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Is it Reasonable to Assume Part 1: that nurses will challenge the authors of high-level guidance ?

Posted in: Let's get talking | Discussion and debate

26-Jun-2011 12:06 pm

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michael stone

michael stone

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9-Jul-2011 10:17 am

I have just checked that, and it was truncated for reasons I do not understand. It should finish with:

'with those persons who are very close to the patient (family, etc) who could reasonably 'express an informed opinion, about his likely wishes' (this requirement comes from section 4(6) of the Mental Capacity Act's best interests guidance).

The Joint CPR guidance is being revised at present, and the BMA's expert has admitted that the above paradox exists within the current version - it has also been noticed, but 'fudged', by various other authors, recently.

But I contacted the BMA, pointing out this defect in the guidance - and the reply implied that nobody else had done so: this was 4 years after the guidance was issued, so how come a 'stream of clinicians' has not been telling the BMA/RCN/RC(UK) 'your guidance is internally contradictory' ?

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Anonymous

Anonymous

9-Jul-2011 10:38 am

A general comment on guidelines
Guidelines are not legal documents. Their purpose is to inform and assist best practice. The do not cover all eventualities so cannot therefore be applied under all circumstances which is why highly qualified professionals are employed who are free to use their own discretion and take responsibility for their actions. Any practitioner can and does write guidelines in their area of expertise and, depending on the extent of their use, often in collaboration with a panel of other experts possibly from different but related fieldds - eg local or national guidelines.

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michael stone

michael stone

Posts: 146

9-Jul-2011 11:31 am

9-Jul-2011 10:38 am

I entirely agree that guidelines are NOT 'law'. And, it is the principles beneath guidelines which can usually be applied to situations, if 'lists of rules' fail.
But, there is another point about the Joint CPR Guidance, which would not apply to most guidance issued to clinicians. This guidance is about CPR decision-making - not the clinical question of how best to perform CPR, if it is attempted. The 'higher authority' for the Joint CPR Guidance is the Mental Capacity Act, which is legislation. The 'correct behaviour', therefore, depends on correctly interpreting the Act, with clinical factors only being part of the decision-making process. This is rather different, from those guidelines where the underlaying evidence-base comprise clinical studies - here, for CPR decision-making, the 'evidence base' is legislation and case law.
And the Head of the Legal department, at one of those '3-letter clinical bodies' signed up to the Joint Guidance, included in a reply to me:

'Further, I share your view that understanding among clinicians of the legal aspects of delivering health care is not perhaps as thorough and comprehensive as one might otherwise hope.'


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Anonymous

Anonymous

9-Jul-2011 12:40 pm


from anon comment before yours
'Further, I share your view that understanding among clinicians of the legal aspects of delivering health care is not perhaps as thorough and comprehensive as one might otherwise hope.'
I studied Medical Law and Ethics at Masters Level in the mid 90s and it is not a clear cut subject at all for anybody and even for our lecturer. As the world has changed so much, as has medicine and nursing and attitudes of governments and society, over the last decades much medical law is set on precedence and ethical societies led by professionals in each hospital have to debate and decide on the full implications of the law and its effect on patients. There are some good tomes on this subject with thorough investigations of many cases which might help throw further light on some of your issues.
Also it must be remembered that clinicians work constantly under considerable pressure within very limited constraints and no aspects of delivering health care are ever "... as thorough and comprehensive as one (including the those delivering it) might otherwise hope.'" If it were all as clear cut and as simple as everybody would like it to be then our job would be very easy but this is the real world where the best (which unfortunately is sometimes only mediocre) has to be done for the masses.
Possibly you go far too far in your search?
Above, I failed to mention 'evidence based' in my post on guidelines which also was mentioned following another article on pressure care. It is probably needless to add here that guidelines are always being update or renewed as new research evidence comes to light and as medical and nursing treatment and procedures change. This is obviously an evolutionary process and these guidelines do not exist for every situation or every procedure and some those which are available become rapidly be out of date, sometimes even by the time they are published. They are also, like the NMC code of professional conduct, 'guidelines' to assist an individual to practice to the best of their ability but in the work and real life situation the onus is on each practitioner whether they choose to be guided by these and how they act in particular situations and to take full responsibility if something goes wrong, which in an organisation the size of the NHS or some private systems inevitably does, unfortunately, from time to time. Codes of practice for nurses have also been modified and replaced over the years and they act as a useful 'insurance policy' when something does go wrong and a nurse says that she was working within these and other official guidelines. However, these also have their limitations and not every nurse agrees with all the points and may find some points that they consider important are not included. Guidelines are all very much a matter of personal interpretation and possibly the more experience one has the better they can be interpreted.
I do not think I need to go into all the details of professionalism here but with all the thousands of nurses who have different levels and years of experience and specialisation and have come from different backgrounds and training schools there is no such thing as 100% consistency although where I practiced we made every effort to deliver our care in a manner which was as consistent as possible which is obviously necessary for the security, confidence, therapy and wellbeing of the patient. Another very important aspect of nursing is building up a therapeutic relationship with the patient which is one of trust, empathy (preferably mutual!) and partnership. It is also a key aim of nursing not to take away a patient's autonomy but to deliver treatment and other forms of therapy and assist them in all daily living activities which they are temporarily or permanently able to carry out for themselves. Nurses have multifunctions and are highly multiskilled but are also human beings each with their own personal limitations as well as the constraints of society, government and their employing organisations who control the financial and personnel resources, shift patterns and have very powerful control over the way that nurses' work is organised often without a thorough understanding of patient care and how it is delivered, let alone the philosophy and process of nursing.

