How do we stop people smoking at the front doors of our hospitals? by Chris Isles

Over a million smokers are treated in UK hospitals each year and a small proportion of these feel compelled to smoke when they are admitted to or visit hospitals. The image of smokers congregating at the front doors of our hospitals in wheelchairs with dripstands and catheter bags is all too familiar for those of us who walk past them as we come to work. We recognize that health risks to others are minimal because smoking in the open air is no threat to anyone’s health, but it nevertheless gives the wrong impression of a hospital as a promoter of a healthy lifestyle. We were particularly concerned that smokers would rapidly migrate to the front entrance of our new hospital in Dumfries when it opened in December last year.

A British Thoracic Society audit in 2016 of 14,750 patients across 146 hospitals in the UK found poor recording of smoking status in medical notes and little evidence that people who smoked were asked if they would like to stop smoking or were referred to a smoking cessation service. In hospitals with designated smoking areas (41% of all hospitals in the audit) smoking restriction was “completely or mostly” enforced outside these areas in only 33% cases. In hospitals with no designated smoking areas, restriction was “completely or mostly” enforced throughout the grounds in only 40% cases. This was despite a NICE guideline in 2013 recommending that hospitals should set out a clear time frame to establish or reinstate smokefree grounds and remove smoking shelters or other designated outdoor smoking areas.

As if in response, Public Health England launched a NHS Tobacco Free campaign in 2017, although the Department of Health in England has no plans to make smoking on hospital grounds illegal at present. Northern Ireland made it a criminal offence to smoke on hospital grounds in 2016. Similar legislation has been passed in Wales though here there is provision allowing the person in charge of the hospital to designate any area in the grounds as being an area in which smoking is to be permitted. In 2016, the Scottish Parliament passed an amendment to the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2005 which made it an offence to smoke within a designated perimeter around NHS hospital buildings. The proposed perimeter is 15 metres. Smoking within this perimeter will lead to a £50 statutory fine which can rise to up to £1,000 if taken to court. When this latest legislation is implemented in Summer 2018, environmental health officers employed by the local authority, rather than NHS staff, will hand out the £50 statutory fines. As it stands there are no exceptions, for example psychiatric hospitals or hospices. It will also be an offence to allow someone to smoke on hospital grounds with a maximum fine of £2,500.

An opposing view is that instead of criminalising smokers, we should show compassion for those who have the capacity to make an unwise decision and for whom smoking may be a comfort at a difficult time. We make allowances for drug users in hospital by prescribing methadone and we do not stop the morbidly overweight buying sugary drinks at the hospital shop, so why not allow smokers to smoke in a designated smoking shelter? The fact that Greater Glasgow Health Board failed to stop smokers from smoking at the front door of their hospitals, despite spending £473,500 on a high profile campaign in 2013, suggests to us that the money could be better spent addressing the findings of the BTS audit and by asking patients if they would like to stop smoking, referring those who do to a smoking cessation service, and by reinstating smoking shelters.

Chris I 1We could endorse the Scottish government’s proposed legislation that will attempt to eliminate smoking within a 15 metre perimeter of our hospitals or we could accept, however reluctantly, that smoking will never be completely eradicated and reinstate smoking shelters, while providing access to stop smoking services and support to help people who would like to quit. In any event it is difficult to imagine exactly how environmental health officers will impose and collect spot fines. And yes, as predicted smokers did rapidly migrate to the front entrance of our brand new hospital in Dumfries when it opened in December (see photo above).

Chris Isles is a Consultant Physician at NHS Dumfries and Galloway.

This blog was originally published in the BMJ online here

Dementia Awareness by Julie Garton

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Dementia Awareness Week runs this year from 4 – 10 June. There are lots of events across the region supported by a wide range of individuals and organisations. This year, I’ll be promoting the use of a document called ‘This Is Me’ within acute hospitals and asking Dementia Champions and other colleagues across NHS Dumfries & Galloway settings to join in.

When someone with dementia comes into hospital, a care home or is receiving care at home, they and their family/friends may be asked if they have a ‘This is Me’ document.

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What Is ‘This Is Me’?

‘This Is Me’ is intended for use by anybody with dementia, delirium or other communication impairment.

