therapeutic mileage in "active treatment".

Dr De'Ath said...

I agree that resuscitation decisions are frequently poorly managed, however the answer to this problem is most definitely not shifing more responsibility and power to nursing staff.

This move will further muddy the dirty waters in an increasingly complex area.

Doctors alone should have the power and responsibility for these decisions. The slippery slope is a very dangerous thing.

Dr De'Ath said...

ps one of your references should be taken with a large pinch of salt, if I say anymore I'll probably be sued

poohbear said...

So there you are lying in a coma after an accident with a 10% chance of recovery, right? and a fucking NURSE gets to decide whether you live or die? What if the Hospital needs donor organs? WHO DECIDES if you live or get cut up for spare parts? Will a nurse at the bottom of the food chain have the nuts to swim against the agenda of keeping costs down?(coma patients are expensive to keep alive) or the courage to face down a demand from the organ snatch squad HQ? Why not just kill and dismantle(for spare parts) all patients that have a less than 100% chance of recovery? Why not give the final say to the fucking receptionist or the local commisar?
This NHS is getting beyond parody isnt it?

the A&E Charge Nurse said...

Yes, poohbear, ITU nurses have been quietly biding their time devoting years to resuscitating and providing advanced life support to patients at the very edge of life.

Now they have finally have a golden opportunty to start killing them all, which is what they wanted all along, presumably.

I'm sure the ITU consultants hold very similar views about their [nursing colleagues] latent homicidal tendencies ?

poohbear said...

Nursey,

I am not saying that most nurses cant wait to start 'offing' the proles BUT they will be far less able to resist the pressures of vested interests and prevailing agendas!
A case in point will be the lack of spaces to accomodate all coma patients AND a lack of funds, so in effect a pressure system will build to force the hand of nurses to follow the agenda or face inevitable black marks by the higher ups! Its a slippery slope that gets more slippery as time goes on! Both you and I know that nurses can be manipulated to serve a cost saving agenda.

CODE... rec d pleb ! how very apt?

Shug Niggurath said...

The same government is pushing for assumed consent over donating organs.

That alone will create an agenda for using the critically ill as potential life-savers in another sphere.

Fuck that.

DNR should and must be the sole decision of medically trained doctors. Even IF the way it is implemented meant that only one nurse was able to make the decisions on a ward, they would be subject to pressures from above to save money, and prejudices from other staff regarding certain patients.

Without any training nurses are being asked to do yet another doctoring task and we are being asked to believe that it's for the best.

Fuck them - I don't think politicians are qualified to make arbitrary decisions like this.

the A&E Charge Nurse said...

poohbear - this may astound you, but the "vested interest" and "prevailing agenda" of nurses is to keep people alive - I won't bore you with the cardiac arrests and traumas I have been involved in A&E, just lets say our department has received one or two thank you letters.

Curiously, nobody suffering a heart attack or spinal fracture, say, has ever referred to me as nursey - I'm sure you'd be different though ?

poohbear said...

Dear nursey,

Sorry if you are not happy with the name!
Again you miss the point of my post? I didnt say the nurses have an agenda Etc! I said that nurses are more liable to be manipulated to SERVE the prevailing agenda and be INFLUENCED by vested interests!
If you are going to comment on my post at least read it properly!
Hospital policy is now run by "managers" and bean counters and risk assessors NOT the nurses and that the nursing staff are subject to performance reviews by those who set the agenda makes it far more likely that nurses will tow the party line than stand up for what is right!
I have watched an aborted baby left to die in a dirty hospital sink(nearly 30mins to die) and I have seen an organ snatch from close up(victim had to be tied down)! so I feel qualified to comment on the NHS and its squalid practices!
There are a great many wonderful people who work in the NHS but to be uncritical of bad practice does nothing to serve their interests!

Henry North London said...

I read this in the Times this morning and I thought mmm I should blog about this but I couldn't bring myself to condemn the government or the NHS. In fact I read it with the disinterested scan of quick speed reading when one knows that one can do nothing, nothing and absolutely nothing about it.

I have been boiling with anger since Wednesday and I simply cannot keep the water boiling anymore the pot has boiled dry and I now have a headache from the amount of boiling that has gone on.

There will be scandals, there will be deaths and there will be recriminations ad libitum about this and it will continue raging for some time.

It is all part of the process to make us slaves and perfunctory technicians.

I do sometimes wonder where all these "nurse led suggestions" emanate from.