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michael stone

michael stone

Posts: 146

9-Jul-2011 2:53 pm



Anonymous
9-Jul-2011 12:40 pm

Thank you, I have just spent 30 minutes typing a reply, for it to be lost with a 'not logged in message'.

I do not have enough online time to type it again - I will take your comment home, and prepare a response which I will post on Monday.

You are clearly 'expert', and as it happens so am I because I have been discussing how inappropriate the current guidance around CPR is, when viewed as a relative for patients at home, for about 2 years. But the law was both tidied up and altered by the Mental Capacity Act, and that Act does have some problems, but it is much clearer and more sensible than much of the secondary guidance. Since 2007, the actual law has been pretty simple - but, clinicians and others do not correctly interpret the Act.

As it happens, the Joint CPR Guidance is currently undergoing a revision, and I am giving the BMA's contributor a serious ear-bashing, over where the current guidance departs from both logic and the Act: I hope, the revised guidance will be improved.

I will post a better response, on Monday.

Thank you for your comments - but I want to know what typical district nurses believe the law states, and why they believe what they do: before arguing about the proper 'aligned belief and behaviour set', it would help to have a better idea of what different groups currently beleive to be true ! I/we need to properly understand the level of knowledge (and confidence about their knowledge) possessed by front-line district nurses, in terms of what would be useful.

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michael stone

michael stone

Posts: 146

10-Jul-2011 12:12 pm

9-Jul-2011 12:40 pm P1

Thank you for your reply. As this is my post, and my hobby-horse, I can decide how to respond, and I am going to post a series of ‘short pieces’ which will each cover a limited aspect of the problem/discussion, headed with an extract from your post. I hope this will make things more digestible, and easier for anyone who wishes to respond with a posting. I’ll use this post, as an ‘index’. Jumping to the very end of P9, might be a good place to start , before getting into a technical discussion of the MCA !

P2 ‘I studied Medical Law and Ethics at Masters Level in the mid 90s and it is not a clear cut subject at all for anybody and even for our lecturer.’

P3 ‘As the world has changed so much, as has medicine and nursing and attitudes of governments and society, over the last decades much medical law is set on precedence and ethical societies led by professionals in each hospital have to debate and decide on the full implications of the law and its effect on patients.’

P4 ‘There are some good tomes on this subject with thorough investigations of many cases which might help throw further light on some of your issues.’

P5 ‘Possibly you go far too far in your search?’

P6 ‘but this is the real world’

P7 ‘They are also, like the NMC code of professional conduct, 'guidelines' to assist an individual to practice to the best of their ability but in the work and real life situation the onus is on each practitioner whether they choose to be guided by these and how they act in particular situations and to take full responsibility if something goes wrong..’

P8 ‘Codes of practice for nurses have also been modified and replaced over the years and they act as a useful 'insurance policy' when something does go wrong and a nurse says that she was working within these and other official guidelines.’

