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michael stone

michael stone

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Comments (3861)

  • Comment on: Game aims to prepare new nurses for life on the ward

    michael stone's comment 11 January, 2017 11:36 am

    There is one thing which has not been mentioned so far.

    It has been pointed out that training by using 'scenarios' can be useful as preparation before encountering the real thing. Clearly if trainers create defined scenarios, they are likely to present scenarios which they consider to be either likely, or significant. A game, if designed well, should have the scope to generate some 'novel scenarios' which might be informative and useful, but which would otherwise never be considered.

    Training can never replace experience - training is designed to help before experience has been acquired, and also to impart 'expertise' more quickly/effectively than experience alone.

  • Comment on: Nurses are at 'breaking point' over winter pressures, claims RCN

    michael stone's comment 11 January, 2017 11:28 am

    Professor David Oliver has also just written about this in his open-access BMJ piece at:

    http://www.bmj.com/content/356/bmj.j146

    His 'slant' is how do the descriptions of what is happening, by the government and senior NHS Bodies, fir in with 'the duty of candour'.

  • Comment on: Game aims to prepare new nurses for life on the ward

    michael stone's comment 7 January, 2017 10:50 am

    Interesting comments.

    I'm not sure that anyone can actually sensibly opine about whether this game is helpful or not, without playing it.

    Surely the important question, is whether there is enough [paid] time devoted to what Marc Evans described as 'intense clinical scenarios during their training': do nurses have enough such preparatory experience before confronting these tricky situations for real ?

  • Comment on: Guidance to tackle delays in nurse verification of deaths

    michael stone's comment 3 January, 2017 10:43 am

    To ANONYMOUS 25 DECEMBER, 2016 1:44 PM

    Do you mean my comments/posts ?

    If you do, in what respect are they unsuitable or offensive - be so kind as to explain why you think that ?

  • Comment on: Guidance to tackle delays in nurse verification of deaths

    michael stone's comment 20 December, 2016 9:24 am

    At the risk of being accused of writing beyond my competence, I’ll explain the issues with ‘expected death’ and verification of expected death by nurses: and I write from the family-carer position. I am very annoyed by contemporary guidance, protocols and behaviour – they are both illogical and also unfair towards relatives and family carers, in the sense that behaviour is not proportionate in the balance between professional objectives and consideration for the mental fragility of just-bereaved people.

    We should stop using terms like ‘expected’, ‘unexpected’, ‘sudden’ in connection with the deaths of end-of-life (within the predicted final 12 months of life) or ‘very frail’ people/patients. We do need SOMETHING in the medical notes – so the guidance is almost correct with (page 2):

    ‘There is agreement for Registered Nurse Verification of Expected Death documented clearly in the clinical notes.’

    Except, you cannot define ‘expected death’ in any way which is not either too inclusive, or else insufficiently inclusive (see ‘Appendix 1’ for a simple proof of this). Under ‘Responsibilities’ and for doctors, the requirement is correctly expressed (page 3 - and it does not mention ‘expected death’):


    ‘Doctors will document in the patient’s clinical record that an RN can verify the death.’


    What we should have inside the notes, are statements by the doctor who could certify the death about ‘how surprised I would be by a natural death’. It honestly isn’t complicated:

    XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX


    These are two notes which the GP (a consultant could do the same for hospital patients, but the problem these resolve is mainly when death in the community occurs) has to write in the medical notes as they become true - and CRUCIALLY all of the patient's carers, both professional and family carers, AND ALSO anybody else sharing a home with the patient, needs to know about these two notes. The two notes are:

    'I (the GP) would no longer be surprised by the natural death of this patient, but I would need to attend post-mortem before deciding whether to certify the death'

    and, at a later stage of clinical deterioration

    'I (the GP) will now certify any death which is not apparently unnatural, even if I am unable to attend post-mortem'.



    The second of those, is actually 'a statement of expected death' [as the concept is used in post-mortem behaviour] but if you use the statement, there is NO NEED to separately define 'expected death'.

    XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

    Of course, some patients will die before one or both statements has been recorded, and GPs will vary – however:

    If the presence and times of these markers, and the time and cause of the death, were collected for all deaths, then many currently 'unanswerable' questions about EoL, could in theory be answered. A few examples are:

    It is accepted that the difficulty of accurately predicting when a patient is going to die, differs according to the illness. If you filter deaths according to the illness, you can then look at the two GP statements for each type of death, and that would tell you which types of illness had [in relative terms] harder-to-predict deaths: you might , for example, discover that it was much more difficult for GPs to predict when a patient suffering from heart failure would die, than for a patient with lung cancer.

    If a GP Practice had 4 GPs, then by comparing the times between the markers and the deaths for each GP's patients, you could see how varied or similar different GPs were in terms of how they predicted the deaths of their patients.

    By doing the same type of analysis but across different regions of the country, you could see 'if behaviour for community EoL death was the same in different parts of the country'.

