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I would be surprised if the NHS had relevant regulation, an ability to enforce accountability, or oversight of possible fraud.

When my father was in ICU (years ago) the lead consultant made a clinical decision to withdraw treatment with DNR on the basis he had, with no witnesses, inflicted on my father sufficient pain to be sure there was no response.

I complained, naturally, and then went to the bed. I showed the nurse how to get a response without inflicting pain, and was too late because the consultant had left the building - the nurses had no power to override a doctor's decision. The nurse went ahead and switched off the treatment after witnessing a response - like a gentle but fanatical military guard.

The only thing that had changed from one day to the next, as far as I can gather, is that the NHS had obtained without witnesses my father's signature for the DNR and probably more - presumably just before he became (subjectively) unresponsive?!

I cannot accept an organised hierarchy following orders can be defended as overworked or poorly trained. This is one of many bad experiences that informs my overall opinion of the NHS.
Gees, there’s quite a lot to try and unpick there. To attempt to get started without this immediately becoming inflamed:

What response were you able to elicit in your father?
What organ support was he on? Ventilator, dialysis (or equivalent kidney replacement), blood pressure support?
Was he sedated?
Regarding your “father’s signature” on the “DNR” — did you see this? I ask because I’ve never come across a form that has a place for the patient to sign.
 

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Gees, there’s quite a lot to try and unpick there. To attempt to get started without this immediately becoming inflamed:

What response were you able to elicit in your father?
What organ support was he on? Ventilator, dialysis (or equivalent kidney replacement), blood pressure support?
Was he sedated?
Regarding your “father’s signature” on the “DNR” — did you see this? I ask because I’ve never come across a form that has a place for the patient to sign.
In my father's case the ICU could provide only a managed decline. The one thing that might have helped before ICU is exercise instead of rest. During ICU he was primarily on adrenaline to keep his heart pumping fast enough to prevent liquids from backfilling his lungs.

He tried to get up each time he realised he was in ICU, and was held down by nurses until he relaxed. I understand the tubes would not stretch far, and he would fatigue, but I feel there are ethical issues in preventing exercise. At the very least they could have helped him sit-up instead of require him to continuously lie flat.

He would spend a few minutes fully responsive and suffered no cognitive issues, but then fatigued quickly. He appeared to sleep most of the time, throughout which I could elicit appropriate facial expressions by speaking to him - these were clearest when speaking at his forehead.

The inability of the NHS to move him, and thus their inability to enable meaningful exertion, leaves me in no doubt that DNR was appropriate for the NHS - but withdrawing treatment is another matter. I did not see any papers. It is my understanding that the NHS obtained his signature before announcing their clinical decisions.

I think it is very likely he could hear and understand what was going on around his bed, and was simply too fatigued to bother responding. He probably felt the consultant's pain test. He probably heard his last rites.
 

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In my father's case the ICU could provide only a managed decline. The one thing that might have helped before ICU is exercise instead of rest. During ICU he was primarily on adrenaline to keep his heart pumping fast enough to prevent liquids from backfilling his lungs.

He tried to get up each time he realised he was in ICU, and was held down by nurses until he relaxed. I understand the tubes would not stretch far, and he would fatigue, but I feel there are ethical issues in preventing exercise. At the very least they could have helped him sit-up instead of require him to continuously lie flat.

He would spend a few minutes fully responsive and suffered no cognitive issues, but then fatigued quickly. He appeared to sleep most of the time, throughout which I could elicit appropriate facial expressions by speaking to him - these were clearest when speaking at his forehead.

The inability of the NHS to move him, and thus their inability to enable meaningful exertion, leaves me in no doubt that DNR was appropriate for the NHS - but withdrawing treatment is another matter. I did not see any papers. It is my understanding that the NHS obtained his signature before announcing their clinical decisions.