It aims to provide important personal information about the person from their perspective and those who know them best (family/caregiver) to help enhance the care and support given when the person is in an unfamiliar environment.  It’s crucial that we understand the person as an individual and take their personal history into account, helping us to communicate and engage with the person, which in turn can help us to prevent/alleviate stress and distress.

What are the benefits of ‘This Is Me’?

For the person, their families/caregiversif the person with dementia has memory and/or communication problems, then a ‘This Is Me’ guides and supports staff to provide care in a way that respects the person’s choices, preferences and routines. ‘This Is Me’ can be a great opportunity to ask and find out information, that as family members we may not know – provoking good memories and conversation. In addition, a ‘This Is Me’ or similar may reassure people with dementia and their caregivers that we see behind the dementia and respect that person.

For stafffor professionals, it can help us deliver person centred care, and importantly, reduce the times we ask for the same information – the detective work has already been done.

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Where can ‘This Is Me’ be used?

‘This Is Me’ can be used anywhere, in hospital, care homes, in primary care, respite care and is offered during Post Diagnostic Support.

When should it be completed?

‘This is Me’ always offered during Post Diagnostic Support but can be completed at any time.

Are there issues around confidentiality/sharing this document?

The document is the property of the person and/or their main care giver – it is not a clinical document and does not belong to any professional or service, the person/care giver decides what information is included and shared.

Once completed, the document should be kept in a place that is easily accessible for those providing care, for example, at the bedside, in a care plan. The information can help staff understand the persons’ baseline abilities, lifestyle, routines, likes/dislikes and gives great opportunities for conversation and engaging with the person.

What happens to the form if/when the person is discharged or transferred?

As it belongs to the person, it should go with them on discharge/transfer, and it’s also useful to check with the person and /or their main carer that the information remains up to date and relevant.

Living Well with Dementia

It’s important to understand that many people are able to live well with dementia, leading active and fulfilling lives for years after they first experience difficulties and receive a diagnosis, but coming into hospital can be daunting for all of us, and for people with dementia , this can be a frightening experience.

Whilst these days, a person with dementia may only be in hospital for a short time, how we communicate and support them will have an influence on the impact of the whole care experience and how quickly they can return home. We know that older people with dementia are more likely to be discharged to a care home than older people without dementia, have longer hospital stays and experience more falls and pressure ulcers.

We know that in Scotland around 93,000 people are living with dementia and we think around 25% of all acute hospital beds are occupied by people with dementia (Alzheimer’s Research UK, 2018), yet mostly, people arrive into our services without a document such as This is Me even if they have one at home.

“This is Me gives me golden information about an individual. The nuggets of information are priceless in helping to smooth the way to getting to know the person behind the dementia”

Gillian, Staff Nurse

‘This Is Me’ is just one of a range of tools that can support centred care, Getting to Know Me, Life Story work and a wide range of personal profile tools are available, many online, helping professionals to see the person, not just the patient.

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I ‘m keen to hear about your experience/s of using This Is Me in your workplace – please contact me or, if  you would like more information about This is Me or would like a copy, please contact me at jgarton@nhs.net or 01387 246981.

Julie Garton, Alzheimer Scotland Dementia Nurse Consultant

Dietitians do Prevention by Laura King

Laura King 1Next week sees the return of Dietitians’ week and the theme this year is ‘Dietitians do Prevention’ with each day having sub-themes. Follow #DietitiansWeek on Twitter, Facebook and Instagram for some insights into our involvement in a wide and varied range of preventative activities.

Here in NHS D&G we have dietetic teams working across these areas which may come as surprise to the majority of folk working in the acute hospital who perhaps associate us mainly with artificial feeding and oral nutritional supplements for those who have scored 2 or more when nutritional screening is done on the wards.

As a small team we recognise that we have to play a role in educating and enabling patients, their families and carers to prevent over and under nutrition by supporting self-management, the dietitian can’t come shopping with you, cook your meals and help you to eat them and make the best choices, so we have to rely on using our communication skills to educate and inform patients and those close to them to help have a healthy, balanced diet that meets their needs.