P9 ‘I do not think I need to go into all the details of professionalism here but with all the thousands of nurses who have different levels and years of experience and specialisation and have come from different backgrounds and training schools there is no such thing as 100% consistency although where I practiced we made every effort to deliver our care in a manner which was as consistent as possible which is obviously necessary for the security, confidence, therapy and wellbeing of the patient. Another very important aspect of nursing is building up a therapeutic relationship with the patient which is one of trust, empathy (preferably mutual!) and partnership. It is also a key aim of nursing not to take away a patient's autonomy but to deliver treatment and other forms of therapy and assist them in all daily living activities which they are temporarily or permanently able to carry out for themselves. Nurses have multifunctions and are highly multiskilled but are also human beings each with their own personal limitations as well as the constraints of society, government and their employing organisations who control the financial and personnel resources, shift patterns and have very powerful control over the way that nurses' work is organised often without a thorough understanding of patient care and how it is delivered, let alone the philosophy and process of nursing.’

Thank you for your post – but, did you answer my question ? Wasn’t my question, ‘If nurses read (high-level) guidance and feel it is flawed, will those nurses contact the authors (the BMA, RCN, PCTs, SHAs, etc) and criticise the guidance ?’, in fact ?
Would you please answer it, now ?
If the authors of high-level guidance, do not receive feedback from the people on the front-line whose behaviour is supposed to be affected by the issued guidance, then how do the authors discover if the guidance has had its intended effect ?



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michael stone

michael stone

Posts: 146

10-Jul-2011 12:13 pm

9-Jul-2011 12:40 pm

P2 ‘I studied Medical Law and Ethics at Masters Level in the mid 90s and it is not a clear cut subject at all for anybody and even for our lecturer.’

Well, we have established that you are ‘expert’, and you will have to take my word for it, that we both are. One of my discussion group’s members is a nurse who is a Senior Clinical Lecturer with a law qualification. She teaches the legal aspects of her university’s nursing courses, and she also organises her university’s Verification of Death Courses. We invariably agree about legal issues, but she is unable to answer my ‘So, after the course, do your nurses understand ….’ questions . The best Carol can say, is ‘some probably do, some probably don’t’.
But the law is much clearer now, than it was in the 90s – because the Mental Capacity Act now covers the treatment of patients who lack mental capacity, and it is a necessary consequence of the cessation of heart-beat that one loses consciousness. The Act states that anyone dealing with an incapable person must act in that person’s best interests, and it does not refer to an external test for best interests: the Act’s best interests requirement, is behaviour in accordance with its own section 4. There is a slight complication, in that the Act does not define ‘best interests’ but only a test for proper best interests decision-making – but, because the Act does that, it effectively consigns to history everything pre-2007 (except for court cases).
So, you need to work out what the best interests test is, if you believe in evidence-based behaviour (unless you have a concept for the test, you cannot check whether 2 people are applying the same test to CPR decision-making: this means that you cannot determine whether the 2 people are applying an evidence-based test {here, we are testing the conssitency of the test itself – it is the principle beneath evidence-based behaviour we are using}).
One can most obviously appeal to sections 24 to 26, which cover Advance Decisions. Following an Advance Decision is above the rest of the Act, and outside of the Act’s best interests test requirement – clearly, following an Advance Decision, which is a clear written refusal of treatment by the patient, is in essence merely following an instruction from the patient. Similarly, there is a court case (Re C (adult: refusal of medical treatment) [1994] 1 All ER 819), translated into section 14 of last year’s GMC guidance, that a mentally capable can refuse any offered treatment, without explaining why. There is no test beyond ‘the patient understanding the clinical consequences of his refusal’ – there is no concept of ‘is he making a wise decision ?’ (see the closing note).

So, and taking into account section 4(6) of the Act, it seems clear that the intention of the Act (for patients whose loss of capacity is proximal to their CPA in temporal terms) is to ‘somehow extend a patient’s absolute right to refuse an offered treatment, into a period of mental incapacity’.

Which is a SIMPLE CONCEPT to grasp !


Closing note: I will not go into it here at length, but the combination of a capable patient having an absolute right to refuse an offered treatment, and the MCA defining the treatment of incapable patients (in other words, ‘best interests’ during incapacity now has a legally-defined test) has in fact relegated the ‘historical concept’ of ‘acting in a patient’s best interests’ to obsolescence – reading section 14 of last year’s GMC guidance, and its very careful wording, should make that point obvious ! The concept is now based on ‘accepting an informed refusal of treatment’ and also ‘being clinically competent when providing treatment’. This clearly stems from the separation between the patient’s right to make his own decisions about his own life, and the competence expected of clinicians if a patient does accept an offered treatment – again, this is not a difficult concept, once it has been explained.

