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.

Wingedharpy I work in a community team and we will be caring for poorly people who don't want/need admission to hospital.

We've already had some covid positive patients die at home (with rather than from covid) and it means they could have relatives with them.

I agree the DNACPR conversation needs to be handled sensitively, But we're in a race against time now. I implore those of you who feel they can have these conversations with their relatives they do so. Not just around DNACPR but advanced care plans. Treatment at all costs doesn't mean if you come out the other side you'll do it with good health and function. I don't want to be ventilated first that reason.

I do agree it has to be done sensitively and I in no way condone that letter being sent. There are better ways.

Drs aren't callous but they do understand the real chances of success better than the general public. The chances of actually being successfully revived after a cardiac arrest and surviving long enough to be discharged from hospital are about 10%.

The chances of surviving to discharge after being ventilated in ITU were 40-50% in the couple of studies I found and 25-30% were alive after a year.
(this is in normal times).

I told you I have encouraged my own mum to do a DNAR. I am not writing her off. She has a great quality of life but she has metastatic cancer. I am so sad that this virus may shorten her life but most of all I will not allow it to rob her of a dignified death. I want her family to be there which we can only do if she's at home. I am super worried about what palliative care resources there will be and I am trying to get some answers from her GP on that.

The more people write a DNAR/ advance refusal of treatment plan who are unlikely to benefit the less likely that Drs have to make bad decisions that no-one wants to make about younger people with co-morbidities.

In ordinary times obviously we would try to save 50 year olds with co-morbidities eg obesity and diabetes. We would try to save fit independent 70year olds too. As long as we have resources I am sure we still will.

This is why we have to do social distancing and we have to flatten the curve so that we have resources to save as many as we can.

NC for this.

A few years ago my father was in a car accident. He was admitted to Icu with multiple injuries and sedated and ventilated. Several weeks later the injuries were healed, but they just couldn't get him off the ventilator. He became hugely distressed when they tried to get him to breathe on his own and even the nurses would cry. In the end we had to turn off the life support and he died peacefully.

He was in his early 60s, fit and well before the accident.

It made me realise that while ventilators will help some people, they are not a magic cure.

I think the current pandemic has bought these issues to light and time is not on our side. The reality is that these sorts of convos should be had between most people and their loved ones. Irrespective of age.

One of my parents passed a good few years ago. They lost a long battle against cancer and had successfully fought it for years. But it was clear to me when no more interventions were going to work. In my culture, talking to an elder about a DNR is deemed disrespectful so no one would talk to my parent about this. And they fought the drs about bringing this up. It fell on me (the youngest in the family) to find a moment and talk to my parent about how they felt about being resuscitated / heart being restarted/ cpr.

My parents (verbatim) response? ‘Don’t be silly, I’m dying, why would they do that?’. I waited for the dr who then confirmed to my parent what I was saying. That unless a DNR order is in place. They will be dutybound to try and resuscitate. The parent in question clearly then stated to bring whatever forms were required and was clearly able to articulate to the dr what interventions they wanted at the end. The only one they asked for? Pain relief so that they could go peacefully. That parent had no idea what a DNR order was or that they would try and bring them back to life (again verbatim) ‘what so I can die again?’

I appreciate that cancer is inevitable and this virus is not. But any sort of invasive procedures / resuscitation are painful and hard, especially so on patients who are frail. More people need to understand that and have these conversations.

One of my siblings has medical POA over me. I picked this one sibling for a reason. I have clearly stated that if I am vegetative/ with no quality of life ahead of me, to pull the plug. I don’t want to live like that and I don’t want my family to care for me / know me as a vegetable. I’m relatively young but I still have had these convos with my loved ones.

Death is inevitable and some of us will go via these situations. Don’t assume the frail/ vulnerable in your lives know about DNR’s. These conversations need to be had.

I think we are all being a bit 'snowflake' ish if we take offence at this kind of thing.

Seriously? You think it's 'snowflake-ish' for people to object to people being confronted in an insensitive way with brutal info about how their lives may end? Just wow.

My parents currently have symptoms (they live in a hot spot in London). We have had the conversation over the phone, if it comes to it they do not want to go to hospital, choosing to die at home. These things need to be addressed so that there is actually less worry for them once they feel they have some say over their own death.

Being miles away there is not much else I can do.

Often these convos never happen until it’s too late and you are having to make a horrible decision as a relative. I had to be the one to make this decision about my relative many years ago and i had to base it on what the doctor said and knowing what my relative would have wanted had they been able to decide. When it’s too late it is horrible rather than before hand and people can come to terms with what could happen

Not so much brave Absolutepowercorrupts as a stone cold utilitarian who would give Bentham a run for his money.

She makes informed decisions always. I have always been grateful for the no bullshit way I was raised but particularly so over the last couple of months.

