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Don’t let the DNR row destroy a good idea



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.