We factor in ‘what matters to you’ and our assessments incorporate a huge range of factors as this poster illustrates:

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Our Team works in the following areas all of which have significant roles to play in prevention:

Community Nutrition Support  (Kerry, Alexandra, Jackie, Jennifer, Lis, Dillon and Carole) – We provide practical, evidence based dietary advice, specifically tailored to each individual. Through dietary advice we aim to prevent and treat a wide range of medical conditions and empower people to make appropriate diet and lifestyle choices. Community Dietitians see patients in a variety of settings including community hospitals, nursing and residential homes, clinics and patient’s own homes. Our role identifies, prevents and manages malnutrition in the community. We liase with individuals to create realistic and achievable goals to optimise/improve their dietary intake.

Various medical conditions require an individual to be provided with their nutrition via a tube. We are responsible for managing these patients in the community, either in their own home or in a nursing home/community hospital setting.

We deliver educational talks on various topics including cardiac rehabilitation, stroke, Parkinsons disease and pulmonary rehabilitation.

Renal (Fiona) – Supporting patients with advanced kidney disease in managing complex nutritional requirements. Preventing further complications that can arise from inability to excrete electrolytes and fluid overload as well as avoiding weight and muscle loss for this group of patients who have increased requirements for protein once dialysis has commenced.

Gastro (Gemma and Sarah) – Preventing complications from poor management of coeliac disease such as the obvious GI disturbances through to the ‘hidden’ consequences such as increased risk of bowel cancer and oesteoporosis. Supporting patients living with inflammatory bowel disease to manage their symptoms and optimise their health and well being. Preventing the often crippling effects of irritable bowel syndrome by supporting patients to use the low FODMAP diet to identify trigger foods and modify their diets in a safe and sustainable way.  Preventing malnutrition in liver disease which is often masked by fluid shifts.

Paediatrics (Mhari, Anne and Tracey)  – Supporting parents & their child in managing children with complex needs, tube feeding, diabetes, gastroenterology issues, cystic fibrosis, weight management, faltering growth and allergies – preventing short and long term consequences of under nutrition.

Diabetes (Katy, Nicola, Sally, Sheena, Wendy): We are an integral part of the diabetes multi-disciplinary team providing a dynamic and evidence based service. We deliver quality assured education, and aim to support patient driven care and safe self management to those living with diabetes and their family. We also provide continuing education and support for health care professionals working with individuals with diabetes.

Weight Management (Katy, Nicola, Sally, Sheena, Wendy): We provide person centred, safe and evidence based advice to individuals with complex needs and requirements. This encompasses a variety of approaches to help aid weight loss and improve quality of life.

Mental Health and eating disorders (Sam and James) – Supporting recovery from mental health crises and from the consequences of living with disordered eating behaviours.

Catering (Debbie)- Working with Catering to achieve menus for inpatients across the region that offer a varied, balanced diet to support their recovery and prevent complications such as poor wound healing and  pressure ulcers. Also ensuring guidance for Catering teams to create therapeutic or special menus for patients’ individual dietary requirements. Training staff who make and deliver food, fluid and nutritional care to patients in hospital.

Acute (Laura, Anneka, Laura, Jennifer, Laura and Sheree) – seeing patients identified as being at risk of undernutrition to assess their individual needs and support recovery. Preventing increased length of stay, poor wound healing, pressure ulcers and other complications of malnutrition and providing advice for discharge to help patients stay well and continue their recovery once home with or without the support of the community dietitians as appropriate.

All this activity is coordinated and supported by our Head of Dietetics (Lorna).

The acute team are planning to pilot some staff education sessions on B3 and D7 to support ward staff in preventing malnutrition as well as identifying the patients who need our one-to-one support, so please get in touch with Dietetics on 01387 241568 if you would like to know more, want to arrange any training on your wards or if you have any questions about this blog post and what we do.

Meanwhile here are some pictures of the acute team (Anneka, Jennifer, Laura and Laura) ….

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Laura King is Lead Acute Dietitian at Dumfries and Galloway Royal Infirmary

Summer of Celebrations Part 1 by the SPSP Team

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Reflections from Improvement Advisor, Paul Sammons

As an improvement advisor with no clinical background, I work closely with people who want to change things for the better, and who know their teams and roles well, but who don’t always have the skills to structure improvement work.  They may not have the capability to use the ‘model for improvement’ – a proven methodology that helps focus aims, identify change ideas and to measure what difference if any, a change actually makes.  Having completed the Scottish Improvement Leader programme (ScIL) in 2015/16 I do have that capability which, when brought together with practitioners who have a will and an urgency to change things for the better, can be very powerful.   I enjoy the privilege of working alongside, enabling, and learning from some fantastic individuals and teams who strive to improve services of their patients and service users.