It is cold to "write people off", it is also the reality and has been the reality in most places and times throughout history. We have just been so cocooned for so long in the West that we forgot.

It's shit, but humans are being reminded that for all our arrogance we control nothing.

There are elderly people recovering from this, including after being on ventilators but particularly after being hospitalised and given oxygen.

Not to mention their good chances of recovery if requiring brief admission for something more minor.

Medical decisions will have to be taken of course, and he may well not stand much chance of getting a ventilator or even an ICU bed...but to have a blanket ban on any hospital care is ridiculous.

I hope people are not being pressured to sign things, but the fact is they are and it is awful.

I'm all for DNR's and not sending people to hospital unnecessarily, but, as well as getting DNR boxes ticked, what I want to know is WHAT IS BEING DONE ABOUT PALLIATIVE CARE PLANNING?

There are very few people IMHO, who would be able to care for their nearest and dearest, dying at home, without some professional support

This.

I also thought today, a propos the announcement in Sussex that no care home residents could expect hospital admission if they contracted Covid, that that was tantamount to a sort of ageist eugenics (if that is the right word) After all, no-one was talking about access to ventilators in that instance and who would be able to give adequate nursing and symptomatic care in the community for these poor people?

Add to that the circumstances of their current care make it much more likely they will be infected, with agency carers going into multiple care homes, and no PPE available for anyone, staff or residents.

It almost looks like a deliberate ploy to get rid of a burdensome sector of the community, whatever the actual logic behind it.

who would be able to give adequate nursing and symptomatic care in the community for these poor people?

Yes, their was a segment about this on Newsnight last night and care home were saying they have no experience at all of dealing with the symptoms particularly in those struggling to breathe, and no idea how to administer the right care. There is another thread at the moment where many care home residents and staff trying to care for them have died.

Ok well where I am the following is being done

Increase stock of syringe drivers
Pooled primary care nurses to free up support for community nursing teams
Prevention of admission teams set up
COVID home care teams in pipeline
Pooled GP resources to support people at home
Discussions around DNAR’s
Monitoring of people who are at home with a long term condition or are symptomatic
Care calls to vulnerable people
Offloading of non priority cases but keeping the vulnerable

Christ, I've got no chance then. Even though I'm 'only' 35 (& a lone parent), due to my health issues it says "Mild Frailty" on my medical records.....Despite being classed as obese, oddly.
So if frailty is the measuring tool used, then I've got no chance!

@Menora

Do you know how this situation might affect the care of someone (friend of the family) who is at home in palliative care for cancer? They are receiving visits from nurses and are on the list for a hospice place at some future point.

If one good thing comes out of this it will be a change in our attitude towards end of life care - with a move towards emphasising quality of life rather than length of life.

When he had capacity, DF now in his 90s physically quite fit but with dementia, was very clear that a long slow death from dementia was the last thing he wanted.But the state denied him the choice of ending his own life at a time and in a state that would have maintained his dignity
.
The last thing on earth we would now want would be for him to taken to an ITU in a hospital and intubated. I cannot imagine anything more terrifying. And for what? To ensure that he would survive another couple of years non verbal and doubly incontinent?

If it's reassuring, friends who are GPs and Community Nurses are being trained to provide palliative care in the home. It isn't about writing people off, it's about providing the best and most compassionate care possible.

I have heard of someone who was put on a DNAR without being consulted! I think this was a mistake rather than a national thing. He's 65 and has underlying health conditions. What a horrid, insensitive letter to receive.

@Inkpaperstars

I really do not know. I think the family may need to prepare that the hospice may not be a viable option and make plans to care for their family member at home where possible

Also I think where community nurses would have spared extra time to spend with palliative patients they may be more focused on the patient being comfortable but unable to ‘hold hands’ with patients or families as much. Also the OT’s and physios have all been moved to a central unit and may be ward based so there might be challenges obtaining equipment or helping with managing ADL’s. I know where possible the care will be there and as good as they are able to provide but it may look a little different. They should talk to the team caring for them to find out what their capacity is

Thanks @Menora

One of my mums last outings before she started isolating was to update her will.She has also made a file of all her important papers.
At 82 with COPD if she gets it her chances of recovery are low,a ventilator wouldn't help.
A ventilator is just a way of getting enough oxygen into you while your immune system fights the virus.If your immune system can't your other organs will fail and that's it.
We don't have a cure.A ventilator just buys you a little time but by the time you need one the virus already has a good grip.
We are not overwhelmed yet,at the moment if you don't get ventilated it is because it would make no difference.The 50% chance of then making it off a ventilator alive is the optimistic view as we are seeing lower.
This is something Everyone should have a conversation and the introduction of th e Respect form will help.