Could have understood this wrong but..

[imamearcat]

I got a text from my cleaner, her elderly farther (80's) has health issues but lives at home with his wife. My cleaner helps care for them but I get the impression they are 'ok'. He had a call from the doctor and to explain his 'end of life care', basically saying if he gets Coronavirus, or anything else for that matter, over the coming months they will not admit him to hospital and they have asked them to sign an agreement that he will me 'made comfortable' but not resuscitated.

Is this a thing that's being done?? Have I got the wrong end of the stick and it's just something they would be done anyway? Can't stop thinking about it, just seems so wrong.

Theres was a legal challenge but basically yes. If it comes to a ventilator shortage. Which it will. Everyone i love who is in any vulnerable is staying inside

I have heard similar from a friend but I can’t verify the information so I’m hoping it’s wrong.

If my mum received such a letter it would mentally destroy her. She's very very vulnerable mentally. She's very frail and hiding at home. I actually think that would push her over the edge.

It’s the cleaners father not other customers!

I assume the cleaner was asking for OP’s advice/opinion?!

A surgery in Wales has has to apologise for doing this so I don’t think you have got the wrong end of the stick.

news.sky.com/story/coronavirus-gp-surgery-apologises-for-sending-do-not-resuscitate-form-to-patients-11966979

We probably all need a plan about what we would like to happen should we need to be resuscitated or if we can’t be treated but this is just such an awful way to go about it.

Yes it's her farther, not another customer. I guess she just told me about it as a friend?

I get that at the time, there might not be a bed for him and sounds like with his age and conditions he would probably die anyway, but there might be a bed and seems awful to just write him off like that!!

I've heard my younger sister tonight say the age is 65... i can only imagine she heard this from my dr sister, I didn't ask my sister directly to confirm cuz she's on night shifts , but I sure will ask tomorrow

I might get a but muddled up but I am convinced I only heard this is something they'd roll out in the Netherlands but my understanding is the individuals at risk would be given a choice. There is a different attitude and experience there in terms of making choices at such stages in life though. The issue was that the conversation would need to take place over the phone which is insensitive but they’d have no other way of doing it.
I am shocked to hear this is happening in the UK. It’s not something many people would be qualified to carry out face to face let alone during a phone conversation and what about patients who are hard of hearing? A letter is even a million times worse.

I think it is reasonable to have a conversation with patients whose health is so poor they are likely to suffer and unlikely to survive despite medical care. GPs do have those conversations when people have terminal illnesses so this has just brought a new group of patients into this category
Do remember though that, if these patients do not catch Covid-19 this would not kick in, it isn't a death sentence

I'm an older people's Dr

There is no age cut off.
It's done on likelihood of benefitting.
This is based on frailty scores. If you need help with personal care, can't walk outside the house etc then these are the kinds of issues that would be considered.
(If you are in a wheelchair in your 20s post an accident etc that is not considered the same before anyone raises that.)

Tbh I have been having a lot of end of life, DNAR discussions lately and many were long overdue and should have been done before.

Realistically a person in their 90s living in a care home will not benefit from ITU. They have a low chance of survival and an even lower chance of good quality of life. My patients who expressed an opinion were 100% not wanting invasive care.

I do think these conversations should be done sensitively but we should not avoid them.

I don't think there are any circumstances in which an 80yo patient suffering from pneumonia would be admitted to ICU and ventilated. Outcomes are terrible.

If we're going to get through this people need to begin to understand that ventilators aren't magic. Prolonged ventilation is brutal and can cause long term health problems afterwards, even for fit healthy young folk.

I had a similar call about DF who is in his 90s in a care home with dementia. I was quite glad they'd thought about it. In the past when he has been in hospital he has only coped because I've been there to explain things, advocate for him etc. If he was suddenly hauled off feeling ill to be amongst a load of strangers without me there, it would be incredibly distressing for him. He's also made it clear several times that he doesn't really want to be here anyway since DM died. It was quite stark being presented with this, but ultimately it wasn't a difficult decision to make.

