Do Not Attempt Resuscitation: Let's Have A Conversation

Posted on 23rd of May by JuniorDoctorBlog

One of the hardest parts of any doctors job is talking to patients about the end of life, and whether to try to resuscitate them or not. I often wish I could have these conversations far away in space and time from the moment a patient is actually ill.
So let’s talk about it now. 
When I sit down with a patient or their family to discuss resuscitation I always find their understanding of CPR very different from mine. We always start with the same questions.

What is CPR? It stands for cardiopulmonary resuscitation, which simply means, trying to restart (resuscitation) your heart (cardio) or lungs (pulmonary).

Which simply means if you get so sick that your heart or your lungs stopped working, we would try to restart them. 

How do we do that? Well, the process of CPR is actually quite brutal. To pump a heart that isn’t beating you have to compress it from the outside, 100-120 times a minute. To do it properly you need to squeeze the chest by 1/3 of its depth, or 5-6 cm deep. 

This sometimes breaks ribs. Trust me, it’s as horrific as it sounds. 

The next step is stripping the clothes, and placing two large electrodes on to the chest connected to a monitor and large battery that can give an electric shock. If there is a heart rhythm that can be shocked, we dial up the machine to a high energy setting, tell everyone to not touch the patient or they will get shocked themselves, and electrocute them. I’ve seen this in semi-conscious patients and it hurts. 

We then carry on with pounding on the chest. 

At some point a specially trained doctor or nurse will try and pass a breathing tube into your throat, insert tubes into the veins in your arms, neck or groin, and give large doses of heart pumping drugs. 

We cycle through this process, deciding every two minutes whether the heart can be shocked, or whether there is something else we can do. This can go on for sometime- we swap the person giving compressions back and forth so they don’t get tired. We even have a machine that does this for us.

At some point we will have tried everything. Resuscitation stops when every single member of the team agrees there is nothing more to do, or the patient’s heart will start beating again on their own.

What happens next? If the patients heart or lungs started working again, then the breathing tube is connected to a machine, and the patient is taken to intensive care.

I’ve looked after lots of patients who went through this, what we call a ‘cardiac arrest’. Some will leave the hospital, many won’t. 

The reason being is that for every second your brain is without oxygen, your brain cells are dying. We can see this on an MRI scan after a long period of ‘downtime’- time without oxygen or blood pumping leaves your brain swollen and misshapen. The chance of recovery is slimmer the worse the damage appears to be.

That all sounds very doom and gloom, but it shouldn’t. This is the very last ditch attempt to save life, and its value is inherent in the few successes we have. But they are few.

I wish everybody knew how few. The problem is our understanding of CPR as a society is based entirely on commercials and television.

A large study many years ago found that on television nearly 70% of resuscitation scenarios end with the patient waking up, and hurrahs all round. But this is far from reality. 

In the average person, the chance of that patient waking up and leaving hospital after a ‘cardiac arrest’ is around 18%. In patients with severe medical conditions, such as stroke, sepsis, or failing heart valves, the chance is about 5-10%. In end stage kidney disease or end stage cancer it can be as low as 1%. 

That is probably news to you. It certainly was to me at med school. It’s news to most of my patients and their families. 

So in summary, CPR is a brutal last ditch process that seldom works and usually has significant and lasting harms for the few that do survive. You may think I’m being grim, but this is the honest truth- please ask any medical professional. 

Now that’s why I always want to talk about CPR when people are well. When things are very hectic and somebody is very sick, it’s very hard to listen to someone saying the chance of success of CPR is low- it sounds like we are giving up. 

But we are not, we are making a plan. Good doctors like plans. We call this plan a ‘do not attempt resuscitation’ order, or DNAR. It’s a very important bit of paper, kept at the front of the patients notes, usually an obvious colour like red, that states very clearly that if heart or lungs stop working we should not try to restart them, and the reasons why. 

It doesn’t change any decision about having an operation, or chemotherapy, or even using life support machines. It’s not about changing the course of treatment, it’s about making a plan for if it all goes wrong.

It might surprise you to know that a higher proportion of doctors who become unwell choose to not be resuscitated and decline treatment than the general population , choosing to die at home rather than hospital. Many doctors have their red line conditions, things they have seen that they themselves would never want to go through the treatment for, knowing the suffering involved and the likely outcomes. 

There’s a great book about medicine and death called “Being Mortal” by an American surgeon called Atul Gawande. In it he talks about five questions that everybody should ask when they contemplate the end of their lives, and he sums them up with one question “what are you fighting for?”

Reading this at home, hopefully very well, it might be hard to ever imagine what you would want if you became very sick. What would you fight for? Please think about it. 

