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At the heart of general practice since 1960

Don't let the DNR row destroy a good idea

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If a surgeon botches an appendicectomy you would want to investigate what happened; you might want to examine the surgeon’s competence and look at the operating environment where they were working; you would look for lessons to learn, and might need to refine the exact surgical technique they were using. What you would not do is to question the surgical treatment of appendicitis.

In primary care we do not operate with laparoscopes, forceps and retractors; the tools of our trade are largely words, phrases and good communication. Sometimes someone utterly botches the use of our tools – the GP equivalent of nicking the bladder during a laparoscopy – we must learn from this, refine our methods and be humble when we receive criticism, but we must not allow the whole profession to be damned by the clumsy methods of the few.

Health commentator and blogger Roy Lilley joined his mother at home recently when the district nurse visited to talk about advanced care planning, as part of the admission avoidance scheme.

According to Mr Lilley’s account of what happened, the one-sided discussion that followed is truly appalling. The nurse had never met his mother and simply worked her way methodically through a form, asking highly emotive questions completely out of the blue like: ‘where do you want to die?’ and ‘do you agree to Do Not Resuscitate?’ It was terrible communication, a real train crash, but should it be used to undermine the whole concept of advanced care planning?

Mr Lilley has a right to be angry about how his mother was treated, but he also loves a bit of controversy and has been slow to ask if other practices might be doing this better. He has blamed ‘the form’ and thrown the whole concept of care plans into question; not surprisingly he has managed to stir The Daily Mail and The Telegraph into a lather about death lists and patients ‘signing their lives away’ – I won’t grace either of them with a link.

The unplanned admissions DES has the wrong name - since it implies that it’s all about saving money rather than empowering patients - but it is one of the few good ideas the Government has come up with. It’s hard work, and (as Pulse has previously reported) the timescale to get the plans done is ridiculously short, but compared with worthless dictats such as GPPAQ, or endless, non-evidence based urines for ACR testing, I know what I’d rather be doing to help my patients.

Advanced care planning involves highly-skilled communication. Of course it cannot be delegated to a district nurse who does not know the patient; while the time pressures may make me sympathetic towards practices that are doing this, I can’t defend it. Neither should advanced care planning ever be reduced to ‘going through a form’ - it should be a high level conversation, with the form used to record wishes, priorities and decisions. Nor should questions ever be asked with the answer already assumed – ‘do you agree to?’ should be something like ‘how do you feel about…?’.

Many of my older patients are surprised to find that they would be resuscitated if they had a cardiac arrest. It seems obvious to them that it would be a bad idea, and they assume that if they know they don’t want it then why would anyone do it to them. The culture we live in, however, says that common sense cannot take place unless things are written down. If we are to live with full-on aggressive care as the default setting when someone gets ill, then advanced care planning is essential and we need to have the means to help our patients get this right.

The reality is that the majority of practices will be doing care plans really well, it will be led by GPs who are some of the best trained communicators in the NHS, and will empower patients to have their say in their treatment. We must not let the media hijack this for the sake of a juicy headline, or the LCP merry-go-round will just keep on going, and doctors and their patients will be left in limbo. 

Dr Martin Brunet is a GP in Guildford and programme director of the Guildford GPVTS. You can tweet him @DocMartin68.

Readers' comments (12)

  • I beg to differ.

    This is not a good idea at all. It is a bureaucratic nightmare that is leading to nervous breakdowns for practice managers and the loss of GPs who are leaving the NHS because they realise General Practice is finished.

    It s an insult to GPs who try and avoid admission in their patients on a day by day basis. Anticipatory care is what we do every day. To tie us to 2 % of our population actually reduces our time for all our patients.

    I have done 20 care plans so far and about the only thing I have identified is the need for a raised toilet seat.

    Martin Brunet please do not insult you colleagues. I think your views are not shared by the majority.

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  • Yep I agree with the above comment..you've got it wrong on this occasion. It's a terrible purely politically motivated idea and it is all about saving money...except in the end we all know it won't.

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  • To above hear hear!

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  • It strikes me that the reason General practice is in trouble is because you guys are your own worse enemy. Soft weak GPC, woolly headed GP's such as this writer and what is frightening is that he's a director of the GPVTS!

    If you don't recognize that you're in the middle of political media war you will be destroyed as a profession. We will all suffer if that happens.