I think it is very likely he could hear and understand what was going on around his bed, and was simply too fatigued to bother responding. He probably felt the consultant's pain test. He probably heard his last rites.
You have my sympathy though this does sound like it followed a pattern that is not unusual.

Restraint sounds inappropriate there, though, if they had gone into palliative care mode.

Yes, it is the hearing that goes last, and I think it is despicable to 'withdraw treatment' rather than administer a final, fatal sedation. To withdraw a treatment so that the painful suffering aspect of the condition gets the better of the patient disgusts me. Withdrawing food and water is even worse. I cannot comprehend the bizarre ethical stance of that, that so long as one steps away from the patient and does nothing that 'this', somehow, is caring for them and helping their pain in their last moments.

Utterly, frighteningly disgusting.

I have had only one experience where I was at a person's side at the level of consciousness you describe. My grandmother was in her last days for pneumonia and it was only a case of palliative care at that point, that was clear, and I think they did a good job in her case. I had been away at the time, and by the time I arrived my family were saying 'no point going, she's out of it now', or to that effect, and she'd been like that for a week or so, but I went anyway. I went in and spoke my name next to her, and she opened her eyes and with a face of joy she called my name. Then she closed here eyes, and that was the last thing she did. That seems quite special to be the last person someone has contact with (and happy to do so! ;) ).

But it has always been my guide in this that a person does remain conscious and is aware, even if unresponsive, and the importance of talking with a person in their last moments even if they don't reply.
 

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Yes, it is the hearing that goes last, and I think it is despicable to 'withdraw treatment' rather than administer a final, fatal sedation. To withdraw a treatment so that the painful suffering aspect of the condition gets the better of the patient disgusts me. Withdrawing food and water is even worse. I cannot comprehend the bizarre ethical stance of that, that so long as one steps away from the patient and does nothing that 'this', somehow, is caring for them and helping their pain in their last moments.

Utterly, frighteningly disgusting.
Fortunately that’s not what happens. Prior to the withdrawal of life-sustaining therapies in any Unit I’ve ever worked in, the patient gets started on infusions of sedation and analgesia and are typically utterly unaware before anything else is changed.

BurningNaturalGas, you of course have my sympathies. In defence of my specialty, for what little that’s worse, I would argue:

  • anyone needing an adrenaline infusion for heart failure either needs to recover rapidly, be a candidate for a heart transplant or advanced circulatory support, or they’ll suffer a prolonged, miserable death;
  • at that point, there’s no amount of “exercise” in the world that would help things;
  • the fact that your father might, at times, been aware of what was going on makes this worse, and even more pressing to make a decision on the merits of continuing or stopping;
  • his conscious level (or lack thereof) has some bearing on how such conversations are had, but being intermittently responsive doesn’t mean you can’t move to a palliative care approach
  • like I said, I’ve never asked a patient to sign anything when instituting such clinical decisions. It’s not their decision to make, any more than I ask them to decide which antibiotic they’d like for their viral infection, or which ventilator mode they want.
Of course, the patient‘s wishes, and that of their family, should be taken into account and communicated well. It sounds like in your case, that didn’t happen.
 

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Yes, it is the hearing that goes last, and I think it is despicable to 'withdraw treatment' rather than administer a final, fatal sedation. To withdraw a treatment so that the painful suffering aspect of the condition gets the better of the patient disgusts me. Withdrawing food and water is even worse. I cannot comprehend the bizarre ethical stance of that, that so long as one steps away from the patient and does nothing that 'this', somehow, is caring for them and helping their pain in their last moments.

Utterly, frighteningly disgusting.
Donald, I suggest your firmly return to whatever area of expertise you claim before you start straying well beyond your station. Accusing doctor's with infinitely more education and experience than yourself in these matters applying pain and suffering to those in their last moments is so far beyond the truth that I can't believe you're suggesting it.
 

