Disgusted with the GP.

[Daisymae15]

This is not a bashing the NHS thread we are so angry with the GP.

My Mil 92 is in a nursing home last Thursday she had a minor stroke the home called the GP and all she has done is send aspirin, wouldn't visit.
Yesterday she had a fall, banged her head, shoulder and back. Not injured enough to call an ambulance.
The GP was called yesterday and was supposed to phone, as of 7pm tonight she still hasn't rung. When WE phoned the surgery told that she is on the list to be called.
The home are frustrated at not being able to give anything stronger than paracetamol. We are frustrated because of covid we are not allowed to visit.
(Someone tested positive on Saturday so they have gone back in lockdown)
We feel as though the GP is hoping she dies so she doesn't need to bother. DH has spoken to the home and they have said that they are worried about her, she is in a lot of pain, very depressed and not even got dressed today. Last night she slept in a chair as she couldn't lie down.

As I have said I'm not bashing the NHS as in the last year I have had breast cancer and my treatment has been first class.(Not under the same surgery)
We can't change surgeries as each home in town has an allocated practice.

Is covid to blame or is it possible that she is a shit GP.

It's not the GP that's the issue here, OP, it's the care home. That sounds downright negligent.

I'd be on the phone 1st thing to the Nurse in charge/Matron or Manager. A fall following any form of stroke needs medical attention not bloody painkillers by phone. That's appalling.

Also DNAR in England do not need to be signed by family they are a medical decision

@MorganKitten

DNRs must be signed by family or this is worked out when you create the care plan. Ambulances are called at the care homes discretion.

No. DNACPRs do not need to be signed by the family. In fact, if the person has capacity to understand the discussion (not consent) it would be very wrong to share that discussion with the family without the person requesting it be shared.

Family members are signing to say there has been a discussion, where a person lacks capacity to do so themselves.

In an emergency situation it isn’t necessary to talk to the family at all (although best practice and attempts should be made to contact them).

Why didn’t the home/you call 999 when she had a mini-stroke? They are often precursors to more serious events and need to be assessed by experts.

@VaccineSticker

“A resident in a nursing home isn’t going to be a top priority because they have professional oversight already. The elderly person at home would take precedence. The person with chest pain would take precedence.”

@LemonRoses huh?A person in a care home has a professional oversight? Since when has a carer become now a nurse or a GP?
A mini stroke is beyond a carer’s expertise.

God, I really hope I never need a care home.

The OP says they asked the nurse from the home about an ambulance, so there is a nurse on site, the OP also says nursing home (although people do mix up nursing homes and care homes, nursing homes have nurses on site 24/7 and care homes are run by care assistants for people who don't have nursing needs)

Anecdotally, I got a terrific ear full from a ward nurse recently after 999 was called for something that could have been dealt with (it turns out, hindsight is a wonderful thing) by the paramedics or by an ooh GP/nurse but the paramedics decided to take the resident in to be checked over. They sent them out at 3am after giving me a dressing down for sending them in the first place.
We called 111 and they dispatched the ambulance, the paramedics decided to take them in - I didn't send anyone anywhere.

You're damned if you do and damned if you don't in many situations since covid, it's become an absolute mine field for residents, their families and the people that work in them, but it's the system that's screwed up, I've spent hours chasing phonecalls trying to get someone to see a resident ooh before, and that includes calling 999 - to have the lowest grade response attached to the call and told we're in for up to a 5 hour wait, with family demanding I do something, I really, really was trying and they'd seen a GP and not been transferred to hospital by them, then deteriorated.
We don't carry stock medications, we're not allowed to give something that someone is not prescribed and can't use one person's medication for someone else.
I'm not saying the home were right not to call 999 after the fall, but sadly the situation may not be all that different if they had.