Only then will we know who we are dealing with.

Having worked in the NHS and in the private system and having worked and seen what happens abroad God where was I

Fuck

Its just too much to process. I know that if I want proper health care I need to go abroad or be treated by people who know me personally.

There are not enough swearwords to express how I feel about this latest development so I'll end on this lovely note.

It is only when a nurse's relative who signs his wealth over to a nurse who then kills him for the money that this abhorrent practice will cease.

lost_nurse said...

I agree that resuscitation decisions are frequently poorly managed.

And Doctors share much of the blame for that.

There was one almighty DNR fcuk-up at work today, and it sure as hell wasn't the nurses' fault, though I'd say that our mutual agreement not to break the ribs of the elderly cheyne-stoker with advanced metastases was probably the "right" thing to do. This after repeated requests for a medical review (and properly documented crash status). On the other hand, the Sister's quiet management of distressed relatives was about as expert a thing as you will ever see. Now, with hindsight, what lame stereotypes shall I wheel out about medics? Even better, how many crappy fcuking conspiracy theories about bumping off patients can I dream up? Then I can spend more time with the Quality Street tin etc etc.

I'm as wary of the slippery slope as anybody, but I doubt that even you, oh De'Ath, has much to teach an experienced ITU or Pallative nurse about popping one's cloggs. There is an issue here about responsibility - but dressing it up in tedious nurse bashing does you (and your otherwise excellent articles) no favours.

Good old fashioned nursing is no longer valued.

Are you Melanie Philips in disguise*? The key word here is "r-a-t-i-o" - I'd stake my tea stash on betting that the theoretical number of sociopathic nurses who are deliberately leaving patients lying in their own faeces is far outweighed by the number of nurses who simply aren't there to do the job properly, because we are so bloody short-staffed. Ask yourself, what are you doing about it? Not fighting amongst our[NHS]selves would be a start.

(*staff nurses now being that most enduring of Mail fantasy targets - women who get above themselves...)

Henry North London said...

Trouble is that the sociopathic nurses are not reported and struck off for life because if they were we would be in a much better position.

If you nurses could get rid of your sociopathic colleagues and weed them out quickly then we wouldn't have the amount of doctor nurse bashing and vice versa that currently goes on

You may not realise that I have been the target of such a sociopathic nurse and as a result this formerly very productive doctor is now on incapacity benefit

You have absolutely no idea how bitter I am and how much psychic torment I have gone through because of a nursing colleague.

Until you can hand on heart say there are no sociopathic nurses in the NHS I will not accept any argument from the Nursing body out there.

lost_nurse said...

Until you can hand on heart say there are no sociopathic nurses in the NHS...

Well, I'm sorry to hear about your particular circumstances. But, with respect, that wasn't really my point - the point being that a large proportion of the incidents reported in the press are the result of a lack of staff - rather than neglectful staff, per se.

Garth Marenghi said...

lost nurse,

I regularly see bad practice as regards resuscitation decisions, and this is frequently down to doctors, as I have previously said,

the answer to this is not to empower nurses as I have been arguing

my 'nurse bashing' as you call it is reasonable in this instance, I may not have explained it completely and for this I apologise,

nurses frequently push for DNAR decisions inappropriately- this I stick to, and this does not make them sociopaths or negligent!

the point I wanted to make was that nurses frequently do not grasp the complexities of individual medical cases, largely becuase they have not been trained in depth to do this, as doctors have been; this means that they frequently push for DNAR decisions due to a lack of understanding of the case, due to a misinterpretation of events and how they can potentially be managed,

for example it would be ludicrous for a 100 year old, with a good quality of life, who had just had an MI to be DNAR; as if the patient went into VT/VF one simple shock may be enough to get them back! however it clearly would be inhumane to jump up and down on their chest for more than a few minutes if an arrest occurred

I digress, the point I mean to make is that DNAR decisions are very complex ones and should only be for senior doctors to make

As you say though, doctors do need to improve their bit when it comes to DNAR decisions, just to reiterate, the answer is most definitely not to empower nurses!

the a&e charge nurse said...

Thanks for explaining the "complexities" of the 100yr old post-MI patient, ferret - I thought it was an automatic DNR once you hit teble figures.

Yes, we certainly need the clever doctors to go into a huddle, followed by a spot of chin rubbing before deciding if old Ernie has any more mileage left in him [as they used to not that long ago].