We aren’t very good as a society about talking about death, as if the discussion of the inevitable somehow diminishes the possible. Normally my blogs finish on an abrupt punchy ending sentence, but I find the hardest conversation in my job never really ends, it just moves on,

Juniordoctorblog.com

References

Decisions relating to cardiopulmonary resuscitation 

https://www.resus.org.uk/_resources/assets/attachment/full/0/838.pdf

What Are the Chances a Hospitalized Patient Will Survive In-Hospital Arrest?

http://www.the-hospitalist.org/article/what-are-the-chances-a-hospitalized-patient-will-survive-in-hospital-arrest/

Being Mortal by Atul Gawande

https://www.amazon.co.uk/Being-Mortal-Medicine-What-Matters/dp/0805095152

Cardiopulmonary resuscitation on television. Miracles and misinformation.

http://www.ncbi.nlm.nih.gov/m/pubmed/8628340/?i=3&from=/19699021/related

Nolan et al “Incidence and outcome of in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit.” Resuscitation. 2014 Aug;85(8):987-92.

http://www.resuscitationjournal.com/article/S0300-9572(14)00469-9/fulltext

The Significant Seven: An Exploration Of The Counter-Evidence For A '7-Day NHS'

Posted on 11th May by JuniorDoctorBlog

The Department of Health’s favourite line is “There are 8 independent studies showing a ‘weekend effect'”. I’ve been through these 8 before, and the terms “independent” and even “studies” are used fairly loosely. This has been the stick Jeremy Hunt and co have used to justify their unfunded and unmodelled 7-day NHS plans, and to beat the junior doctors with. This week the stick broke.

To borrow the Ministry of Truth’s own language: “There are now 7 independent studies showing that the 7-Day NHS plan is a bad idea”.
Juniordoctorblog explores the counter-evidence against the 7-day NHS spin.

---

The ‘Weekend Effect’

Three separate studies this week came out against the established narrative of ‘poor care’ at weekends creating excess deaths.

“Higher mortality rates amongst emergency patients admitted to hospital at weekends reflect a lower probability of admission” by Meacock et al in 2016

All previous research has shown increased rates of dying amongst patients who are admitted to hospital at weekends, but not those already in hospital or attending A&E. Meacock et al used the same data from the original Freemantle paper that Jeremy Hunt was quoting his ‘11,000’ excess deaths figure from, which covered 12,000,000 admissions to all 140 hospitals between 2013-14. They found for patients attending A&E on the weekend, far fewer were being admitted to hospital vs a weekday. When you look at all patients attending A&E, as opposed to those being admitted, there is no weekend effect. The authors attributed this to the differential admission threshold – well patients are less likely to be admitted on a weekend, so this makes the group admitted on weekends sicker on average, thus increasing mortality rates slightly.

Bottom line: the ‘weekend effect’ appears to be about how patients are counted, not how they are looked after.

Professor Rothwell, Oxford University, interview on Radio 4
– so far, unpublished study

Now the purists amongst you will claim this is unpublished, and therefore not available to scrutiny. I agree. However, we are using the DoH definition of ‘study’, which includes all manner of reports, audits, and human resources documents. So it’s in the Seven.

Prof Rothwell group based from Oxford Univeristy found similar problems with the ‘weekend effect’ amongst stroke patients. Looking at patients in Oxford, they found those labelled ‘strokes’ weren’t strokes at all, but were admitted for other things, like urgent investigations, or rehabilitation. These admissions happened primarily on weekdays- meaning only truly sick stroke patients came on weekends, but weekdays had a mix of very well patients and unwell patients. Once these was corrected, the weekend effect disappeared. Prof Rothwell said “nobody had done… the basic due diligence” on these studies to look at this.

Bottom line: the weekend effect again was found to be a statistical artifact, based on how patients are counted, not how they are cared for.

“Weekly variation in health-care quality by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care” by Bray, 2016

There were a lot of statements about stroke care, and a huge backlash from stroke experts who had already spent 10 years improving the urgent care of stroke. Now a new study from Bray that used national data between 2013-14 on 74,000 patients with stroke found no association with weekend vs weekday admission. No weekend effect. It did find variation across many variables in different patterns, including a small increase in mortality in weekday night admissions. The study called the weekend effect ‘an oversimplification’.

Bottom line: Again, no weekend effect, small changes on weekday nights, and further work needed. Oversimplification not helpful.

