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michael stone

michael stone

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Comments (3015)

  • Comment on: New guidance emphasises need for training in 'care after death'

    michael stone's comment 25-Apr-2015 3:05 pm

    Anonymous | 25-Apr-2015 10:41 am I am not 'high and mighty' ('opinionated' yes - strongly-developed views, yes), but I am however 'seeing things from the lay perspective' - and an awful lot of the behaviour 'around dying and death' which is not 'the care itself', does not 'meet with my approval'. In particular, the muddle and 'biased behaviour' around 'early EoL community deaths'. It is 'complicated' - but the present 'balance' is also wrong.

  • Comment on: New guidance emphasises need for training in 'care after death'

    michael stone's comment 24-Apr-2015 1:26 pm

    The piece above tells us that: 'In addition, it incorporates detailed elements of care provision in the immediate aftermath of someone’s death. One particular aspect of care that has been identified as needing attention is the verification of expected death, particularly in a community setting – care home or patient’s home.' I have not yet read through the guidance, but I have searched to see 'how it defines' the term 'expected death'. It does not use the only logically-correct definition of 'expected death' - which, incidentally, is a term I think should not be used in guidance or protocols {you can just require that a 'marker' is present for the situation, in notes: then, by adding a second 'marker', you could resolve a serious issue around the uncertainty about 'the point when a death becomes 'expected'’} - although 'the clues are there'. The correct definition of 'expected death' is IMPLIED by the wording on page 11: '... in order that a Medical Certificate of Cause of Death (MCCD) can be appropriately issued without involving the coroner.'. A community EoL death is 'expected' if the GP has formally indicated that 'I will certify a future death which does not appear to be obviously unnatural, even if I (the GP) CANNOT ATTEND post-mortem'. I have been writing about this for ages - most recently, on the Marie Curie website (see the comments to this piece): http://blog.mariecurie.org.uk/2015/04/20/end-of-life-care-challenge-for-government/ My comment at 22 April 2015 at 12:08 pm (my second comment - with a typo correction immediately afterwards) explains the problem, and the link goes to another of my online pieces where I explain the solution. So this guidance does not, in fact, resolve the problems with 'expected death' as an operational concept: if you search the PDF for 'expected' these are the references you come up with: All people die – some deaths are expected, for example, due to ill health. Some deaths are unexpected, either due to a sudden event, or to an accident / violent event. (page 5) Unambiguous and documented communication on all of the above decisions ensures there is clarity about whether the death is expected or not and allows for appropriate preparation of the dying person and their family/carers. (page 10 - and it is also wrong) In care home and home settings where death is expected, it is crucial that the GP reviews the person regularly and at least every 14 days, both from a care perspective and in order that a Medical Certificate of Cause of Death (MCCD) can be appropriately issued without involving the coroner. (page 11) I have explained why that is crucial on the BMJ website: http://www.bmj.com/content/347/bmj.f4085/rr/654490 Where there is a rapid, same day discharge home (to a private home, social care or mental health care setting) from hospital for expected end of life care, and this occurs on a Friday, it is essential that there is a GP visit that day or the hospital consultant is happy to issue the MCCD, should the death occur at the weekend. Alongside the care planning – including equipment, care of the person’s hygiene and nursing needs, and family support – the practicalities of who will verify the death and issue a MCCD, including the paperwork for cremation (cremation part 4 and part 536), should be considered. For rapid discharge from hospital to prison it is essential that the prison has 24 hour healthcare provision and the lead nurse is contacted to ensure the health needs of the dying prisoner is met. (page 11) It is recommended that all care settings – including care homes - ensure adequately trained staff to verify expected deaths of patients in and out of hours. The role of GPs in verification of death for residents of care homes has been specifically addressed (page 13) Section 23 on page 13 also mentions 'expected death' but it is 'a mere aside' so I'm not reproducing it here. It isn’t either logically correct, or satisfactory, for flawed ‘proxy markers’ to be used for ‘expected death’: a DNACPR decision is not necessarily an indicator of ‘expected death’ [because a patient has the legal right to refuse attempted CPR irrespective of whether or not the death could be certified], and ‘palliative-only treatment’ is also not necessarily inevitably an indicator of ‘expected death’.

  • Comment on: 'Students’ concerns must be listened to'

    michael stone's comment 22-Apr-2015 9:35 am

    Anonymous | 21-Apr-2015 3:49 pm Apology accepted, Mike.

  • Comment on: 'Qualification feels far away at times but I am so close to fulfilling my dream'

    michael stone's comment 21-Apr-2015 3:06 pm

    'Still we have essays to submit, exams to do and presentations to give before we can breathe an almighty sigh of relief.' Just out of interest, about 'exams to do'. When I was a chemistry student in the 1970s, the degree awarded depended on a mark carried forward from laboratory work (which I think was about 20% of the final degree) and how we did on the written papers - if memory serves, we had about 6 papers, each of 3 hours, over a 2-week period. So about 80% of our degree, depended on those 6 papers. To say that there was a lot of stress in that final term before the exams, is an understatement !

  • Comment on: 'Students’ concerns must be listened to'

    michael stone's comment 21-Apr-2015 3:00 pm

    Anonymous | 21-Apr-2015 12:04 pm Are you implying that I have committed some offence ? 'The offence' ? Because I haven't.

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