We wouldn't want any thicko nurse [or nursey, if you prefer poohbear] sticking their ore in, I mean what the fuck do they understand about it ?

Presumably patients are able to understand the "complexities" - you do actually discuss DNRs with patients don't you, ferret, I mean some of them are thicker than some of the nurses [if that's possible] ?

Strangely the Patients Association, BMA & RCN all seem to think that nurses might know a thing or two about end of life decisions, and that in some circumstances might be very well placed to represent the views of the patient [or the views of the managers if we accept poohbears analysis].

But clearly these bodies have all failed to recognise that a nurse with 20 years experience in oncology, say, would have very little understanding of the pros/cons of resuscitating a patient with terminal cancer, for example.

Thanks for clearing that up for us.

Dr De'Ath said...

A and E charge nurse,

the chip on your nursing shoulder is now in the open for all to see! thanks for that

nurses are nurses and doctors are doctors, they are different and trained for different roles if you hadn't noticed by now

it is not arrogant to claim that a doctor's extensive training makes them better equipped to deal with the complicated management of patients, it is what doctors are trained to do!

in a world full of your lovey logic no health professional is better than any other; doctors, nurses, HCAs, physios and cleaners are all equally good at doing everything, and for one health professional to claim they are better at one thing than another is seen as arrogance!

this kind of nonsensical politically correct rubbish is the typical limp defence for this dumbing down

who would you want making a decision about your ressucitation?

an experienced nurse with nothing more than experience of nursing and a nursing degree, or an experienced consultant physician with a medical degree and numerous postgraduate qualifications?

oh sorry, it would be arrogant of me to want the consultant physician!

the a&e charge nurse said...

Dr De'ath will pick up the thread later - I'm just off to see the Ian Curtis biopic "Control".

I will try to address your issues but please, please, PLEASE raise your standards above the corny old "chip on the shoulder" cliche - it belongs in the same bin as the quality streets & angel bullshit.

poohbear said...

Nursey,

Who is at fault for the C-difficile deaths in the M&K NHS trust? Is it the nurses? Is it the doctors? Is it the Managers who prefer to spend cash on Stupid and trivial nonsense like 'equality advisors/media comunications staff'and big cash bonuses and the like instead of well paid and motivated cleaning staff? Its no good employing a 'manager' on a big wage when what you need to do is employ a team of valued permanent cleaners on decent money!
The scumbag who was in charge of M&k NHS trust should have been put up on charges BUT she was given a near 1/2mill payoff! How many cleaners would that have paid for?
And the new manager went on leave a few days after taking up the job!
If anyone is destroying your reputation it is the legions of useless parasite manager class!

Dr De'Ath said...

A and E charge nurse,

I am sorry but the chip argument stands!

I am not saying that nurses are 'thickos' as you insinuate, stop putting words in my mouth.

I am also not saying that nurses should not contribute and participate in DNAR decisions.

What I am saying is that only doctors should be responsible for the ultimate DNAR decision.

Unless you know something remarkable that I do not, nurses are trained in nursing and doctors are trained in doctoring, these are different things.

Making a DNAR decision does not only require experience, it also requires a detailed undertanding and knowledge of medicine, which nurses are not trained to possess, while doctors are.

Experienced nurses are invariably very valuable team members, however they should not be given this responsibility, it is beyond their means.

Nurses are not doctors and doctors are not nurses, it is not rocket science or arrogance to point this out.

If I told a nurse how to move a patient or dress an ulcer etc, then I'd expect to be told to f*ck off.

So why do nurses feel they can do the jobs for which doctors are far better trained without any consequences?

Anonymous said...

Nurses should nurse & Doctors should doctor. If Nurses want to be Doctors, they should do the training.

Project 2000 was & is a total fucking disaster. The politicos are using it to get to the lowest (cheap) denominator.

Be afraid, patients, be afraid!

lost_nurse said...

All this talk of chips is making me hungry, so I will be brief.

in a world full of your lovey logic no health professional is better than any other...

I don't see anybody here claiming such a thing. As I've said before, I have no problem with nurse autonomy, but not at the expense of medical cover. And frontline staff can hardly be blamed for the fiasco of MTAS, or the political drive behind Crippen's beloved hospital-at-night - or, indeed, the acquiescence of senior docs (and, yes, senior nurses) to NuLab diktat. The irony being that said grunts are right in the frontline when it comes to the adverse effects of reform. Is doing yer best in the face of the gathering apocalypse necessarily the same thing as jealously coveting professional turf? No, not really. Not at three in the morning, when nobody is answering their bleeps.