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michael stone

michael stone

Posts: 146

10-Jul-2011 12:14 pm

9-Jul-2011 12:40 pm

P3 ‘As the world has changed so much, as has medicine and nursing and attitudes of governments and society, over the last decades much medical law is set on precedence and ethical societies led by professionals in each hospital have to debate and decide on the full implications of the law and its effect on patients.’

I have commented in P2, about the way the MCA has set the rules for CPR since 2007. The law cannot have different meanings in different hospitals – so, if interpretations differ but the law has a clear meaning, some interpretations are necessarily legally wrong. Of course, it is possible the law is unclear, and nobody knows whose interpretation is correct. I am happy with that – provided nobody ALSO claims that the interpretation of a relative, or the guy who runs the local pet shop, is wrong: if nobody knows what is correct, then nobody knows what isn’t correct, either !

Some things in the Act are ‘prima facie clear’, which is the normal ‘literal test’ judges usually apply first. Other things have been left unresolved, presumably intentionally – for example, the Act does not address the problem of ‘multiple decision-makers’ except by resorting to secondary guidance, and it excludes most family carers and relatives from any secondary guidance (section 42). The way qualifying conditions for a refusal of treatment are used in the rules for Advance Decisions is also clummsy and not very satisfactory: it would have been better to use the phrase ‘the refusal may be unrestricted and absolute, or it may be qualified by stated criteria’ and then ‘if the refusal contains qualifying criteria, the refusal is only valid if these are fulfilled’. As it stands, it is very difficult to obey the laws of logic and grammar, and to use clinical qualifying circumstances. And it is qualifying circumstances – these need not be clinical in nature, as a wider-life circumstance could validly be a qualifying circumstance.

Ethics are a consideration after the unambiguous bits of the Act – not, to be used to alter a law ! It is also necessary to consider ‘sense’, ‘logic’, and morals along with ‘ethics’, at the point when ethics are considered.

It is indeed the BMA’s senior ethics person, who is their person for the revision of the Joint CPR guidance which is currently underway – she is the person, who I e-mail in connection with that revision. Pretty regularly, as it happens.

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michael stone

michael stone

Posts: 146

10-Jul-2011 12:14 pm

9-Jul-2011 12:40 pm

P4 ‘There are some good tomes on this subject with thorough investigations of many cases which might help throw further light on some of your issues.’

Now, here we are going to disagree, I suspect. The MCA introduces a best interests test, which is NOT clinical in nature: its test is actually, once you work this out (which you are forced to do), ‘If I could ask him, would he refuse resuscitation ?’. To be complete, with also ‘assuming he knew everything relevant to his own decision making, which he might be unaware of and which I am aware of’.

This does not require ‘real-world cases’ – it is easier, to consider ‘thought experiments’, and to construct imaginary clinical situations tailored to the problem one is pondering, because doing this makes the ‘thinking’ easier. By ‘looking to experience’ it is HARDER to ‘separate the fundamental legal, logical, moral and pragmatic rules from my own clinical experience’.

By a literal reading of isolated sections of the Act, and not thinking properly, one can be misled into writing something which many clinicians write, including some of the people who are writing CPR/VoD policies for entire SHA regions of England, but which is sheer nonsense:

‘A valid written and witnessed Advance Decision refusing CPR is legally binding, but a verbal refusal is not’.

Now, this MUST be nonsense – and it is nonsense, but at first sight it appears to be true. It is untrue, because of ‘valid’. Section 25(4)(c) allows you to go against an Advance Decision and attempt CPR, if you are aware of something which, had the patient also been aware of, you know would have meant he would not have refused attempted CPR. So, what actually matters, is your certainty that had the patient been able to refuse CPR for the CPA under consideration, he would have refused CPR. The wording of section 25(4)(c) is very clear, and it should not really need further explanation:

An advance decision is not applicable to the treatment in question if— ‘there are reasonable grounds for believing that circumstances exist which P did not anticipate at the time of the advance decision and which would have affected his decision had he anticipated them.’