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.. anyone needing an adrenaline infusion for heart failure either needs to recover rapidly ..
I agree. My issue is that all intentions appeared to be to disable hopes of rapid recovery. Internal family politics did not help, but my view is that there was unhelpful communication from medics to patient.
  • There was no NHS leadership to make rapid recovery a realistic outcome.
  • Pressing patients down is an explicit instruction to not exert themselves.
  • There are no facilities in ICUs to support physical exertion.
I suggest that if an 'end game' contains needless suffering then the patient might not be a suitable candidate for that type of care. Surely the NHS should provoke certain patients to get up, no matter how uncomfortable that may be?

I anticipate the counter-argument will be that patients could fall onto a hard floor or against a metal bed frame. My engineering background would respond with two points: You cannot break something that is already broken. You can create a safe testing environment.
 

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....Accusing doctor's with infinitely more education and experience than yourself in these matters...
Oh, gawd. Really?

So, if I present recorded and evidenced medical incompetencies where they did worse than any person with common sense and half a brain would have done, is that enough to disprove your statement?

It should be self-evident from the context I am talking about a class of behaviour, not that all members of some classification are all incompetent.
 

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Donald, I suggest your firmly return to whatever area of expertise you claim before you start straying well beyond your station. Accusing doctor's with infinitely more education and experience than yourself in these matters applying pain and suffering to those in their last moments is so far beyond the truth that I can't believe you're suggesting it.
Tell me a little about this story, right?

The guy was made SOOO comfortable by medical staff, he actually called the police, who also ignored him and he died of dehydration.

WOW, that must have been reeeeealllly comfortable for him.

 

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Tell me a little about this story, right?

The guy was made SOOO comfortable by medical staff, he actually called the police, who also ignored him and he died of dehydration.

WOW, that must have been reeeeealllly comfortable for him.

A great example of your ignorance. Well done. Firstly, let's actually look at a news report from the conclusion.


Firstly, his death should never have happened. It was medical neglect.

But let's clarify based on the points you made.
He was not in end of life treatment.
He was not under a medical direction to withdraw treatment or food or water.
He had an underlying medical condition which mean he required additional water in his diet.
He had been moved to a isolated bed because of of aggression caused by another underlying medical condition.

A tragic death, but so far removed from the implications of your original post it's unbelievable.
 

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A tragic death, but so far removed from the implications of your original post it's unbelievable.
I tentatively suggest you are repeating the general mistake of trusting those with authority. End of life care, or any prescription, can be the result of misdiagnoses or weakness in NHS policy.

The underlying issue is that medics are not gods, and this makes all cases comparable.
 

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I tentatively suggest you are repeating the general mistake of trusting those with authority. End of life care, or any prescription, can be the result of misdiagnoses or weakness in NHS policy.

The underlying issue is that medics are not gods, and this makes all cases comparable.
I'm well aware doctors, nurses, clinical workers and pharmacists are not gods. If they were, they wouldn't have professional indemnity insurance and they wouldn't be constantly undertaking training and research.

But please point out where I was wrong in the critique of Donald's chosen example.
 

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Because that bridge collapsed in Italy, I now make sure I review all of the structural calculations and inspection reports before I go over bridges.

Also, I like to check the training records for my EasyJet pilots. I’ll also critique their departure plans. Pilots are not gods even though they behave like them, flying around everywhere.
 

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.. please point out where I was wrong in the critique of Donald's chosen example
All example cases share questionable clinical decisions, a lack of due diligence, and no recourse for patients to take mitigating action.

Dehydration would have been avoided if medics or visitors had a means to challenge clinical decisions, if medics checked with family and/or medical histories, and if medics overturned a clinical decision.

In my world of actual critical systems anyone can call a STOP. I have witnessed Engineers escalate C-suite executives to legal and overturn decisions. The NHS lacks this type of safety. My view is that such shared responsibility is a fundamental need in environments that can determine life and death, and it baffles me that the NHS is exempt.
 

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In my world of actual critical systems anyone can shout STOP.
In mine too (but we prefer to say it three times).