...however they should not be given this responsibility, it is beyond their means.

"Dumbing down"? Beyond their means? On any number of issues, I could say exactly the same about the forlorn HOs I see wandering around in despair, at nights and on weekends. Your OWN profession is doing a poor job of supporting and educating juniors. Do please bear that in mind.


(Hmm - must see Control. Wonder what Curtis would have made of the changes that swept thru' Manchester - and his own band? Plus it stars Samantha Morton - excellent in the strange and luminous Morvern Callar.)

the doctor said...

Do not resuscitate orders are not just a clinical decision but an ethical one to . The success rate for CPR is no more than 5% , and the process is , in some (most) cases very traumatic for every one concerned . Therefore the ethical judgement of nursing and medical staff are of equal quality .

Anonymous said...

lost nurse

you have failed to grasp the point that doctors are trained to do doctoring and nurses are trained to nurse

slagging off junior doctors on their first few days of work is no more productive than slagging off new nurses in their first days of practice

it is rather interesting that you ignore the main point of the argument in hand:

ie that nurses are not trained and educated to the same level as doctors

I am sure you will try to evade this rather obvious fact, however you will then be digging with spade in hand again, the hole is getting deeper

Devil's Kitchen said...

To the nurses on this thread,

Do you seriously want to take responsibility for such life and death decisions? Why?

How are those professional indemnity insurance payments, by the way?

Were I a nurse, no matter how experienced, I would not want to take responsibility for these decisions: why on earth do you want to?

The point seems to be that very highly trained doctors make mistakes and serious errors; do we want to compound the likelihood of such errors by introducing less highly-trained nurses into the mix? I would say not.

As A&E CN pointed out, discussion amongst the entire medical team would seem to be the best idea; it is often the case that a nurse will see far more of a patient than a doctor and, as such, will be better placed to assess the patient's frame of mind and likely wishes (if they have not been recorded).

However, a doctor is better trained and rather more likely to be able to assess the efficacy of any line of treatment (all other things being equal).

DK

the a&e charge nurse said...

Devil - the decision not to resuscitate is usually an ethical, or existential dilemma, rather than a clinical issue.

Most commonly such decisions are made for patients with advanced cancer, who have exhausted all chances of cure [chemo, surgery, radiotherapy, etc], and are suffering an accumumlation of worsening symptoms - or patients with severe disability after a CVA, again with no meaningful prospect of recovery.

The other main group are frail, elderly patients [usually 80+] who would have such a poor quality of life even if they were resuscitated [which is a remote possibilty statistically] that it is probably kinder to let them die a more peaceful and dignified death.

Resuscitation is a brutal procedure and ribs can be fractured on elderly patients after repeated sternal compressions [few wards will have an "autopulse" cardiac pump support].

Consultants cannot reverse any of these clinical outcomes [after a certain point anyway] but are expert on palliating symptoms - a slightly seperate issue perhaps ?

In reality it is the nurses [mostly] who provide TLC at the bedside while the patient edges toward death - that's not to say the consultant doesn't pop his/her head round the curtain every once in a while but there is unlikely to be any dramatic or inspirational medical intervention that will alter the inevitable outcome.

I must admit I'm not exactly sure what the catalyst is for these changes, but ALL patients admitted to hospital will have been seen by a registrar and then by the consultant within 24hrs - any patient can be discussed with the consultant at any time of the day, by phone, if necessary - so in theory there should be no excuse for not having considered the patients Resus status at senior medical level.

I can honestly say I have NEVER heard a nurse say, oh, I wish I could be soley responsible for DNR decisions.......perhaps some individuals are simply turned on by the thought of litigation.
Personally, I wouldn't want to go there.

But I do get majorly fucked off hearing doctors bleeting incessantly about "dumbing down" whenever nurses are afforded an opportunity to utilise all of their skills [theses advanced practices are usually backed up by research evidence].

I'm coming to the rather sad conclusion that in many instances this is more about trades unionism rather than patient care - as I mentioned above, historically doctors placed DNR orders in the notes without even discussing it with the patient first - so I ask again, how can nurses do any worse than that, eh ?

the a&e charge nurse said...

BMA guidance on DNRs recommend;

Decision to be made in advance [whenever possible].

Consideration of "likely outcome" including likelihood of restarting heart/breathing, and overall benefit.

