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Rachel @doctor_oxford says it has never been more important to do advanced care planning, to reflect and chat with loved ones about what intensity of medical care you would want if you became sick enough with corona virus to need intensive care, a ventilator to breathe, etc
If we don't talk to our loved ones now about care planning, we will end up with a panicked call from a hospital asking whether a frail elderly relative wishes to be put on a ventilator. We need to know in advance what people would wish for if the worst happened.
In the current circumstances we are denied the intimacy of a face-to-face conversation. But, these conversations often don't measure up to people's worst fears of how difficult it is going to be.
Broaching the fact that a relative may not survive, in @doctor_oxford's experience, can be a relief and not as difficult as we fear.
"If you were unlucky and became seriously ill, would you want to go to hospital? How would you want to be cared for?"
"If you were unlucky and became seriously ill, would you want to go to hospital? How would you want to be cared for?"
Rachel says there are fantastically good resources to help guide people - organisations including the association for palliative medicine have published these and @RoySocMed will post these after the seminar.
Normally at end of life the patient is centre-stage, but the restrictions on visitors in hospitals and hospices is making it incredibly difficult to provide high-quality palliative care, because of the absence of the warm, intimate physical presence of a patient's loved ones.
Symptom management is one thing - with COVID-19 the main one is breathlessness and this can be well managed with drugs. But the existential crisis of approaching the end of life is different. There is a great loneliness and the key 'drug' is a human presence.
That might manifest in ways other than physical presence - including pictures, writings, familiar items brought in from home.
Most hospices are trying to facilitate the presence of one loved one at the bedside of someone who is dying from coronavirus but not always possible.
Most hospices are trying to facilitate the presence of one loved one at the bedside of someone who is dying from coronavirus but not always possible.
If that isn't possible, hospice and palliative care staff will try to put dying patients in touch with loved ones via Zoom (etc) or will read out messages or emails to them.
"The very best substitute love and care at the bedside that we can provide."
"The very best substitute love and care at the bedside that we can provide."
Rachel @doctor_oxford says that the hospice sector is suffering terribly the lack of personal protective equipment. Hospices are having to beg for masks from, for example, local veterinary practices. It has been at the point where hospices may not be able to stay open.
So, the existence of hospice care currently is tenuous.
Currently says Rachel @livingwelldying the victims - those who are dying - have been somewhat neglected in the planning so far for #covid19 in this country.
This is very, very hard to listen to and to hear.
Rachel @doctor_oxford is asked whether there is an absence of official guidance on the hard decisions in this extreme situation.
She says it is an issue that has created enormous stress, anxiety and fear in the British population, not helped by sensationalist headlines...
She says it is an issue that has created enormous stress, anxiety and fear in the British population, not helped by sensationalist headlines...
...about doctors rationing care. We know of some of the terrible decisions which have had to be made in Lombardy at the epicentre of the Italian outbreak. In some hospitals there was a cut-off age of 65 for consideration for an ITU bed and a ventilator.
But it's not quite right that we have no national guidance. NICE have published guidance on this type of decision-making and a key factor here will be the patient's frailty, as that is linked to the chances of surviving.
The question has to be, how likely is it that the patient will benefit from intensive care and survive?
Rachel @doctor_oxford is asked what happens if there is a conflict between the patient's wishes and what's available. She answers that this dilemma is not unique to the pandemic situation - it is the bread & butter of ICUs up and down the country all the time.
Some patients want all possible treatment, all the time, no matter how toxic or risky, because they want to live. The decision is always a best interests decision made on the part of doctors - you are not entitled to receive a treatment simply because you want it.
Sometimes these conflicts end up being adjudicated upon in the High Court. Intensive care beds are a scarce resource and doctors are having to weigh up every day who should have access to them. Crucial to consider who may survive.
Rachel @doctor_oxford is asked what the impact of the pandemic will be on junior doctors. She says that impact is not wholly negative. "Apocalypse" actually means "revelation" - through these apocalyptic times important truths are being revealed. The NHS is a huge machine...
...but that machine has moved like lightning in the past few weeks with hospitals being reconfigured, large numbers of new wards, everything being transformed.
As a junior doctor it is inspirational and extraordinary to see what the NHS is capable of and to see the best of human nature. That is inspirational and will endure long after this pandemic is over.
Going back now to the subject of so-called difficult conversations with vulnerable loved ones. Find the best way - over a video link? Find a good time which is calm and peaceful when the frail person is not too tired. Get a sense of what the relative already understands.
What do they already know and what are their views already about it? Maybe talk more generally in an exploratory way: "Mum, what do you think about what's happening? Are you worried about the number of people dying?"
It's easy to fear that by broaching the subject you will cause harm, that you will distress your loved one. So often in palliative care, doctors are surprised to find that the patient has been thinking about the topic of (eg) a terminal diagnosis and is in fact ready to talk.
It may not be painful but actually a relief for you and your loved one to have this conversation about the end of life.
It's also an opportunity to say really vital, simple things like "I love you and what a wonderful mother you are".
It's also an opportunity to say really vital, simple things like "I love you and what a wonderful mother you are".
Make sure your vulnerable loved ones know how loved they are.
Finally, we at the seminar all want the @RoySocMed to bottle @doctor_oxford and make her available across the land! Thank you so much Rachel, you are amazing. And thank you to the Royal Society of Medicine.
[Ends]
Finally, we at the seminar all want the @RoySocMed to bottle @doctor_oxford and make her available across the land! Thank you so much Rachel, you are amazing. And thank you to the Royal Society of Medicine.
[Ends]