If you discuss CPR with a patient, and he makes it clear he doesn’t want you to try it in the future, and then he arrests a few minutes later, you are certain that he wouldn’t want you to try – because, you reassured yourself that you understood his refusal, during the earlier conversation. But if he became mentally incapable (comatose for example) after writing an Advance Decision which he had not discussed with you, and you read it only after he had lost capacity, then there is always some doubt about what he had considered (although you are told by the Act to assume he had considered everything he needed to) and also about whether you are correctly interpreting his written words.

The logic, and this must be right but it is a sod to ‘dig out’, is as follows.

The most valid reason to not attempt CPR, is if you personally have been told face-to-face by the patient, that he is refusing it – even if this conversation is an explanation of an Advance Decision he has already written, provided you have had the face-to-face discussion, it is the discussion, not the Advance Decision, which provides the justification for not attempting CPR.

If you personally have not had this face-to-face discussion, then if you are presented with an Advance Decision which appears to be valid, you should follow it. Unless someone who knows better, tells you not to (moving into a tricky area, there: if you have not had the chance to discuss an Advance Decision with the patient, it is almost certain that you will not know enough about the patients ‘thinking’ to be able to attempt CPR on the basis of section 25(4)(c) – paramedics who attend an arrest, are almost certainly in that position. But a relative, would normally understand the reasons for a patient’s Advance Decision, well enough to apply section 25(4)(c), if someone provides details of the clinical consequences of the CPR attempt.).

Otherwise, the MCA’s best interests rules apply.

It cannot be sane, to depart from the ‘I am more certain he doesn’t want me to try’ principle: this particular complication, is really bothersome – I also would have wanted ‘signed and witnessed’ for refusals of life-sustaining treatments, and it is only when you read ‘so a verbal refusal is not legally binding’ that you realise how problematic this is !

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michael stone

michael stone

Posts: 146

10-Jul-2011 12:14 pm

9-Jul-2011 12:40 pm

P5 ‘Possibly you go far too far in your search?’

Not in my opinion.
Firstly, only about 1-in-5 patients currently die at home, and it is thought that about 2 or 3 times as many wish to die at home, and allowing more to achieve that wish is an objective of the DH. I can be pretty much certain of the published objectives of the DH – another member of my e-mail discussion group, is the Head of End-of-Life care at the DH. And death at home, is an entirely different matter from death in hospital.
At home, the first person a patient may talk to can be a relative, and the first person to notice something, can also be a relative. Furthermore, if the patient arrests at home, with only a relative present, it is the relative who has a decision to make.
You must design a consistent behaviour set, which sees things from the perspective of patients, relatives and family carers and not just from the perspective of clinicians, etc. Currently, professionals are designing ‘the rules’ from their own perspective, and simply assuming they can then impose their own ‘desired behaviour’ onto amateurs: not only is this unreasonable, and immoral, but it is not anything which the Act allows, if you read section 42.

Secondly, are nurses and paramedics trained professionals, or are they untrained and assumed to be incompetent ? Which is it ? If these staff are now effectively graduate-level, then even if it takes someone else to design the correct behaviour set, nurses and paramedics must surely be able to follow clearly-explained guidance ?
And I go back to P2:

‘So, and taking into account section 4(6) of the Act, it seems clear that the intention of the Act (for patients whose loss of capaciy is proximal to their CPA in temporal terms) is to ‘somehow extend a patient’s absolute right to refuse an offered treatment, into a period of mental incapacity’.

Which is a SIMPLE CONCEPT to grasp !’

There is NOT any presumption, there, that non-professionals are dishonest or immoral – stop trying to superimpose, such an assumption ! ANYBODY CAN LISTEN TO WHAT A PATIENT IS SAYING ! But NOT unless you ARE present, when the patient says it ! Knowing something means you personally cannot ignore it – it does not necessarily also mean you can prove it happened, but this country is supposed to have a presumption of innocence.



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michael stone

michael stone

Posts: 146

10-Jul-2011 12:16 pm

9-Jul-2011 12:40 pm

P6 ‘but this is the real world’

Quite !

