One challenge in talking about patients and important issues is that cliches so often are the best way to communicate the point.

“There is no one size which fits all.” All medical specialists use this sentence to begin to talk with patients whose symptoms and treatment don’t fit the norm. Human bodies, while alike, are also maddeningly smart about the ways in which they can express their individuality in the clinical sense. Being unique in life is a great thing. Being unique or very different as a patient is not so great.

“Patients die who should live. Patients live who are expected to die. That’s how it goes.” That’s another cliche that gets a lot of work-outs.

It appears that the “guidance” developed by the National Health Service about caring for people at the end-of-life is not working as intended.

Those experts who oppose it say that it is defeating the purpose: To make the end of life easier for the patient.

What the “guidance” calls for may not be given at the patient’s end-of-life. That guidance, it is alleged, may bring death on.

Seven palliative care experts wrote a letter protesting this practice, saying it is causing a “national crisis.”

For example, a patient who is badly dehydrated—something that easily happens in elderly people, among others—-can need immediate medical attention, says MedlinePlus.gov.

“A physical examination may also show signs of:

• “Low blood pressure
• “Blood pressure that drops when you go from lying down to standing
• “Rapid heart rate
• “Poor skin turgor — the skin may lack its normal elasticity and sag back into position slowly when pinched up into a fold by the doctor; normally, skin springs right back into position
• “Delayed capillary refill
• “Shock”

Let’s look at shock, which likely is one of the main culprits in these mis-assessments, again from MedlinePlus.

Shock

“Shock is a life-threatening condition that occurs when the body is not getting enough blood flow. This can damage multiple organs. Shock requires immediate medical treatment and can get worse very rapidly.

Considerations

As you can see, a patient who is elderly could have one or more of these symptoms and appear to be dying.

Coming, at the time these charges do— as the “death squad” claims were made by conservatives in America— this debate across the pond may well be a setback for American health care reform efforts, which are already in trouble.

The credentials of the experts who wrote the letter to the Daily Telegraph are those of professionals with expertise and experience in managing palliative care.

While the NHS is widely accepted—and in some quarters, beloved—it is important to note that a small percentage of Brits use a private system. An accurate figure for that percentage does not seem to be readily available online but the Princess Diana went to an NHS hospital to produce the heir to the throne—their most important baby. On the other hand, that baby is now in his 20s. Times have changed.

None of them say it is perfect, to be sure.

However, this is a story that is sure to rock the British as much as it will Americans.

This bears no resemblance to the palliative care I have seen provided many, many dozens of times in the U.S.  Careful monitoring of vitals. IVs kept going unless the patient or patient’s authorized representative said they were to be removed. It is very, very hard for the American system to stop treatment, which is one reason the palliative care movement took off. Their view is: It also is time to know when to stop.  Over-aggressive management at the end of life  is the American issue.

The Brits, on the other hand, are saying the system is stopping too soon.  The trust the NHS has had will be eroded if this is not dealt with and fast.

Slatest and Daily Telegraph

“In a letter to The Daily Telegraph, a group of experts who care for the terminally ill claim that some patients are being wrongly judged as close to death.

“Under NHS guidance introduced across England to help doctors and medical staff deal with dying patients, they can then have fluid and drugs withdrawn and many are put on continuous sedation until they pass away.

“But this approach can also mask the signs that their condition is improving, the experts warn.

As a result the scheme is causing a “national crisis” in patient care, the letter states. It has been signed palliative care experts including Professor Peter Millard, Emeritus Professor of Geriatrics, University of London, Dr Peter Hargreaves, a consultant in Palliative Medicine at St Luke’s cancer centre in Guildford, and four others.

“Forecasting death is an inexact science,”they say. Patients are being diagnosed as being close to death “without regard to the fact that the diagnosis could be wrong. (Emphasis added)

“As a result a national wave of discontent is building up, as family and friends witness the denial of fluids and food to patients.”

Source: Daily Telegraph,September 2, 2009

Source: Slatest, September 3, 2009