Patients known or ascertainable wishes.

Patients human rights including the right to life and right to freedom from "degrading" treatment.

The BMA go on to say;
"The views of ALL members of the medical and nursing team, including those involved in the patients primary and secondary care and, with due regard to confidentiality, people close to the patient are valuable in forming the decision.

I could not find any recommendation to suggest that consultants alone, should be responsible for making these decisions.

Incidentally, if having discussed resuscitation with a patient, and that individual insists on CPR, then these wishes MUST be respected [by doctors and nurses], irrespective of how remote the chances of success are.

Anonymous said...

A and E charge nurse

"Devil - the decision not to resuscitate is usually an ethical, or existential dilemma, rather than a clinical issue."

this really wins the argument in favour of nurses being kept firmly out DNAR decisions, 'being and nothingness' is a good description of this meaningless statement.

also the guidelines you quote are the old ones, get up to speed.

if you bothered to answer any of the logical points put to you ( you probably don't because you can't )- then you would realise it is because nurses do not have the level of training and education, hence they do not have comparable skills to a senior doctor

the attitude of nurses such as yourself on this issue is actually one of protectionism towards nurses, against the best interests of patients

you want nurses to have an amateur crack at anything without the comparable training that other people recieve, this is selfish and not in the interests of patients

this is SECOND RATE and dumbing down, and is not fair on patients

some nurses seem to be happy to do anything, no matter how inadequately trained, yet insist its all about ptaient safety when defending their weak position

I suggest you go back and re-read the above postings, because you are missing the point time and time again

the a&e charge nurse said...

Anonymous - please remind me where I suggested that nurses should write up DNR orders, or have "an amateur crack at it" to use your rather hysterical phrase - I seem to recall suggesting the complete opposite [and more than once too].

I have simply raised an unpalatable truth, namely that [some] doctors decided on a patients resuscitation status without ever discussing it with them first - so in this respect its hard to see how nurses could do any worse.

I notice that none of the doctors here have had the bottle to comment on these all too recent, and rather furtive practices.

I think many of the commentators reading this thread will immediately understand the existential dimensions I am alluding to [for example, if they have spent time with a relative dying from cancer] but if you wish to willfully misinterpret these views then that is entirely up to you - I'm sure I stated quite explicitly that it is the consultant who will provide the expertise in palliation but perhaps I just imagined it.

Incidenatlly how many resuscitations have you been involved in ?
I've been involved in at least 300, not that this qualifies a nurse to have a view on these matters, of course.

Faith Walker said...

"Fuck them - I don't think politicians are qualified to make arbitrary decisions like this."

Yes, I agree, politicians are not qualified to make decisions like this. The decisions were made by three professional bodies:

The BMA, The NMC and the Resus Council.

I think that DNAR decisions should be made by the whole team- nurses know the patients the best, and are obliged to act as advocate for the patient. If that means suggesting the resus is not the best course of action, so be it. A nurse is required to sign the form for DNAR anyway.

I think in an emergency situation where a DNAR has not been filled out, then it is fine a senior nurse to decide- especially in situations with terminally ill or palliative care only patients. In all other situations, nurses are required by their code of conduct to initiate CPR- in and out of the work environment.

So for all those people who think thata nurse should wait for permission to do CPR think again. Most of the time in hospital its the nurse that starts CPR and initiates the crash.

I've done it, and i was one of those awful HCAs you talk about (student nurse now).

Faith Walker said...

A+E Charge Nurse-

"I have simply raised an unpalatable truth, namely that [some] doctors decided on a patients resuscitation status without ever discussing it with them first".

And if you read the resus guidelines, it does say that resus status doesn't always have to be discussed with the patients.

the A&E Charge Nurse said...

Faith - I realise it was a little way back now but it seems you might not have not read my earlier comment, may I refer you to the 4th entry on this thread.

I fully appreciate that it is not possible to discuss resus status in every case but my concern was the unsavoury practice of [some] doctors making a UNILATERAL DECISION then entering a DNR order into the notes when a patient had the capacity to understand the issues.

There are lots of stories, anecdotes and reports out there identifying these perenial concerns - I'm sure they were a minority of cases but it certainly did happen.

Dr De'Ath said...

