Community nurses may be being put under pressure to probe frail and elderly patients on their end of life wishes without the right support and training, say palliative care experts.
The warning comes amid growing concern – and mounting complaints from patients and relatives - about the way these sensitive conversations are being handled.
In one distressing case brought to the attention of Nursing Times an elderly man in a rehab unit told his wife not to bother buying him some new slippers because he was convinced he was about to die.
England’s chief nursing officer Jane Cummings recently pledged to review an official questionnaire that prompts district nurses to discuss resuscitation with vulnerable patients following “disturbing” accounts the questions were being asked in a “blunt and impersonal way”.
Since then more evidence of poor practice has emerged including practice nurses cold-calling patients to broach subjects such as continuation of treatment and preferred place of death.
Ruth Nicholls, a palliative care clinical nurse specialist working in the South East, told Nursing Times she was horrified by the way conversations were being approached – often by inexperienced nurses.
One upsetting example involved her brother-in-law who has heart problems and lives in the north of England.
“He came back from an outpatient appointment having not had very good news and later that afternoon got a phone call from one of the practice nurses at his GP surgery,” Ms Nicholls said.
“She said ‘Hello, we’re ringing all our patients with chronic conditions to see how you are and whether you have you thought about resuscitation’. This conversation was absolutely out of nowhere. My brother-in-law was shocked and my sister was distraught.”
Ms Nicholls also described the case of an elderly man in the South East who had just come out of hospital and was asked about resuscitation by a newly-qualified nurse who had come to his home to do a continence assessment.
“He had never had any contact with the district nursing team before and one of the first questions he was asked was whether he wanted to be resuscitated,” she said. “These are conversations that need to be had but with the right person at the right time and not just to tick a box. People are being left in great distress.”
As part of the new GP contract practice are required to collect information about how patients with long term conditions wish to be cared for in a bid to avoid unnecessary admissions to hospital.
Amanda Cheesley, the RCN’s lead on end of life care, told Nursing Times she feared practice nurses might be under pressure from hard-pressed surgeries to quickly gather data.
“I hope these are isolated incidents but we need to find out more and we are keen to hear nurses’ experiences,” she said.
“I suspect some GP practices already under pressure feel this is just another thing they are being asked to do and are simply handing questionnaires to practice nurses alongside a list of over 75s and telling them to go through the questions with them. People may not be thinking too hard about what it is they are asking.”
Claire Henry chief executive of the National Council for Palliative Care said if conversations were not tackled in the right way it was distressing for patients but also “destructive for nurses who want to do a good job”.
Examples gathered by her organisation include one patient who was devastated when they were invited to attend an “end of life clinic” because they had no idea their condition was life-limiting.
She said it was vital all nurses got training on how to tackle difficult conversations.
“It is all about building that relationship up with someone and having these conversations in a timely way,” she said.
“The nurses who are being asked to do this need to challenge it and ask for more support in having these conversations.
“All the professionals involved need to look at how they are working as a team and where the opportunities are to have these discussions say if someone’s coming in for a GP or outpatient appointment and also how to have these conversations over a period of time.”