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
NEXT OF KIN APPEAL - JOHN MULLIGAN
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.
CLEANERS ON THE
FRONT LINE IN WORLD WITHOUT ANTIBIOTICS
"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
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
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:-
WANTED - DANNY WHILE
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.