In the real world, patients and their relatives tend to care about each other: it is reasonable to assume that relatives lack clinical knowledge, and various other quite complex factors about ‘the pschology around death’ come into play, but it is simply offensive, to adopt a default position of DISTRUSTING relatives.
So, for patients who are at home, the role of relatives and family carers is central, not ‘peripheral’: relatives are not ‘passive bystanders’, but active participants. Any behaviour set based around ‘doctors make decisions and clinicians can discuss things without patients and relatives’ is fundamentally flawed: the aim, must be to integrate patients, relatives and clinicians.
And the roles, should be properly defined. Clinicians must describe clinical prognoses and treatment options – patients, or if the patient is incapable ‘those close to the patient’ (usually relatives), decide if the treatment is acceptable (to the patient – if acting as a proxy, the question the relative must consider is ‘Would my dad refuse ?’). This assumes there are no Welfare Attorneys or a Court Deputy involved, when those people ‘make’ the decisions (as usual, I would need to elaborate on that – but not here). And ‘Welfare Attorneys make the decisions’ is significant: a Welfare Attorney is no more clinically qualified than any other relative, so clearly CPR decision-making is not a consideration of clinical factors (it is a consideration of whether the ‘way a predicted clinical situation ‘feels’ {after ‘successfully’attempted CPR, compared to being dead} combined with ‘wider life factors’, would be acceptable to the patient).
The current guidance does not properly fit the above.





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michael stone

michael stone

Posts: 146

10-Jul-2011 12:16 pm

9-Jul-2011 12:40 pm

P7 ‘They are also, like the NMC code of professional conduct, 'guidelines' to assist an individual to practice to the best of their ability but in the work and real life situation the onus is on each practitioner whether they choose to be guided by these and how they act in particular situations and to take full responsibility if something goes wrong..’

Now, several issues are raised here. Firstly, CPR decision-making must be in line with the MCA, which is a law – not a guideline. Nurses and others, seem to read not the MCA, but its Code, or possibly other guidance which is even more distant from the Mental Capacity Act: if that guidance is flawed, and following it breaches the Act, then nurses are actually acting illegally.

And, the issue of ‘discretion’ is much mis-understood. The theory behind evidence-based behaviour, is simple. If the best treatment/behaviour for any given presentation has been established, then all similarly-qualified professionals will provide the same treatment/behaviour. If you have proper evidence-based behaviour, then the professionals actually have no discretion, because they all provide the same (best) treatment.
Now, in the real world, no two presentations are completely identical. But in the ‘world of written questions’ – as in my ‘Musings’ series, etc – all of the discoverable information is contained in the wording. This means, that the test of evidence-based behaviour, can be applied to the clinicians answering the questions: if the answers are not all effectively identical, either the respondents have different levels of expertise, or else there is not an established ‘evidence-based’ behaviour present.
In theory the behaviour of different people in the same situation can differ because of differences in their own knowledge of the situation, so a nurse and a paramedic might behave differently: but by the same reasoning, a family carer and a GP could each react differently, but equally correctly, to the same situation. This turns out to be true, when one runs it through, for CPR decision-making – my objection, is that ‘the system’ is trying to simplify that by imposing ‘the correct behaviour for the GP’ onto a relative, who is just as entitled to have a DIFFERENT ‘correct’ behaviour (again, rather lengthy to explain here – but easy enough to work out).

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michael stone

michael stone

Posts: 146

10-Jul-2011 12:17 pm

9-Jul-2011 12:40 pm

P8 ‘Codes of practice for nurses have also been modified and replaced over the years and they act as a useful 'insurance policy' when something does go wrong and a nurse says that she was working within these and other official guidelines.’

Now, basically that is saying that professionals can use the concentration camp guard defence, of ‘I was only following orders’. And when uncertainty rears its head, nurses, paramedics, etc, tend to forgo all vestiges of ‘sense’ and to fall back on ‘ The Guidelines say ….’.
Relatives, do not have ‘guidelines to use as a ‘shield’’ – it is unreasonable for professionals to behave in this way, because their own guidance invariably ‘usurps all of the leeway’ leaving none for the amateurs. When you combine this with ‘professional perspective bias’ and poor ‘training and understanding’, then the behaviour of a group of confused professionals in an unusual situation (the one I experienced was paramedics, police and district nurses) can appear absolutely imbecilic to an intelligent amateur !