However, in a medical environment you have to realise the limitations of this. Outside the context of the example provided, if someone requires urgent medical attention then who should be empowered to shout stop? Because saying anyone instantly introduces the ability for people who are not thinking in the best interest of the patient to cause delay.

Take an urgent blood transfusion to an unconscious adult. The mother, for religious reasons, says stop you can't do that I raised the patient as X religion. Do you stop? Do you check if that's actually the patient's wish?

In the example there were definitely failings throughout, and perhaps there was an issue of excessive respect for clinical authority, but I don't think that is balanced by giving everyone the shared authority for clinical direction.
 

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I agree. My issue is that all intentions appeared to be to disable hopes of rapid recovery. Internal family politics did not help, but my view is that there was unhelpful communication from medics to patient.
  • There was no NHS leadership to make rapid recovery a realistic outcome.
Can you expand on that? Or does it relate to your related points, below, that mobilisation would have fixed things?

  • Pressing patients down is an explicit instruction to not exert themselves.
  • There are no facilities in ICUs to support physical exertion.
I suggest that if an 'end game' contains needless suffering then the patient might not be a suitable candidate for that type of care. Surely the NHS should provoke certain patients to get up, no matter how uncomfortable that may be?
Yes, certain patients. We have physiotherapist involvement daily in ICU, and we have mechanisms by which we can mobilise patients (hoists and specially designed seats), along with facilitating exercise in bed (bikes, amongst other things). However, there are some patients in whom any activity is contraindicated according to best current evidence, which would very much include someone with inotropic-dependent heart failure, as in your poor father’s case. As I’ve said, there’s no exercise known to man that can fix that.

 

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OMG what an absolute nutcase. It scares me that people like him target vulnerable people. This sort of thing is worse than the 5G stupidity imo.
I'm inclined to agree though I didn't watch it all. I got two seconds in and read "the soul" ... and gave up.
 

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Donald, I suggest your firmly return to whatever area of expertise you claim before you start straying well beyond your station. Accusing doctor's with infinitely more education and experience than yourself in these matters applying pain and suffering to those in their last moments is so far beyond the truth that I can't believe you're suggesting it.
Never has an 'appeal to authority' logical fallacy been so poorly, and obviously, applied.

Your saintly god like doctors have absolutely no comprehension whatsoever of the conscious experiences of unresponsive patients at the moment of death.

None.

Zero.

Even the medical profession had wrug its hands over the problematic scenario of refusing a treatment.

The ONLY reason that withdrawal of treatment happens, rather than a good ol' over dose of morphine, is because judges in courts have made such decisions.

Medical practices now instruct their doctors to do that, to remove treatment and let patients starve and suffocate to death, simply and only because a court told them to and set a precedent.

That's the fact of it.

They used to just give them a humane shot of morphine and everyone just moved on with life. Then a few folks brought stupid 'life at any cost' arguments into court. So instead of now taking the act of ending a life, they do the coward's thing and walk away, let the patient rot to hell.

You can tell me all you like that the patients don't know what is happening, but my Grandma told me otherwise in her own words, in that single moment she called my name while everyone else said that was that and she no longer knew what was happening.

Doctors know nothing of the experience of death. They barely understand it physiologically.
 

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Can you expand on that? Or does it relate to your related points, below, that mobilisation would have fixed things?
I am dropping the term mobilisation as it conjures thoughts of electric scooters rather than physical exertion. It is interesting you mention cycling in ICU. No form of exercise was discussed at the time - as said more effort was spent on keeping him in bed than getting him out of it.

If the topic had been raised then the NHS would have discovered my father had been a keen cyclist. The physiotherapist stretched his arms and fingers while he lay in bed - I'm not seeing the utility here.

His heart was in poor shape, but actions can either reinforce decline or struggle against decline. The actions chosen appeared to support the former and prevent the latter.
 
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