    Etc - it is very easy to see how that type of analysis could be performed, if everyone used the 'marker system' and the results were available for analysis.


    CERTIFICATION

    Coroners have been complaining that too many deaths are unnecessarily referred to them, but from my family-carer or live-with relative perspective, my problem is not about what happens once the coroner is involved – my issue is with what happens when a patient is at home and ‘dies a bit early’ AND the GP CANNOT promptly attend the death. In this situation, you tend to get police involvement – my issue is with what happens in the hours immediately after a death when the police become involved and it is not clear whether the death will be certified.

    As I pointed out in my piece at:

    http://www.bmj.com/content/347/bmj.f4085/rr/654490

    XXXXXXXXXXXXXXXXXXXXXXXXXXXX

    Laurie R Davis (this series of rapid responses, 11 July 2013) has commented ‘It can have workload implications as there appears to be a widespread belief amongst care homes that patients who might die should be visited by their GP every two weeks.’

    The reason is probably the grossly inappropriate and hugely insensitive behaviour of police for EoL community deaths, when the death is not ‘expected’. In this context, expected has an obvious logical meaning: an ‘expected death’ is one which occurs after the GP has ‘promised to certify even if I cannot attend post mortem’ (with the safety provided by that promise, the coroner can hugely relax the investigative aspect of post mortem behaviour, effectively instructing suitably trained nurses/etc that ‘unless the death was obviously unnatural, just arrange for the body to be removed, try to keep the police out of it, and do not pester grieving relatives’).

    There is no guidance within current community policies, which properly addresses ‘I would not be surprised if the patient dies, but I would need to attend post mortem before deciding whether to certify’ – currently police behaviour tends to treat ‘early EoL death’ as very much akin to the sudden death of a believed-to-be-healthy 25 yr old. This is absurd, to put it mildly, when you are in the position of a person who is living with the patient. The transition from considerate treatment by nurses and the GP, to ‘being treated by the police like a suspect when my loved one finally died’, is a huge shock to the just-bereaved, and very ‘disturbing’. I also think such police behaviour reinforces long-term memories of the death itself, which is a bad thing, and is being ignored by policy creators.

    So the death of an elderly patient who ‘might die any time, but I (GP) cannot say whether tomorrow or in a year’s time’ is treated as a ‘sudden death’ unless the GP attends post mortem and decides to certify: and even an ‘expected death’ will become, from the perspective of the care home, ‘a death we, and the police, are not certain will be certified’ if the GP has not visited within the previous 14 days. The police have a strong tendency to ‘seek to investigate in depth’ any death until certification is effectively a certainty – this damages bereaved relatives, and is neither ‘balanced’ nor rational, if a patient is known to be ‘very elderly, final-year-of-life or has a condition which involves an ongoing but small probability of ‘dying at any time’’.

    And the care home, or a relative in the patient’s own home, cannot be certain that the GP will be able to attend promptly, when the death occurs.

    XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

    VERIFICATION IS NOT CERTIFICATION

    Coroners seem to be very reluctant to clearly explain 'expected death' - perhaps because in effect it amounts to 'a very light 'investigation' of deaths which the GP knows are going to happen soon, in order to keep the police away, because the police when involved, tend to 'harass the just-bereaved relatives''. Doubtless coroners are aware that some people, and some media, would scream 'You might be letting people get away with murder !' - which is a possibility, but the balance on the other side, is that 'aggressive police investigation' into the vast majority of home EoL deaths, which are overwhelmingly natural, leaves entirely innocent relatives with 'long-term trauma memories'.

    But, one consequence of the reluctance of coroners to explain this properly, is that many nurses believe that when they (nurses) verify an expected death, they are 'supposed to be linking the death to the known terminal illness'. Those nurses should only be confirming that the patient is dead, and noticing any obvious signs of an unnatural death - 'linking the death to the known illness' is CERTIFICATION, and ONLY a doctor who could certify the death, should be doing that. People such as nurses and paramedics, should definitely NOT 'be offering an opinion about why the patient died' [except for drawing attention to signs of an unnatural death].

    IT IS UNREASONABLE TO WANT TO KNOW ‘UNKNOWABLE THINGS’

    The police, seem to confuse not understanding why a person died, with evidence of possible wrong-doing: it is evidence of something unnatural, which is correctly evidence of wrong-doing. Typically if a frail elderly person dies, it will not be obvious why this has happened – but unless there is some evidence to the contrary, ‘live-with relatives’ should be treated as witnesses who have just lost a loved-one: the police have a nasty tendency to treat the relatives as ‘suspects’.

    I’m not going to develop these themes any further, partly because they are developed in Appendix 1, and partly because I’ve given links to my pieces about this topic previously.

    You don’t need to be ‘an expert’ to analyse this – you only need to do a bit of thinking !

    APPENDIX 1

    I will explain the problem with contemporary Community End-of-Life Death policies, and also why it would help if everyone - all of England's GPs and all of England's regions - adopted my 'marker' system, and also recorded and analysed deaths in terms of the presence or absence of these markers.