A letter or a tick box form isn't great but a phone call from a Dr you know isn't all that bad.

I think this is the kindest thing I can do for my elderly patients. Better I talk to them now than an A&E Dr they don't know makes the same call with less information in a crisis scenario. This way we have a chance to talk about their wishes and they can have their say.

One so far has said 'I want the whole works' and I dutifully recorded that also.

It's a conversation about an important topic not a write off/ forgone conclusion. Older people shouldn't be offended to be asked and most are not at all.

BTW I have encouraged my own mum who would be unlikely to survive a ventilator to make an advanced directive so I do practice what I preach.

I think it’s really important this is discussed and made clear before it’s needed.

These discussions go on all the time with patients not all to do with Covid.
Would also like to endorse what was said above.Because the government is putting so much emphasis on ventilators people seem to think that this will cure people It will not We don't have a cure.A ventilator may help but this gives you about a 50%chance but there is a cost in all these very invasive interventions and for a some patients only difference a ventilator will make is to give family false hope.

I had this phone call on behalf of my mum who was in hospital but doesn't have capacity. It nearly broke me after a few difficult months. I totally understand why they are doing it but it was just a shock.

Makes sense. My cleaner (friend) said she wasn't surprised by the news but said the rest of her family had been quite upset. I guess maybe she she's him more than they do?

I have had elderly grandparents who have now passed, but it wouldn't have made sense to put them on a ventilator.

It's a shame we have not had a bigger conversation about this until it is needed.

It's tragic but I know for sure if my outcomes were looking limited I would not want to take a ventilator that could be used for a child or a young parent. I'm 52 with no kids.

I must write a living will and send it to my mum and sister.

Can I ask a question about ventilation please? If a patient needs ventilating, what is the average length of time they could expect to be on one before either progressing to recovery, or not?

I think in Italy it was a couple of weeks at least but most were dying anyway?

I don't know why people are so shocked by this. I frequented the elderly parents thread before my mum died last year, and most of the people on those threads, who have been around our parents in the final years, say we do not want the long drawn out existence that our parents have in extreme old age (not everyone has this; I know some 95 year olds do that standing on aeroplane wings thing etc.). Many people say, 'take me to Dignitas when I don't know who I am.'

I have filled in an Advanced Directive for myself, declining treatments in many situations.

COVID has created a situation where unfortunately there will have to be decisions made about who gets the ventilator. An extremely old, already ill, already fragile person, will just suffer even more, confused and alone on a ventilator. Hence asking for a DNR.

jimmyhill

I don't think there are any circumstances in which an 80yo patient suffering from pneumonia would be admitted to ICU and ventilated. Outcomes are terrible.

If we're going to get through this people need to begin to understand that ventilators aren't magic. Prolonged ventilation is brutal and can cause long term health problems afterwards, even for fit healthy young folk.
X

Can you tell something more, please? I am not medically qualified hence never heard of that. Why are ventilators bad when used for a long time?

I work in the nhs and we are having advanced care planning with our community patients about if they were to get ill would they want admission to hospital and invasive procedures. As part of this we are discussing DNACPR.

A lot of our patients are very frail and likely to have a poor outcome even with admission. Most would rather die at home. It has not been clarified whether people would not be admitted to hospital based on frailty scores or just the level of treatment they would receive once there.

Also from a self preservation point of view I would prefer it if frail patients have DNACPR forms in place as they are unlikely to survive a cardiac arrest and I don't want to be a position where I'm expected to attempt CPR by my trust.

CPR is a high risk for passing on the virus to health care workers. I have got to say I would think twice about attempting if I felt it was futile and that it would put me at risk.

Our trust is advising chest compressions and defib only (no airway or breathing support) if Covid suspected and you don't have very high level PPE ie gowns and a respirator.

Actually doing CPR on a frail person with little chance of survival is a bleak and brutal thing in any circumstance and nothing has convinced me of the value of advanced planning more than those experiences.