AE charge nurse,

read the f*cking document:

"When a decision not to attempt CPR is made on these clear
clinical grounds, it is not appropriate to ask the patient’s
wishes about CPR, but careful consideration should be given
as to whether to inform the patient of the DNAR decision"

resuscitation decisions are very much clinical decisions, and nurses are not as well trained as senior doctors in making these decisions

giving nurses this responsibility is misplaced and nothing other than second rate (am I being hysterical in saying this? probably with your incoherent twisted logic!)

there are many porters who have taken part in hundreds of arrests, doesn't mean they should make DNAR decisions though, your point is lame

many senior consultants haven't taken part in arrests for many years, however they are frequently expert at making these complex DNAR decisions

fundimentally you should get it into your head that nurses are not adequately trained to be doctors, and these kind of attempts to shift more responsibility to the undertrained can only be bad news for patients

of course you are allowed your view, I still happen to think it is incoherent, nothing you have argued addresses the crux of the issue

lost_nurse said...

you have failed to grasp the point that doctors are trained to do doctoring and nurses are trained to nurse

Bollox. I know my job, and I have no desire to do yours (though as an Oxford graduate, I'm guessing I probably could go down that route, if I wanted to have an amateur crack at it). I do not doubt the value of being "confidently uncertain", as opposed to just ticking boxes (or however it is that you imagine I take decisions..). And I'd rather DNAR status was decided by the consultant, in discussion with (that fabled entity) the "rest of the team." Similarly, I have no desire to take on the kinds of responsibilities (and liabilities) that DK alludes to, especially not given NuLab's corner cutting agenda.

But that doesn't remove from the fact that down here in shitsville, nurses are having to make snap decisions, in less than ideal conditions, with less than ideal support from their medical colleagues. Pontificate about your own effortless superiority as much as you as like - the senior medics were fcuk-all use yesterday, so much so that the HO was in tears. Put your own house in order, before you patronise the nurses - some of us are getting rather tired of the dumb-and-dumber routine. Not whilst Rome is burning. Nurses are not responsible for the woefully inadequate levels of medical cover on general wards - but they sure as hell have to pick up the pieces.

FFS, it's not even as if I think that this is a good idea (though it's interesting you assume I do) - but to suggest that senior outreach, pallative, ITU, A+E etc nurses are somehow "untrained" in these matters is simply absurd. And you know it.

the a&e charge nurse said...

Dr De'ath - I have read the document.

Maybe you are recently qualified, and have no direct experience of the kind of thing I'm talking about ?

Try this report by the Ombudsman - it typifies the sort case that raises genuine concerns around unilateral DNR orders, for ease of reference I'll quote some of the daughters comments;

"Mrs A told the ombudsman's investigator that the family found out about the decision not to resuscitate her mother only after her death.
She found it incredible that one day her mother had been classified as mobile and self caring and the next it was decided she was not to be resuscitated".

http://www.ombudsman.org.uk/improving_services/selected_cases/HSC/ic9909/pt2-e926.html

Sounds like the [medically trained] consultant handled that one really well, doesn't it ?

By the way, just remind me what role do porters play in a cardiac arrest ?
I cannot ever recall one putting out the crash call, attempting airway manouvres, defibrillating, getting IV access, pushing in the adrenaline, capnography, pacing, chest drains, etc, but perhaps I'm wrong about this as well, maybe the nurses are no more qualified than the porters to make decisions when it comes to this issue ?

Dr De'Ath said...

We could list examples of bad practice until the cows come home, doesn't really affect the points made though.

When it comes down to it, I want to be treated by a medically qualified doctor and if I need a resuscitation decision then I'd want it done by a senior medically trained doctor thanks.

Some of you may be happy to provide a second rate service, I'd rather aspire to a first rate service.

As you both say there are ways in which the current system could be far better managed, for example decisions should come from senior doctors all the time and patients should be more involved in some situations.

However I shall repeat until I am blue in the face, the way to improve the situation is not to hand the responsibility to nurses.

The way to improve it involves good local policy that ensures senior doctors are aware of their responsibility, patients must be engaged to discuss these issues and people must be better educated as to the actual facts about resuscitation.

There are many examples of doctors failing in their work, the answer to this problem is not to empower even less trained workers like nurses! The answer is to improve the system so that these failings can be openly addressed and not brushed under the carpet.

The top down autocracy that is the NHS management and the DoH work very much against an open and honest culture, and we'll be fighting a losing battle until those at the top change their tune.

the a&e charge nurse said...

Dr De'ath - if you ever have the misfortune to suffer a cardiac arrest, the overwhelming likelihood is that your life would be in the hands of a paramedic, or nurse........not a doctor.