Some of these moments will be with me forever – I recall working with Dr. Grecy Bell to motivate and enthuse a group of primary care staff about Medicines Reconciliation – not the most lively of topics, but Grecy created the ‘med rec fairy’ concept – a local champion in each GP practice who would carry the ‘wand’ to ensure their team saw med rec as a vital part of their work.

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Another great memory for me was working alongside Dr. Mark Colwell – we teamed up to lead a local dental improvement collaborative, creating a structure around better decision making and treatment planning for patients on high risk medication.  Mark showed me how ceding power to his team enabled a flat hierarchy where all team members were able to critically observe each other’s practices, and contribute towards a more collaborative approach to patient care.   With the practices involved we improved much – starting even before patients arrived for their appointments – maximising the use of text messaging, moving through the patient’s journey. The work involved reception staff to engage with patients to obtain highest quality patient histories, and enabling dental nurses to observe and to prompt their bosses into even better patient conversations.

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I have observed people in health and social care who once invigorated with a little QI magic, will stop at nothing to deliver better care, and who seem to have the energy to drive improvement forward in the most unlikely circumstances.  I spend time with Julia Hutchison in DG Smile dental practice, and I leave with a real spring in my step.  What is it about these people and all of the others that I get to support that is courageous, different and special?  I do reflect on a wee video that helps me answer that question.  You might like it too.  It is available on YouTube and can be viewed here.

I believe that attention to QI capability and capacity is key to improving services, and that we will see this develop through our local ever-expanding network of QI capable practitioners.  In the near future we will expand our practitioner level QI education and training – to ensure managers and leaders are well equipped to support, coach and supervise improvement projects.  In 2018/19 I plan to focus improvement efforts into the Women’s and Children’s teams as they settle into their new DGRI home.  I contribute to the improvement force field that is growing stronger across Dumfries and Galloway in health care and in social care.  I work as part of a small but wonderful team of hand-picked curious and quirky individuals – who quietly and tirelessly support each other, creating a synergy of support to our customers.  Perhaps you are close to that growing network of improvers – perhaps you feel the force like I do?  Well I do, and as I work with a widening spectrum of fabulous people I can honestly say that there is much joy in my work.  Long may it continue…

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What Matters by Ken Donaldson & Alastair McAlpine

I recognise that it is a bit cheeky of me to put my name to this as I haven’t written any of it. A few months back I was scrolling through Twitter and came upon this thread that really moved me. The messages are simple yet immensely powerful. I have therefore simply taken some screenshots from Twitter and published them here. As you can see this is by a Doctor called Alastair McAlpine who is a Palliative Paediatrician in Cape Town, South Africa. Read on…..

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Food is about so much more than just nutrition… by Claire Angus

Are you someone who craves the crunch of crisps? Enjoys a chicken and rice soup? A chocolate sundae where you delve through layers of whipped cream, ice-cream, chocolate brownie, chocolate pieces, and chocolate sauce?!

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We could describe the foods above as containing lots of textures, or as having different consistencies… runny, crunchy, crispy, flaky, smooth, chewy, soft, thick, thin.

The consistency of your dinner is unlikely to be a high priority.. unless you’re a food critic or a chef! Most of us decide on food choices based on what sort of flavours we fancy, how ‘filling’ or for some folk ‘light’ a meal is. When we order in a restaurant, we often peruse the menu before picking a firm favourite dish, or maybe we pick something we know we could never make as well at home, or something expensive – if someone else is paying!!

For some people with ‘dysphagia’ (swallowing problems), choices about what to eat, and what they can safely eat, are more restricted.

The adult Speech and Language Therapy team work closely with many adults who have acquired ‘dysphagia’ as a result of a health condition i.e. stroke, brain injury. Our main roles are in assessment of an individual’s swallow (how strong is it? How quick is it?), giving handy hints and tips about how to make swallowing easier depending on the particular difficulty (sitting upright whilst eating, tucking chin to chest), and advising on how food and drinks can be modified so that they’re easier to manage (and prevent unpleasant coughing/choking, and pesky chest infections!!)

