As physicians, we fail to put patients’ needs first, causing end-of-life harm | Letters

My condolences to Adrian Chiles on the death of his father. His column describing the futility of his father’s last “precautionary trip” to the emergency room (April 3) highlights a growing challenge posed by an aging population. As health and social care services collapse, the harm and indignity of hospital admissions increases, especially for those least able to advocate for themselves. As a trainee doctor in the Emergency Department, I hated seeing frail, often elderly people languishing on trolleys in the corridors, receiving substandard treatment that they did not want and from which they were unlikely to benefit. to have. This is now the norm in every hospital I have been to.

a Study from 2014 it turned out that more than a quarter of hospital patients die within a year. The risk, perhaps unsurprisingly, increases with age. It is our responsibility as physicians to have difficult and candid conversations with patients ahead of time; to be pragmatic, realistic and kind in our decision-making. Unfortunately, much of this falls under ‘planning for the future’, which often falls off the to-do list during a crisis. It is the most rewarding part of my job to have the time and opportunity to create care plans with patients, to know what matters most to them, and to put an end to the “shrugging of shoulders” that Chiles had to deal with every time. But drug-by-protocol is faster and cheaper than thought and pragmatism, so as resources continue to be stretched, it can continue to flourish. I am so saddened by Peter Chiles’ grief, and so grateful that his son is using his voice to draw attention to it.
Zachary Tait
Manchester

I have been a GP partner in Battersea, London for 20 years. Unfortunately, Adrian Chiles’ op-ed absolutely resonates. As physicians, we are now taught to prioritize “safety” over all other considerations – despite the dangers involved. In reality, we often protect ourselves more than we protect our patients – an unintended side effect of our brutal regulatory system.

We physicians behave as “artificial persons” representing the health care system, rather than as moral agents with a duty to create meaning for our patients. We urgently need to transition to a moral age of medicine – one that rejects both the protectionism of the past and the reductionism of the current context that so often results in the cruelties and inefficiencies Chiles describes.
Rupal Shah
Co-author, Fighting for the Soul of Family Medicine – The algorithm will now see you

Adrian Chiles’ article sparked my thinking as I have been on a similar journey. My husband died two weeks ago after being told he had three months to live. This turned out to be the case. With the Hospice at Home service, the NHS has been truly amazing. However, he died as the morphine slowly killed him. This could have been prevented if there was an assisted dying law. One of the nurses said what we were doing was cruel.

We were able to oppose a possible hospital admission due to chest pain by having a so-called ReSPECT document signed by our GP for “do not resuscitate”, and because we had an advance directive, dated 2022, which had been submitted to the GP and stood in his medical file. This made the whole process so much easier for us, but also for the several wonderful clinicians. Parliament must update our laws to bring it in line with so many in this country who want greater clarity and support Dignity in dying.
Jo Visser
Brampton, Cambridgeshire

In response to Adrian Chiles’ article, and having recently lost my own father, the best advice I can give anyone is to make sure you have power of attorney for your parents. This way you can ensure that you have the power to override the decisions of the medical staff who, even if they act with the best intentions, may not know your parents as well as you do and may not make the decision that is best for them. or what they would have wanted. Having a power of attorney is, in my opinion, more important than a will because it allows you to assist your living parent and ensure that their wishes are met. In my father’s last days, I was asked several times, “Do you have power of attorney?” I was very relieved when I could answer, “Yes.”
Rebecca Crying
Toft, Cambridgeshire

As the daughter of an older parent, I fully understand the need to avoid emergency care to cause as little suffering as possible. Undoubtedly, waiting unhappily for hours alone will hasten the demise. However, as a GP, I know that the dramatic increase in lawsuits over the past two decades poses a very real threat to doctors’ livelihoods. Even a simple complaint from a patient or their family can cause weeks, months, sometimes years of stress for a healthcare provider. Ruminating over every decision, every action or omission, every justification is enough to give us a heart attack – or worse, make us follow in the footsteps of Paul Sinha and Adam Kay and abandon the profession for a more peaceful existence .
Name and address provided

Dear Adrian, I’m so sorry this happened to your father. Unfortunately, it is a story that repeats itself over and over again. I am a so-called ‘late career’ doctor (over 55), and I have recently switched from my work as an emergency consultant to a general practitioner in aged care. Over my 30-year career, mainly in emergency medicine and other hospital specialties, although there was also a significant period in palliative care, I slowly came to realize that the way we have set up our emergency system is not benefiting people at all elderly, and that the The most vulnerable elderly are generally so poorly served that transferring them almost inevitably makes matters worse.

My residents (200 spread across five elderly care institutions) all have discussions and documentation about whether they should go to hospital and under what circumstances. The staff knows to call me if there is anything unclear, day and night. I organize many family meetings so that family members can trust that the right decisions are being made. I love caring for old people and ensuring they receive the best care suited to their individual circumstances.

I am convinced that elderly care in particular is a subspecialty of the general practitioner. Too often, care is embedded in lunch breaks and visits ‘on the way home’, and delegated to out-of-hours telephone services. This is no way to treat our oldest and weakest people, who deserve so much better. Again, I’m so sorry.
Fiona Wallace
Sheffield, Tasmania, Australia

I read Adrian Chiles’ article about his father’s experience with empathy. My own father headed a district health authority, with many hospitals under his charge. He was intensely proud of the NHS, but in his 90s he was very clear that he did not want to die in hospital or even be readmitted unless absolutely necessary. If he had an infection, he was treated at home. If things got worse and Dad died, it would be in his own bed. As a family we listened. I cared for him and know it took a huge burden off my father to know he didn’t have to fear the ambulance or the bewilderment of a strange place. Too many elderly people die in the backs of ambulances and emergency rooms. Allow those who are able to make informed choices about their end of life. It is a great comfort to them.
Dr. Jane Lovell
Ashford, Kent

Adrian Chiles is right when he says that decisions about sending vulnerable and elderly patients to hospital may be due to doctors being risk averse. Doctors face a double threat from the General Medical Council, which can provide them with their livelihood, and from the legal system if something goes wrong.

Not all families can accept when beloved elderly relatives have reached the end of their lives. Some people have unrealistic expectations about what healthcare can achieve in vulnerable patients, pushing for tests and treatments even when it seems unlikely to affect the final outcome. If these are not carried out, doctors can be accused of negligence or age discrimination. Most physicians want less invasive end-of-life care for themselves and their own families than they routinely provide to patients.

I would encourage everyone to make an advance directive or ‘living will’ setting out how they would like to be treated if their health deteriorates. I would also suggest giving a trusted person power of attorney for health care. These can be very useful in reducing incidents as described in the article.
Dr. Stephen Docherty
Consultant radiologist, Dundee

I would like to express my condolences to Adrian Chiles on the death of his father. I can sympathize with him on many levels. I too recently lost my father under similar circumstances. I am a practicing GP, a former medical director of an out-of-hours GP service, and now spend most of my time as a management consultant influencing changes in the NHS to prevent these types of incidents.

When I talk to doctors and managers, I am always humbled by their dedication, despite the pressure they work under. In my current assignment, over 32% of physicians feel burned out, and many more express intense frustration with the low-value clinical work they undertake. There is a limit to how much the system and the individuals who support it can give. The demand for care increases every year.

I suspect that the GP who decided to send Adrian’s father to A&E without seeing him was under pressure to make some decisions that evening. If they had more choice, I’m sure they would have prioritized cases like Adrian’s father over often unnecessary, lower priority cases. What we as a society don’t talk about with as much enthusiasm as the system and those who provide care is the way we consume care so that we can create time and space to support those who really need the attention they need.
Dr. Riaz Jetha
London