You will know [if you're an ALS provider] that the chain of survival depends on immediate recognition of arrest, rapid and effective BLS, then electricity [if VF/pulseless VT].

It is unlikely that you would have the luxury of a doctor either at the roadside or bedside, at least not until they are summoned by a nurse or paramedic.

The simple fact is nobody can afford to wait for a senior medic to do the "doctoring" as you quaintly put it, there is too much to be getting on with once the clock starts ticking.

You know as well as I do how vital these first few minutes are, and if you were in my tender hands I would not delay for a nano-second to push the button if you were in VF - I'd just have to deal with your complaint [about dumbing down, etc] on another day.

You might want to think about this before you make crass generalisations about the responsibilties nurses have when it comes to cardiac arrest.

Additionally you may wish to share your ideas about the indistinguishable contribution of nurses and porters [during arrest] with the rest of the faculty during your next ALS course - I'd be very interested to hear how many of the instructors agree with your bizarre assertions.

Dr De'Ath said...

Your argument is deeply disingeuous Charge Nurse

The point is that DNAR decisions should be taken by doctors, not nurses.

The new guidelines are not talking of people who do not know the patient well making DNAR decisions in the heat of the moment at an arrest!

They only give the power to experienced nurses who know a particular patient well.

Hence your ramblings above are completely missing the point.

(again)

the a&e charge nurse said...

Dr De'ath - perhaps we can at least agree that this thread has stimulated debate extending beyond the parameters of your original post ?

You maintain [in good faith no doubt] that job title alone, rather than the actual abilities of individuals must ALWAYS be the most important arbiter of who does what in ALL situations ?

My own experiences, first as a psychiatric nurse and then in A&E has led me to rather different conclusions.

You also claim that diagnosis and treatment are exclusively, and always, the domain of doctors ?

I mentioned cardiac arrest simply to illustrate that a nurse [or paramedic] can "diagnose" a VF arrest and institute "treatment", namely defibrillation - so maybe things aren't always quite so cut and dried as you would have us believe.

Fairly recently an A&E FY2 missed a true posterior MI, while the resus nurse [who happened to have a background in cardiology] spotted it - no disgrace, doctors are bound to overlook stuff and a little, aherm..... from a nurse can help doctors reach a correct diagnosis.

Perhaps your tendency to stereotype and generalise may point to inexperience rather than vindictivemess ?
But once you become a consultant you will appreciate just how much trust is placed in the hands of experienced nurses.

Dr De'Ath said...

ps the point about the porters that I was trying to make was in response to you talking about how many arrests you had taken part in and how this somehow has anything to do with who should make decisions about DNAR decisions

In many hospitals porters are trained to be the first responders and trained in ALS

A lot of these guys will have attended hundreds of arrest- therefore by your logic this would help them make DNAR decisions!

A large knowledge base, a lot of experience and a lot of training all help a doctor make complex DNAR decisions

Nurses are simply not trained and examined to the depth that doctors are

I don't know what planet you are from thinking that nurses are as knowledgeable and qualified as doctors, howevere some would call it cloud cuckoo land

the a&e charge nurse said...

As I say Dr De'ath please bring your "porters' analogy up at the next ALS faculty meeting, let me know how many of the participants or instructors share your idiosyncratic point of view.

I haven't stop chuckling at your assertion that porters are trained in ALS - presumably you meant BLS ?
At least we agree there is no reason they should not be utilised if they are first on scene.

Perhaps you can think of a "complex" DNR issue that a nurse with years of experience in palliative care, say, or acute medicine would fail to grasp ?

Bock the Robber said...

I suppose if you take the view that nurses are there to clean up shit, you have a point.

The reality is, though, that all junior doctors learn their doctoring from the senior nurses on the wards, and only then go on to become god-like consultants.

dr cromarty said...

Well, you all seem to have missed the point that this is a piece of guidance from a trade union. The minute I start letting a bunch of Len Murrays and Arthur Scargills who also happen to be on the medical register tell me what to do in terms of clinical governance is the day I jack it all in.

The BMA has all the moral authority of the UN Human Rights Commission when Libya chaired it.

the a&e charge nurse said...

Dr Cromarty,

Is the Resucitation Council a trades union ?

Is the Patients Association a trades union ?

Both bodies seem to concur with your latterday Scargills and Murrays ?

dr cromarty said...