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michael stone

michael stone

Posts: 146

10-Jul-2011 12:17 pm

9-Jul-2011 12:40 pm

P9 ‘I do not think I need to go into all the details of professionalism here but with all the thousands of nurses who have different levels and years of experience and specialisation and have come from different backgrounds and training schools there is no such thing as 100% consistency although where I practiced we made every effort to deliver our care in a manner which was as consistent as possible which is obviously necessary for the security, confidence, therapy and wellbeing of the patient. Another very important aspect of nursing is building up a therapeutic relationship with the patient which is one of trust, empathy (preferably mutual!) and partnership. It is also a key aim of nursing not to take away a patient's autonomy but to deliver treatment and other forms of therapy and assist them in all daily living activities which they are temporarily or permanently able to carry out for themselves. Nurses have multifunctions and are highly multiskilled but are also human beings each with their own personal limitations as well as the constraints of society, government and their employing organisations who control the financial and personnel resources, shift patterns and have very powerful control over the way that nurses' work is organised often without a thorough understanding of patient care and how it is delivered, let alone the philosophy and process of nursing.’

Well, yes – but of no help, to the improvement of guidelines ! I asked the BMA’s person, ‘Do you only want analytical comment about the existing guidance, or do you also want suggested wording ? And do you want real-world observations, such as nurses seem to find ‘this wording’ easier to understand than ‘that wording’ ?
The answer was ‘both are helpful’. I ask very specific questions on the NT site, because the answers would help me !
And wasn’t the original question here, ‘Is it reasonable to assume that nurses who find a flaw in the Joint CPR Guidance, WILL CONTACT ITS AUTHORS and point out the mistake ?’ or the equivalent ? I am asking on the NT site, because I need the answers of actual operational nurses !
And, unless I missed it, you have posted a lot of comments – but you have not answered the question in any clear (very few would, most would, I think hardly any would, etc) way !


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Anonymous

Anonymous

10-Jul-2011 1:28 pm

like you and all your comments which you have posted elsewhere I was merely posting mine here, which I said at the outset was general, with my personal opinion and interpretation of guidelines to try and clarify their use since you raised this issue. it was not intended as an answer to your questions which i do not have, and doubt whether many others do either.

please look at the definition i copied and pasted from the Concise Oxford English Dictionary 11th Edition following one of the articles on what is meant by 'comment'. It was aimed at nobody in particular and I looked it up to see if I was using this valuable resource to the best of its advantage and then thought it might be useful to share as a reminder. We all know roughly what words mean but often tend to use them very loosely so eventually the meanings may change but I find the dictionary a very useful resource for verifying meanings and changes in our language.

we are all here as readers of the NT to BRIEFLY comment on and discuss and debate issues mainly related to the articles and those raised by other commentators but not necessarily to answer all 'your' questions and i find your continual criticisms of the profession and what they should and should not be doing highly offensive especially when you comment on something you clearly know nothing about, and which I and others have also said on other occasions as the unwritten rules of online etiquette are constantly breached although this is rare among other commentators. I only regret that I tried to make my comments as objective as possible and these have on occasion been followed by other more aggressive ones.

I doubt very much whether busy front line clinicians, no matter what their professional background and qualifications, have the time to analyse all the points you raise in such depth and detail as you have done.

If your 'specific' questions are aimed at a 'specific' grop why don't you target that particular group to get your answers or the relevant academic department of a university where somebody might be able to find the time to study them and answer them for you?

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Anonymous

Anonymous

10-Jul-2011 1:49 pm

"The answer was ‘both are helpful’. I ask very specific questions on the NT site, because the answers would help me !
And wasn’t the original question here, ‘Is it reasonable to assume that nurses who find a flaw in the Joint CPR Guidance, WILL CONTACT ITS AUTHORS and point out the mistake ?’ or the equivalent ? I am asking on the NT site, because I need the answers of actual operational nurses !
And, unless I missed it, you have posted a lot of comments – but you have not answered the question in any clear (very few would, most would, I think hardly any would, etc) way !"

kindly note that nobody is under any obligation to answer your questions unless they wish to do so, or feel qualified to do so, and your various bullying and coercive tactics to attempt to elicit an answer by criticizing others who post their comments and playing one commentator against another as in the whistle blowing comments is both offensive, and abusive of online etiquette to other commentators.

Perhaps you are also unaware that hc professionals are under legal obligation not to give out false information and your issues would require detailed and lengthy study in order to search for coherent responses which for many is time that we do not have or are not prepared to give.


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Anonymous

Anonymous

11-Jul-2011 7:39 am

references

Ackermann RJ (2000)
Withholding and withdrawing life-sustaining treaatment.
American Family Physician 62.7.