So that you look less like Theresa May coughing on water at this conference…

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And more like this happy lady.. happy whilst eating her chips from the canteen…

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We used to use ‘stages’ to describe the consistency of drinks, and ‘textures’ to describe the consistency of foods. As is often the case with healthcare which develops and evolves, there is to be change! This change comes in the form of introducing a new way to talk about food and drink consistencies. The plan is for these to be used internationally, as pretty colourful triangles and numbers can be understood in any language. Here’s a diagram of the new International Dysphagia Diet Standardisation Initiative (IDDSI) triangles.

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Essentially, starting from the very bottom at level 0 is the ‘thinnest’ liquid available – think plain old water. As you work your way up the levels, the consistency gradually thickens – think of yoghurt drinks and smoothies. At level 3, there is an overlap where the consistency can be provided as a moderately thick drink, or a liquidised food (e.g. McDonald’s chocolate milkshake/custard) and as you work your way up to level 7, the food becomes more challenging – requiring more mouth control in biting, chewing with your teeth, mashing with your tongue, co-ordinating a mix of different textures (think of that chicken and rice soup/chocolate sundae I mentioned right at the start!) and controlling a strong timely swallow.

Our adult Speech and Language Therapy team embraced a food challenge to try and understand the new descriptor ‘levels’ and to experience what it might be like to be recommended a specific consistency ‘level’ and to prepare meals accordingly. It was much harder than we anticipated!

Here are some of our reflections:

Level 3 – Liquidised Food

Laura’s first stumbling block was when she realised she doesn’t own a blender! She therefore changed the task to see if she could buy a day’s worth of convenient food and drinks at level 3 consistency.

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Whilst it’s maybe not as healthy as making a meal from scratch, and probably more expensive, she felt it was more realistic for people like her who prefer meals that are more easily prepared. She was required to think ‘out of the box’ – buying fruit and veg puree from the baby aisle, although she highlighted that this might feel slightly demeaning to an older adult. She reflected on the challenge, saying “If I had to have my food and drinks modified to this level on a long term basis then I don’t think I would manage with the hunger! I would probably ask for the support of a registered dietitian to offer suggestions on improving oral intake and maintaining nutrition and hydration.”

Level 4 – Pureed food

Becky cooked a mushroom risotto, before putting it through the food processor!

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Becky reflected on the experience, saying that she would feel frustrated if she was having to prepare food to level 4 consistency out of necessity, as she struggled to ensure that the consistency was correct. Claire who also prepared food to level 4 consistency felt that it took longer than usual to prepare dinner as she was having to blend and sieve everything. This can be a real pain if you only have one of each and are required to keep washing everything as you go! Jan who also completed the challenge felt that she would miss the different textures of foods if she was required to prepare all meals to level 4 consistency.

 

Level 5 – Minced & moist food

Amy cooked bhurjee, an Indian take on scrambled egg.

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She felt that the challenge helped her think about how complicated it can be for patients/family/carers of people with dysphagia to prepare food to the correct consistency level. Whilst Helen was completing the challenge, she reflected on the fact that food is about so much more than nutrition.  It is often used for social occasions, and gifts, and she thinks that she would struggle going out to eat in cafes/restaurants with friends and family if she was only able to eat food which was minced and moist. Another valuable insight offered by Helen was the added layer of difficulty there may be whilst preparing food of modified consistencies, if an individual’s cause of dysphagia is post-stroke, and they are required to do food preparation (i.e. small chopping, dicing, blending, sieving) with their non-dominant hand.

 

Level 6 – Soft & bite-sized food

Kirsty cooked a Balmoral chicken with peppercorn sauce, level 6 style!

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She felt uncomfortable as an adult having her dinner presented cut up into 1.5cm bite-sized pieces almost as if for a child, but still managed to present it beautifully!! Helen prepared macaroni cheese, assuming that this would be an easy way round a level 6 meal. Turns out that pasta which measures up as 1.5cm when dry, expands to 2cm when cooked, and therefore each and every piece of pasta had to be trimmed by 0.5cm to meet the IDDSI descriptor of 1.5cm!! Talk about time consuming! IDDSI’s 1.5cm thumb nail sized pieces have been proposed as this is smaller than the adult trachea (wind-pipe), and therefore minimises the potential of a choking risk. Helen felt as though the challenge made IDDSI’s strict descriptors more practical, and personal, and removed them from just being on paper. 