Is the Resucitation Council a trades union ?

Well let's see:
The Resucitation Council

There are two categories of membership - Full Membership and Associate Membership. New members will initially be Associate Members; those who display exceptional ability and who show a commitment to resuscitation beyond that normally expected of their employment may be elected Full Members of the Council after a minimum period of one year as Associate Members.

Applications for Associate Membership are invited from persons with a bona fide interest in resuscitation


Membership is only offered on an individual basis and is not available to Corporate bodies, Companies or such groups. Membership does not imply any recognition of expertise and must not be used to imply such - for example by using membership as a qualification.


So anyone with 'an interest in resuscitation'

hmmmmmm.

Is the Patients Association a trades union ?

The Patients Association


The Patients Association was set up more than 40 years ago to promote the voice of patients in healthcare. We are a registered charity based in North London staffed by paid and unpaid staff committed to making a difference to the ‘Patient Journey’.

So no they're not trades unions. They're just self-interest groups. Not sure they carry any more moral authority, therefore, than the BMA.

the a&e charge nurse said...

Self interest or patient interest ?

dr cromarty said...

Self interest or patient interest ?

In both cases they represent the interests of their members. Whether the PA truly represents patients' interests is difficult to say as I don't know the demographics etc etc of the membership. It may no more representative of patients than the German Democratic Republic was democratic.

Grumpy Med Reg said...

A&E CN - you clearly have a great deal of experience in A&E. That's lovely. The reality of general medical wards is that ALS is not initiated until the team arrives - the doctor led team. BLS is, and generally done well, but regardless of how often the ward nurses have done ALS they do not initiate shocks/airway manoeuvres without us. The only exception is CCU/a cardiology ward attached to CCU.
DNAR decisions are not primarily ethical, they are primarily clinical with a large ethical component.
I don't know a single senior nurse I respect who would want to make these decisions. But then again, I don't respect rank arrogance so maybe it's all in the subselection. Senior nurses are involved in resus decisions all the time, they just have the sense to know that at the end of the day it will be the doctors held responsible for the decision so they leave the final say to the buck-holding registrar.
And I disagree with your assertion that nurses could not make a worse job of it than doctors do. As an example in point:
Pt A is found to have a cancer late on a weekday afternoon. He is not expecting this news. His family cannot be with him until early the next morning. The team doctors decide to wait to tell him until his family are with him the next morning and write CLEARLY in the notes that he is UNAWARE of the diagnosis and will be until the next morning. Then the patient hears two nurses at the end of his bed in handover, "Mr A has just been diagnosed with cancer. Don't tell him though." That right there would be a way you could do worse. Don't ask such facile questions, you know you're talking nonsense.

the A&E Charge Nurse said...

Thanks grumpy med reg - I don't disagree with you.

The general tone of the post got on my tits a bit, that's all, although I'm sure Dr D is an excellent doc ;o)

It seems clear from this thread [and others] that nurses are just as perplexed as the docs where this has all come from, does anybody here know the background to it, I don't ?

The blogshere is one thing, but in the real world we all just get on with our jobs - I think this nurse/DNR thing will simply die in the water [no pun intended].

the a&e charge nurse said...

Sorry, grumpy med reg, just can't resist it.

I notice that you don't deny the past habit of doctors filling in DNRs unilaterally, even though a patient may have capacity - perhaps all those stories we hear, including reports by the ombudsman, are fabrications ?

On balance this type of paternalism is probably slightly worse than the moronic nurses cited in your vignette [weighing up the cost of psychological damage vs witholding CPR from a patient whose life MIGHT be saved by it, assuming that's what the patient wants of course].

I'm sure I don't need to tell you that there are anecdotes about doctors who dished out bad news like they were reading the football results - can you honestly deny there is not a percentage of bullies and psychopaths in the medical profession, or are doctors so unique that they not affected by a problem that plagues every other type of profession ?

Read the posts again, none of the nurses here, or anywhere else that I can see in the blogsphere, are asking for these powers - but that still doesn't give you a licence to board the "doctor always knows best" bandwagon.

Doctors may be extremely knowledgeable medically, but that still doesn't exclude a minority who clearly have failed to develop communication skills that are comparable to clinical skills - you might have come across one or two of them, I know I have.

the a&e charge nurse said...

Would nurses be any worse than this?
http://www.guardian.co.uk/society/2011/aug/26/addenbrookes-andrew-lansley-sued-resuscitate