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Issue:- 25 April 2013

Should we say patients are terminally ill

IN this week's BMJ, experts debate whether patients need to know they are terminally ill.   Emily Collis and colleagues at the Central London Community Healthcare NHS Trust say that decision making can only be ethically sound with a fully informed patient, saying that:- "accurate information enables patients to make informed, realistic choices and helps achieve patient preferences of care."

They point to General Medical Council guidance stating that information should only be withheld from terminally ill patients if it is thought that giving information will cause serious harm, specified as "more than becoming upset." And if information is withheld, the reasons must be justified, documented, and reconsidered at a later date.

Therefore, the key consideration for doctors is not whether patients are informed that their disease is incurable, but how this information is communicated, they argue.

They believe is that patients:- "should be given the information they want or need in a way they can understand" and "ideally these conversations would occur throughout the course of the patient's illness, enabling him or her to come to terms with the situation in their own time."

They acknowledge that estimating prognosis "can never be completely accurate", but say this "should not obscure the clarity that the illness is incurable." They add that no one can make decisions on behalf of patients who have capaCity, and that unless a patient refuses information, withholding information at the request of a relative is not ethically justifiable. They added that in their view:- "Breaking bad news is challenging in any context, but the consequences of neglecting this duty may directly affect the trust between doctor and patient, the patient's autonomy, and ultimately his or her quality of life."

But Leslie Blackhall from the University of Virginia believes that insisting on prognostic disclosure to facilitate "patient choice" regarding end of life care "is a failed paradigm for medical decision making that creates more suffering than it relieves."

Leslie Blackhall thinks the concept of "terminal illness" is not clearly defined and that prognoses can never be certain. For instance, she asks, does telling someone that they are terminally ill mean telling them how long they have to live (hard to know for any individual)? Does it mean telling them that they will eventually die (true for all of us)? Does it mean telling them there is "nothing we can do" (never true)?

This lack of precision she concludes:- "indicates an underlying failure of the medical profession and wider culture at large to consider how the fact of human mortality should be accounted for in the practice of medicine."

The real question, she says, is not whether patients should be told that they are "terminally ill", but how can we provide excellent care to patients with incurable, progressive illnesses?

Blackhall believes that to make decisions about care, patients with life limiting illnesses do not necessarily need to know how long they have to live or be informed when they pass some ill defined threshold of "terminal illness", or choose to accept death. Instead, she says, they need:- "to understand the limitations of disease modifying therapy for their condition; what medical care can do for this disease; what side effects treatments might have; and what may happen as the illness progresses; or to delegate that task to a trusted surrogate. This is not an argument for deceiving patients, or for reverting to a paternalistic mode of care. On the contrary, it is an argument for honesty about the efficacy of various types of medical care throughout the spectrum of life limiting illness."

So what are your views on this? Please us your feelings about this issue to:-


MERSEYSIDE Police are this week appealing for the next of kin of John Mulligan, aged 73 year old, to contact Sefton Coroners Office. Mr Mulligan was found dead at his home in Stile Hey in Thornton on 18 April 2013. There are no suspicious circumstances surrounding his death. Mr Mulligan may have had relatives in Liverpool and anyone who can help the coroner trace his next of kin is asked to call:- 0151 777 3481.


"NHS Hospital cleaning will become our main defence against potentially lethal infections such as MRSA, E. coli, Clostridium difficile (C. diff) and Norovirus in a world without antibiotics" is the stark warning from Christina McAnea, UNISON Head of Health. Antibiotics that are effective against these are likely to run out in the next 20 years, as infections become increasingly resistant to the drugs available.

In a survey of more than 2,000 health workers, 25% revealed that operations had been cancelled in their hospital in the past year, due to outbreaks of infection. And 40% said that their hospitals had been forced to close wards because of infection.

Managerial concern over infection control has encouraged expensive cleaning systems such as robots that use hydrogen peroxide and UVC. Companies that sell these are subjecting some hospitals to high pressure selling tactics, and wasting precious NHS resources, said the union.

Christina McAnea, UNISON Head of Health, went on to say:- "Hospitals are turning to these costly systems because they are desperate to find solutions to a world without antibiotics; a world we will all have to face in the next 20 years. These are expensive gimmicks that do not do the job as well as good old fashioned soap, water and elbow grease. There is no room for complacency; people will be dying of untreatable infections in only a short time frame. But, instead of spending taxpayers' money on expensive kit, that money would be better spent on increasing the hours spent cleaning. Cleaning staff should be given the training to tackle routine cleaning of high risk, near touch sites, besides the patient's bed, the bedside locker, bed frame, buzzer, overbed table, etc. That is the way to cut down the spread of these potentially lethal infections."

One well-known 'superbug' is MRSA and the union is highlighting flaws in the way that Government is currently gathering statistics on the number of cases in hospitals, which mask a very real threat to patients.

Dr Stephanie Dancer, Consultant microbiologist, said:- "National figures show the number of MRSA infections as falling, but these are misleading because they only reflect the cases where MRSA has gained entry into a patient's bloodstream. MRSA can still be acquired in hospitals on patient's skin, in a wound, or cause chest and other infections. Some of these superficial infections require powerful and toxic antibiotic therapy as well as increasing the amount of time patients need to stay in hospital. Hand-hygiene has been rigorously implemented in hospitals but this only represents one way to control the spread of infections. Screening patients for MRSA has allowed more cases to be picked up prior to hospital admission. However, hospitals have to cope with accident and emergencies that don't allow for early screening, so other measures need to be implemented. Targeted cleaning of hand-touch sites near the patient remains an inexpensive method for reducing the risk of MRSA and other hospital infections for patients."

UNISON is calling for stricter accounting of MRSA cases amid fears that the number of patients picking up MRSA continues, without knowing the full extent of the problem.

What are your views on UNISON request for stricter accounting? Do you think that they are correct in what they are asking for? Email us your views to:-


MERSEYSIDE Police are appealing for the public's help in tracing the following man from the Southport area who is wanted after failing to appear at Liverpool Crown Court. Danny While, 37, of Hall Street, Southport is currently wanted by Liverpool Crown Court for failing to appear for the offence of production of a controlled Class A drug (Meth Amphetamine) and also for breaching a susended sentence that was given for the same offence of producing a Class A drug. He is still believed to be in the Southport area and may be using trains to travel in the local area. While is described as white, 5ft 10in of medium build with brown hair and brown eyes. Officers searching for While would urge him or anyone who knows of their whereabouts to call Merseyside Police - Sefton Tactical Team on:- 0151 777 3013 or 101 or Crimestoppers anonymously on:- 0800 555 111.

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