“What are the Costs and Benefits of Providing Comprehensive Seven-day Services for Emergency Hospital Admissions?” by Meacock in 2015

Put aside the fact for a moment that the ‘weekend effect’ probably doesn’t exist. Don’t get bogged down in methodology, as Jeremy Hunt doesn’t. This paper by Meacock in 2015 looked at the actual size of the supposed ‘weekend effect’ and then worked out the cost to address it. It found the cost, £1-£1.5 billion, was far higher for the small supposed benefit than any medication or treatment recommended in the NHS.

Bottom line: even if the ‘effect’ existed, the money would be spent better elsewhere for greater patient benefit.

“The 7-Day NHS”

So despite the evidence being weak, the government has plowed forward in making their “7-day NHS” plans. Except they haven’t.

“Managing the supply of NHS clinical staff in England”

Public Accounts Committee 2016 

The PAC is a group of MPs that examine public policy and hold public departments to account for their decisions. This report found that the Department of Health had made ‘no coherent attempt’ to work out how much a 7-day NHS would actually cost, or the doctors or nurses needed to staff it. They were told they were ‘flying blind’ on this issue. A leaked report suggested they needed £1 billion a year, 4000 more doctors, and it ‘probably wouldn’t alter’ the supposed weekend effect anyway.

Bottom line: close scrutiny of policy for 7-day working found it to be woefully lacking. 

While the 7-day policy seems to be a shambles, a further report shows the existing NHS  heading to disaster;

“Sustainability and financial performance of acute hospital trusts”
Public Accounts Committee 2015-16

This second public accounts committee focuses on hospitals and funding. It revealed that No. 10 created “unrealistic” and “unsustainable” budget cuts to hospitals. As in the report above, hospitals had to cut regular staff but many refused to cut quality in favour of cost- hiring back temporary staff at a higher rate. The committee were clear that the excess cost running the NHS into a deficit of £2.8 billion was 80% due to the gaps created, not the fees themselves. The report also found dodgy accounting practices – which came from a whistleblowing hospital accountant who requested anonymity for fear of losing his job. It would seem a lot of ‘creative accountancy’ was going on to make hospital budgets look healthier than they are, to cover up the extent of the ‘black hole’ in NHS finances.

Bottom line: NHS hospitals are currently in a budget and staffing crisis created by No. 10 who then attempted to cover it up. 

---

Still with us?

So far we’ve established that the 7-day NHS is an unfunded and unmodelled solution to a non-existent problem, which probably isn’t fixable itself, but even if it was, isn’t cost effective to do so. Meanwhile the real problems of the NHS are not only being unaddressed they are being actively covered up.

So what’s it all about then?

Throughout this drive for seven days services has been this narrative that there aren’t enough doctors at weekends, and this leads to harm; the ‘weekend effect’.
So having already discussed there is no weekend effect, we should probably still address this ‘lack of doctors’.
Firstly, no study has ever looked at junior doctor staffing levels. Full stop. So we actually cannot possibly say that is associated. One study from the Hateful Eight actually showed that medical cover is 100% across seven days, and this is true, all hospitals have junior doctors Monday to Sunday, midnight to midnight. Despite this Jeremy Hunt embarked on a damaging junior contract fight anyway, despite all the evidence to the contrary.

What’s surprising is that the Department of Health themselves don’t even know how many juniors are already working weekends.

Freedom of Information Request to Department of Health 2016 and Commons Question, 2016

In two unrelated freedom of information releases NHS England first revealed they had no idea how many junior doctors typically work on a Saturday or bank holiday nationally, and then in a written question from MP Norman Lamb it transpired that the only research into this that had been done was a ‘snapshot’ of 14 hospital rotas, in January 2016 (well after the contract had already been ‘imposed’, I might add).

Bottom line: despite no evidence to show a link to junior doctors and weekend mortality issues, a new contract was ‘imposed’ anyway, without anyone actually studying the problem they were trying to ‘fix’.

Confronted with this last week, the Department of Health shifted the goalposts once again– now saying the ‘weekend effect’ is about consultant presence and diagnostics. Except it isn’t.

“Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study” by Aldridge in 2016

This is a study looking at a snapshot of weekday to weekend cover of consultant specialists attending hospital admissions. It found that consultant specialist presence varied between weekend and weekdays, but found no link to any change in mortality.

This follows from another study by Bray in 2014 looking in stroke units specifically whether the presence of a consultant on weekends and weekdays made a difference to mortality. In that study consultant presence made no difference, but the number of nurses had a direct link to survival.

Bottom line: in the only study that looked at weekend and weekday mortality in NHS hospitals there is no link to consultant presence. 

Nursing numbers are much more important but this government cut training places in 2011 and cut the bursary in 2016- the PAC recognised this would continue the shortage for at least another three years. 

Wrong again.