Allmark P, Tod A (2009) End of life care pathways: ethical and legal principles. Nursing Standard 24, 14, 35-39.

Antoun S, Merand M, Gabolde M (2006) Artificial nutrition at the end of life: is it justified? Euroopean Journal of Palliative Care, 13, 5, 194-197.

British Medical Association (2007) Withholding or Withdrawing Life-Prolonging Medical Treatment: Guidance for Decision Making. Third Edition. Blackwell Publishing. Oxford.

**************
Department of Health (2005) Mental Capacity Act Deprivation of Liberty Safeguards.
www.dh.gov.uk/en/
Media Centre/Media/DH_097314 (Last accessed: Novembeer 25 2010)
******************

Ellershaw J. Wilkinson S (Eds) (2003) Care of the Dying: A Pathway to Excellence Oxford University Press, Oxford.

Fallowfield LJ, Jenkins VA, Beveridge HA (2002) Truth may hut but deceit hurts more: communicaton in palliative care. Palliative Medicine 16, 4, 297-303

*****************
General Medical Council (2002) Withholding and Withdrawing - guidance for Doctors. http://tiny.cc/with (Last accessed: November 25 2010)
*****************

Marie Curie Palliative Care Institute (2010) Liverpool Care Pathway for the Dying Patient. www.liv.ac.uk/mcpcil/liverpool-care-pathway (Last accessed November 25 2010)

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UK Clinical Ethics Network (2010) End of Life Decsions. www.ethics-network.org.uk/ethical-issues/end-of-life/end-of-life-decisions (Last accessed November 25 2010)
*************************
***********************
Wheat K (2009) Applying ethical principles. British Journal of Nursing. 18, 17, 1062-1063
***********************

Woods S (2005) Respect for persons autonomy and palliative care. Medicine, Healthcare and Philosophy 8,2 243-253.






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cogito

cogito

Posts: 5

11-Jul-2011 11:48 am

10-Jul-2011 1:28 pm

You mentioned 'and discuss' - the person who posted this, quite clearly wants to get some answers from operational nurses. Isn't discussion, a process which involves both making comments, and also posing and answering questions ? I cannot see where he has said you are obliged to answer his question, as you imply - but why do you waffle on, WITHOUT answering it ! He has requested answers to specific questions - I suspect, he has a sound reason for asking very specific questions.

11-Jul-2011 7:39 am

Why have you provided a list of references containing foreign (where the laws are presumably different) and out-dated (before a more recent law was enacted) items ?

10-Jul-2011 1:28 pm

it was not intended as an answer to your questions which i do not have, and doubt whether many others do either.

If you can't answer this guy's questions, because you are unclear in your own mind about what the correct answers would be, why did you not just comment 'I have tried to follow your postings and they are exploring areas I don't properly understand' ?

And when you asked 'If your 'specific' questions are aimed at a 'specific' grop why don't you target that particular group' having read the posts, I myself get the impression, that he is posting on NT because the 'specific group' he is seeking answers from on NT, are NURSES !

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Anonymous

Anonymous

11-Jul-2011 4:03 pm

copied from the NT Forum Webpages

"Let's get talking (85)
Posted in: Discussion and debate

Debate the issues and stories of the day, seek advice and share ideas

ADD NEW DISCUSSION"

"Posted in: Let's get talking | Discussion and debate"

"Discussions
Share advice, debate the issues of the day, or just gossip with other nurses. Get it off your chest on the Nursing Times forums.

Discussion and debate"

_________________________________________________
From the COED 11th Ed

comment
n noun
1 a remark expressing an opinion or reaction. Ødiscussion, especially of a critical nature.
2 an explanatory note in a text. Øarchaic a written explanation or commentary.
n verb express an opinion or reaction.

DERIVATIVES
commenter noun

ORIGIN
Middle English: from Latin commentum 'contrivance' (in late Latin also 'interpretation'), neuter past participle of comminisci 'devise'.

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michael stone

michael stone

Posts: 146

15-Jul-2011 2:29 pm

11-Jul-2011 4:03 pm

I am interested in how someone who appears to have such an interest in linguistic pedantry, posts in something called 'Let's get talking' as opposed to persistently contacting NT and arguing that it should instead be called 'Let's get writing' ? Talking = spoken word !

And debate and discussion, whatever your dictionary may have to say on the matter, involves an exchange of reasoned arguments, when academically-minded people are taking part.

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