If this was my relative I would be seriously upping the anti now. The elderly can deteriorate very rapidly. I suggest you:
talk to the duty manager at the home ASAP. ( There should be one identified at all times so don’t be put off by the fact it is evening now.) Ask them what actions they are going to take this evening ( & if necessary tell them you will refer this matter to CQC as safeguarding.) Ask them to contact the rapid response team for a visit this evening. (The team are designed to assess if a visit to hospital is needed and can medicate etc.)
Ring 999 if you get no joy from the home.
Also read the govt guidelines Re care homes. There are various ways you can get access such an nominated essential caregiver.
Have you requested DNR ? I may be wrong but believe your MIL will have had to agree this is her wish and it cannot just be a blanket home policy.
If all goes well look for a new home ( & therefore GP) for MIL. This is no way to treat a resident & not care. We moved our parent just before lockdown one & they were so much happier plus we trusted their new home. Homes vary hugely.

I had elderly aunt in very good care home until she died recently. There’s no question they would have called an ambulance for both events.

1. DM should have been sent to hospital after the TIA and after the fall. The two things may be related.

1. Don’t bugger about with the GP or the home, call the ambulance yourself, tell them you’re concerned she’s not getting appropriate care, then call the home and notify them one will be arriving.

1. While legally a DNR order does not need consent of the patient or family, good GPs and care homes do not put them in place without the family’s agreement.

@reesewithoutaspoon

A nursing home is only required to have 1 nurse on duty for legal reasons. The bulk of the actual care is done by carers

No. A nursing home in England is required to provide sufficient, suitably qualified and experienced staff to meet the needs of the people receiving care. That has to be properly assessed based on numbers and complexity of needs. In a small home it might be one RN, but in bigger homes or where people have more complex needs it would be more. NI, Scotland and Wales have similar legislation but specify numbers. .

I’d definitely be more annoyed at the nursing home than the GP. Unless she has an advanced care plan in place then they should be calling an ambulance. They surely don’t have a policy that says that they have to wait for a GP to authorise the need for one! I hope your MIL is okay.

I’d be putting a complaint in about the nurses to be honest. They have a duty of care. And as pp said just because a DNAR is in place doesn’t mean you can neglect and not provide basic nursing care for patients. I really hope she’s ok and gets seen properly soon! X

I would have thought the majority of patients in a nursing home would have DNR, this is entirely appropriate. However I dont think you can be privy to everyone's medical records. She is 92, requires nursing home care, had a recent TIA. CPR is unlikely to add anything to her life

However DNRdoes not mean do not treat. If the fall has caused pain severe enough to need more than paracetamol then Ibwould have thought A&E was appropriate. Even if just to assess, images to know exactly what's going on so it can be prescribed for appropriately

@MorganKitten

DNRs must be signed by family or this is worked out when you create the care plan. Ambulances are called at the care homes discretion.

They definitely don't need to be "signed by the family"

It's good practice to involve family in discussions and to record that discussion, some forms even have a space where the family can sign to say they were consulted but it's not a legal requirement. Some institutions could mandate this as a local policy, but I've never worked in one that has.

Resuscitation is like any medical treatment, it should only be provided when it is appropriate and stands a good chance of working. No patient, competent or otherwise, and definitely not their family even with an LPA can compel a healthcare practitioner to provide an inappropriate or futile treatment. No different to someone going to their GP and demanding a antibiotics for a viral infection, arsenic for covid or a heart transplant for an ear infection...

DH has persuaded the home to call for an ambulance after a lot of pressing from him. They are going to call him when it gets to the home.
Re the DNR all the residents do have one in place. It was a condition to get in the home last April.
This was told to Mil as she has full mental capacity.
We both have POA for health in place.
They only have one registered nurse for each shift otherwise it's HCAs. This home has 60 patients.
Regarding registrating for another surgery. 5 homes in town and 5 surgeries so it was decided that each surgery would take all patients in one home.
This is something that happened from covid.

@LemonRoses

Some real misconceptions about DNACPR forms.

In care homes now all residents should have a ReSPECT form completed on admission. Some are completed in hospitals, some by GPs. Certainly every resident in a nursing home should have one.