 

Completion of this challenge highlighted for many of the team just how important food is.. for socialising, for comfort, for enjoyment! Most of us will celebrate good news by popping open a bottle of bubbly, or heading out for dinner in a favourite restaurant! Whilst these new descriptors have rigid descriptions – they have been created and tested so that everyone can enjoy food and drink as safely as possible!  

 

Claire Angus is a Speech & Language Therapist for NHS Dumfries and Galloway

  

(The International Dysphagia Diet Standardisation Initiative (IDDSI) is being implemented throughout Dumfries & Galloway over 2018 in all hospital, care and home settings. From 21st May, the fluid thickener Nutilis Clear changes to follow the new levels of drink, and anyone using Nutilis Clear will need to mix their drinks slightly differently.)

 

  • For more information on IDDSI, look for links on the Beacon flash adverts or visit:

http://iddsi.org/Documents/IDDSIFramework-CompleteFramework.pdf

  • Follow the adult SLT team on social media using:

@SLT_DG on twitter

@SpeechandLanguageTherapyadultService:NHSD&G on facebook.

Realistic Medicine—is it achieveable? by Heather Currie

A few months ago I was fortunate enough to be able to attend the Realistic Medicine conference held at Easterbrook hall. Hearing personal stories was, as always, moving and thought provoking. Little did I know that I would be having my own Realistic Medicine experience within a week.

My dad was a legend. Cantankerous, stubborn, opinionated, yet determined, resourceful, creative, inventive and mischievous! He has had many encounters with the NHS over recent years, mostly good but not all, from which I have learnt much. His outpatient journey, which I described in a previous blog, inspired me to look into how our outpatients run in the hope that we could do better.

He was always a farmer and continued to be involved, always knowing best (!)  until he was no longer physically able. At the age of 89, despite cardiac failure, chronic kidney disease, gout, peripheral vascular disease and osteoarthritis he managed to stay at home in the country, looking out onto hills and fields of sheep and cows, with help from family and carers until June 2017. Then, with decreasing mobility and some cognitive decline, he agreed to move into a care home. A care home on a working farm with a room looking out onto a field of cows was perfect. The staff were wonderful and he settled well, enjoying the company, feeling safe and good cooking! But he was inevitably becoming frailer.

One Sunday morning in October when I was visiting, he was quite drowsy. On discussing with the staff they mentioned that he had had blood tests showing worsening renal function and this was being monitored. My response was that perhaps blood tests were not needed and that most important was that he was comfortable. 

The following night around 11.00pm I was phoned from the care home to let me know that he was going into hospital and that the ambulance was about to leave.  Further blood tests had been taken. The results had been seen by an out of hours doctor somewhere in the north of England, who recommended hospital admission and ordered the ambulance. When I asked “What are we hoping to achieve?” the response was that while the care home staff and paramedics agreed that keeping him comfortable was the correct path for him, they could not go against the recommendation of the out of hours doctor.  I knew that he would not want to be taken to a hospital many miles away, for what? Phone calls to family members confirmed that they felt the same. Dying in the ambulance or on a hospital trolley was a distinct possibility, instead of comfortably with family with him, in the room looking onto a field of cows.

Several phone calls later enabled me to speak to the out of hours doctor. After explaining dad’s history, he agreed to cancel the ambulance and send a colleague out so that the care home had whatever was needed to keep him comfortable.  Having only blood results to go on, he could not make the fully informed recommendation. But why were blood tests taken in the first place? 

Dad died the following evening. Several family members had been able to visit during the day, he showed no signs of distress and at the end my daughter and I were with him, in the room looking onto a field of cows.

 If a death can be good, this was one, but could so easily have been very different. As my nephew later said, “Heather, none of us could have had that conversation. To move him would have been a disaster.” But why, when the family, the care home staff and the paramedics all believed that the right course of action was for him to stay, were all of us initially over ruled by a doctor who had never met my dad and had limited access to his medical history, albeit he was acting in good faith? 

So we achieved a realistic outcome this time, but is Realistic Medicine universally achievable? 

Possibly, but a major change in mind set from ourselves and from the public is desperately needed.

First and foremost we need to be kind,

But we also need to be brave

And we need to be realistic!

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Heather Currie is an Obstetrician and Gynaecologist and Associate Medical Director for Women’s, Children’s and Sexual Health and NHS Dumfries and Galloway