 The Significant Seven are a damning group of ‘studies’ that highlight how ill thought out and potentially dangerous both the 7-Day initiative and the current NHS management is. Is this incompetence or something else?

---

Let’s change the perspective.

Imagine you are in government. You made a back of the envelope promise of a ‘7-Day’ NHS without defining anything for voters, but you’re also ideologically against increasing funds to a socialist medical system.

You can’t be seen to cut costs to a beloved and vital national institution, so you announce ‘efficiency’ drives and streamlining of services, a ‘pay freeze’ which cuts pay by 25% against inflation. You get wind of new NHS contracts, and decide to make some subtle changes- increase basic pension contribution, reduce junior doctors pay and remove financial penalties for hospitals that make doctors work illegal and unsafe hours.

Obviously you can’t be seen to want to attack doctors to cut costs, you need a PR message that will travel. You find an already running plan to improve urgent 7-day Care, and in the words of Fiona Godlee, editor of the BMJ, derail it.

You never really believed hospitals needed that much money, or that costs really do rise at that rate, so when hospitals started to report crisis level failings, you didn’t listen. When junior doctors protested and demonstrated and even sat outside your office for three weeks, you still didn’t listen.

I am a doctor- I want a 7-day health service more than anyone, because I know what that would really mean. I also know that we need more funds just to keep the staff and the hospitals we have already going, and if we want to ever improve our health service, Mr Hunt, we must use the evidence properly.

Now the evidence is knocking on your door.

It’s The Significant Seven, and behind them 68 million people. We’d all like a word about our national health service. It’s time to listen.

Juniordoctorblog.com

 

Jeremy. Let's Make This Simple.

Posted on 7th May by JuniorDoctorBlog

“Everything should be made as simple as possible but not simpler.”

Albert Einstein

There’s a great book called Thing Explainer by Randall Munroe that explains lots of complex stuff in the simplest terms possible, using only the thousand commonest words in the English language. The dispute over the new junior doctor contract has become increasingly confusing, so let’s keep this really simple.

---

Jeremy Hunt said this new deal for doctors was meant to make ‘7 Day hospitals‘. He said ‘more people die on Sunday compared with Wednesday‘ and this is because of poor care and less doctors. He called this a ‘weekend effect’. The papers where we read about new events said this too, many times.
But new findings show there is no ‘weekend effect’. People sick at weekends go to hospital, but fewer people actually stay in hospital at weekends, and less people die, not more, on Saturday or Sunday. Only very sick people stay in hospital on weekends, while slightly less unwell people go home and come back during the week.

It is easier to explain if you use a story.

Here is a story.

Ten people go to hospital on Wednesday, two are very sick and will soon die, two are well but need urgent advice. All ten stay in hospital, and the two who need advice are seen by a special doctor who gives it to them. For that Wednesday ten people stayed in hospital, two people died, so the ‘risk’ of death is 2 in 10, which is 20%.

The same ten people go to hospital on Sunday. Two are very sick and will shortly die, two are very well but need urgent advice. The two who need advice see a general doctor, who arranges a special doctor to see them on Monday. They go home. The eight left stay in hospital. For that Sunday eight people stayed in hospital, two people still died, so the ‘risk’ of death is 2 in 8, which is 25%.

So because two well patients waited at home for advice, instead of staying in hospital, the ‘risk’ of dying on Sunday seemed to go up, by 5%, because of how they were counted, not because of how they were looked after.

So Jeremy Hunt said we need to make 7 day hospitals. We have ‘7 day emergency hospitals’ and we know now that those 7-days look after emergencies the same, every day.

Doctors don’t like the ‘new deal’ because it’s unfair to women, reduces pay, and spreads five days worth of doctors across seven days, for what we now know is no good reason. It also takes away the rules that stopped hospitals making doctors work unsafe hours. 

Doctors told Jeremy Hunt this was a bad idea, but he forced the deal on them anyway. Jeremy Hunt told doctors they were killing patients by not agreeing to the new deal. This was a lie, and it made doctors sad. Many have now left.

Now Jeremy Hunt wants to talk again, but only about Saturday pay. Doctors know this was never about Saturdays, and now so do you. Jeremy Hunt told everyone that the new deal wouldn’t cost any more money than the old deal. So without a reason to change things, what does Jeremy want?

I’ll tell you what I want. I want to go back to looking after people again. I want to go to work and have enough doctors to look after everyone properly, every day. I want hospitals to have enough money to help us do that. I want the people in charge to only want that too. I simply want hospitals that continue to look after everyone based on need, not on how rich they are.

Now that you’re up to speed, what do you want?

Juniordoctorblog.com