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  • absolutely agree with the above comments

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  • Dav

    You've hit the nail on the head, well said

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  • I have clearly stirred some feeling with this post, and I'm grateful for people taking the time to give a different point of view, but I need to defend myself.

    Regarding the first comment: yes, GPs have been doing some anticipatory care for a long time, but if we are honest this has mostly been for real end of life care, and often in the context of malignancy. If you have been helping all your frail elderly with advanced care planning then I take my hat off to you, but I suspect most GPs have not - we haven't had the time or resources to do it.

    The post is about the value of doing advanced care planning - this is a good thing! The design of the DES, and whether or not it has been properly funded, is another matter; I certainly don't defend the time scale and agree that it is ridiculous to expect us to do them all by the end of September. Why 2%? Well, I'm not sure that's ideal, but if we weren't given a target then would we actually do them? This is the world we live in.

    You said you had only identfied one thing after doing 20 - I don't think these plans are for the GP to identify anything as such, they are for patient's wishes to be discussed and properly recorded so that they are taken into account when their regular GP isn't around. Every plan I have done has been worthwhile. Again, I think this is a good thing, and not to do with death lists or people 'signing their life away' as the Mail would have the public believe.

    I have been accused of being soft and weak. Well, if you read my other posts you will see that I am not shy of criticising the Government when they have got it wrong. My primary concern, however, is that we should do what is right for the patient. If that would make me a poor rep on the GPC then so be it, but I will stand up for good medicine that cares for the vulnerable even if at times that means harder work for me. I would rather shout back at Mr Hunt when he tells me to do non-evidence based dementia screening, for instance, than when he instructs me to spend time with my elderly patients.

    In my training role on the VTS I like to encourage the trainees to think for themselves, and to challenge what the government is doing, but I am always enthusiastic about what a fantastic job it is to be a GP; I don't think that's too frightening, but maybe I'm not the right person to ask!

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  • Like Martin, I am also a Trainer and TPD for a VTS program; I think it is unfair to raise these associations as it implies we are indoctrinating trainees to our point of view, as opposed to facilitating stimulating discussion. Trust me - they are adult learners with all sorts of views, some of which are very different from ours.

    That said, I am completely opposed to this sort of tick box medicine, because in my view, this is all it is.

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  • 87% of people say they would like to die at home, surrounded by their family. In my borough 12/13 24% actually did. Clearly 'care planning' is as useful as the conversation developed by the professional enables it to be. My patients only die once and I want to feel I have done all I can to make that the kind of experience that does them justice - in contrast to many of the horrific undignified deaths I witnessed in hospital. If they become incapacitated as a potential 'best interests' decision maker, I need to be very clear about what they would have wanted, and who they would like me to talk to. If I need to tick a few boxes, in the course of having those conversations and that gets me some resource for doing the right thing all the better.

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  • I'm afraid Martin makes vitally wrong assumption - he assumes we know our patients well enough to raise such sensitive question and will find opportune time before 31st September to discuss it.

    I'll give you an example from my personal life. My father in law has had 3 respiratory arrests in the last 12 months. My wife is a specialist nurse dealing with cancer and end of life discussion on daily basis but it took her till now to raise her courage to discuss her dad's end of life care with her mum. Neither of them knew the answer as to what their dad/husband wanted and my wife was shouted down by her sister for "wishing him dead". Father in law's response? He just said he's not ready to die and he was very upset. Her family is just not the kind of people who would rationalize death and even my wife didn't anticipate the degree resistance she would encounter. Thank god it wasn't a random DN or GP whom they've never met before asking the question.

    Yes, it is right to ask the question in the right circumstances but general public is not ready nor emotionally detached enough for a "care plan" detailing their death to be acceptable. I write this as I've just lost a patient who died soon after having such discussion with me - the family still ended up calling an ambulance despite the DNR form being signed and left on their care note as the elderly wife could not deduce wether her husband was dead our just fainted. Although the family thanked me for my part in his care, I cannot feel all I've done was to cause unnecessary upset and made no real difference to the poor patient or his wife. And this was a patient whom I felt was important to have end of life chat!

    By the way, did you know if you loose a patient from this 2% register you'll have to replace with another? So I'll have to pick another victim now do that I can get paid. Surely no conscientious GP would advocate such scheme?

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