ReSPECT stands for Recommended Summary Plan for Emergency Care and Treatment. The ReSPECT process creates a summary of personalised recommendations for a person’s clinical care in a future emergency in which they do not have capacity to make or express choices. Such emergencies may include death or cardiac arrest, but are not limited to those events. The process is intended to respect both patient preferences and clinical judgement. The agreed realistic clinical recommendations that are recorded include a recommendation on whether or not CPR should be attempted if the person’s heart and breathing stop.

DNACPR does not require consent. It is a clinical decision made in discussion with patients or LPA. You cannot consent to treatment that isn’t offered. To attempt resuscitation on a very elderly person in a nursing home would be cruel.

The idea of a ReSPECT form is to allow people to remain in their usual home. Transfer to hospital is rarely in people’s best interest by the time they need a nursing home.

It is entirely possible they are very good GP who has had the conversation with your mother in law. What would you expect from transfer? A long wait in a busy confusing environment, on a trolley? Far better to remain at home. What treatment would you want for a TIA on someone of her age and frailty?

Your GP can prescribe painkillers and the home should have stock supplies, so perfectly able to give without a pharmacy dispensing personal ones. Many Many GPs are working through calls at 7pm.

A resident in a nursing home isn’t going to be a top priority because they have professional oversight already. The elderly person at home would take precedence. The person with chest pain would take precedence.

All of this. I'm a GP; I started work at 8 am this morning, and I still have 213 documents and medication requests to go through and action before I finish (before anyone asks, I am reading MN while I take 10 minutes to eat supper). Two of my colleagues are off with Covid. There are no locums available.

I need to prioritise the patients in greatest need. I would expect someone in a nursing home to receive proper care after a fall without needing intervention from me. The callback request on the GPs' list probably says something like "review painkillers" so the GP probably thinks it is a routine medication issue and has no idea that your mother is in distress.

@Daisymae15

DH is on the phone to the home now. Just to say all the residents have a DNR in place.

I don’t see how you can know this. Their private medical notes are just that - private. Do you actually know what happens if someone is resuscitated? It’s brutal, usually unsuccessful and where successful can lead to severe injuries.

With a suspected minor stroke, MIL needs to be assessed. They can be precursors to more major ones. Anticoagulants such as warfarin or rivaroxaban may be more appropriate than aspirin.MIL can’t be fully assessed without tests.

@Pixie2015

Also DNAR in England do not need to be signed by family they are a medical decision

Yes that’s correct Good practice is a discussion and formally record the decision

This issue does not lay with the GP the home has a duty to provide care and that right now is in the form of an ambulance.

They only have one registered nurse for each shift otherwise it's HCAs. This home has 60 patients.

Yowzers!! I do hope the home is split into units and the RN just works on the nursing unit (the unit for residents with nursing needs....)

Lemon Roses - it's a nursing home not a care home. There has to be a RN on duty. (Though I still question the decision making in this scenario, also the GP stating the covid status of another patient as a reason not to visit someone who needs assessment is negligent in my opinion).

Just to say all the residents have a DNR in place.

I'm surprised a random relative would know that about "all" -- is that because it's a facility policy, they must all have DNR? Or only a handful of people so not many people to know about?

Oh missed update from OP. Well done.

Why didn’t the home/you call 999 when she had a mini-stroke? They are often precursors to more serious events and need to be assessed by experts

Generally because dragging old ladies from their home environment, usually against their will, to wait hours for an ambulance, then hours on a hospital trolley in a&e, subjected to scans, tests and whatnot, then sitting on a ward, is not best care.

Many elderly are terrified of going into hospital because it’s well known that most don’t make it out again. They’d rather be in familiar surroundings. The issue is there should be policy in place to enable this, especially if there is a DNR in place.

All this talk about DNACR shouldn't detract from the fact that there is a 92 year old woman who is going to be spending yet another night in a lot of pain. Is there anything that can be done to change that ? At the very least can 111 and the out of hours Doctors provide pain relief for tonight ?

It was a condition to get into the care home to have a DNAR in place!? What the actual fuck?