    At the moment, the behaviour for EoL death at home, varies from region to region, and depends on what the local NHS has agreed with the local coroner. The only policies in existence are invariably 'Expected Death' policies, but the term doesn't mean, as a family member might expect it to mean' 'my dad was expected to die'. It actually means 'the GP has indicated to the coroner, that even if the GP cannot attend the deceased patient, the GP will certify the death (i.e. provide a note to the coroner, stating 'what the patient died from') unless it appeared to be obviously unnatural. .

    In other words, the marker on my timeline of:

    'I (the GP) will now certify any death which is not apparently unnatural, even if I am unable to attend post-mortem'

    indicates an 'expected death'.

    The point of 'expected death' is to keep the police away from 'imminent natural deaths'. So any well-organised and competent region, will have in place arrangements which allow people such as trained nurse to confirm that the patient is indeed dead (Verify the death) and to arrange for the body to be removed from the house, and for the relatives to be given the necessary paperwork, etc, even if the GP cannot turn out.

    All other EoL deaths, are currently described as 'unexpected' or 'sudden', and the police tend to be involved in these deaths, unless the GP turns up before the police, and the GP decides to Certify the death.

    In England this promise that the death will be certified even if the GP cannot attend post-mortem, requires that the GP has visited the patient within 14 days before the death: the GP can decide to certify the death even if the most recent visit was more than 14 days previously, but ONLY IF the GP attends the death and examines the deceased.

    If the death wasn't 'expected', and the GP doesn't visit post-mortem and decide to certify the death because for some reason the GP cannot visit, the GP might still end up certifying the death, after a discussion with the coroner - this made an attempt to 'count the percentage of unexpected deaths' very complicated, in a paper you can find online.

    www.endoflifecare-intelligence.org.uk/view?rid=116

    Within the paper, the authors explain the complication of deciding what is or isn't 'an unexpected death', and they comment that 'it could be assumed, however, that referrals to the coronial service where no inquest and no post mortem were required were in fact not unexpected deaths because a death certificate could be issued following a discussion between the clinician and coroner only,' - and if that assumption is made they came up with a figure of 22% of deaths as being 'unexpected', whereas if you include 'there was a conversation with the coroner' in the description of an unexpected death, the figure for 'unexpected' deaths was 46%.

    Coroners seem to be very reluctant to clearly explain 'expected death' - perhaps because in effect it amounts to 'a very light 'investigation' of deaths which the GP knows are going to happen soon, in order to keep the police away, because the police when involved, tend to 'harass the just-bereaved relatives''. Doubtless coroners are aware that some people, and some media, would scream 'You might be letting people get away with murder !' - which is a possibility, but the balance on the other side, is that 'aggressive police investigation' into the vast majority of home EoL deaths, which are overwhelmingly natural, leaves entirely innocent relatives with 'long-term trauma memories'.

    But, one consequence of the reluctance of coroners to explain this properly, is that many nurses believe that when they (nurses) verify an expected death, they are 'supposed to be linking the death to the known terminal illness'. Those nurses should only be confirming that the patient is dead, and noticing any obvious signs of an unnatural death - 'linking the death to the known illness' is CERTIFICATION, and ONLY a doctor who could certify the death, should be doing that. People such as nurses and paramedics, should definitely NOT 'be offering an opinion about why the patient died' [except for drawing attention to signs of an unnatural death].

    The fundamental problem with 'expected death', is twofold: nobody is 100% sure 'how imminent a death should be, to qualify as 'expected'', and also doctors are not at all good, at predicting exactly when a patient will die.

    If the idea is to keep the police away from 'imminent deaths', the death would need to become 'expected' at least a few days before the patient died - it would be pointless the GP 'classifying a death as expected' when the GP expected the patient to die within 24 hours.

    As the GP must visit post-mortem if he has visited during the previous 14 days, 'expected to die within 14 days' looks like the upper limit.

    So, let us assume that 'when the GP expects the patient to die within 14 days', the death becomes expected, and the GP writes in the patient's notes:

    'I (the GP) will now certify any death which is not apparently unnatural, even if I am unable to attend post-mortem'

    In reality, no GP can be sure of when, a patient will die: if a GP says 'I think this patient will die in 10 days time', the GP could not honestly be surprised if the patient dies in 7 days time, or in 15 days time.

    It is easier 'for the thinking' of the next part, to switch the prediction to a different type. Imagine that the patient has got a fixed chance of dying, on every day, until he dies. So imagine that someone is very ill but is not 'getting worse' - so if the patient has a 1-in-5 chance of dying today, and if he does not die today, he has the same 1-in-5 chance of dying tomorrow (and so on - a 1-in-5 chance of dying, on every day until he actually dies).

    What, thinking about this patient, does the chance need to be, for the patient to be 'expected death' ? It turns out, that a 1-in-10 chance of dying on every day, is approximately 'death within 14 days' (about 4 in every 5 patients with a 1-in-10 chance of dying on every day, will be dead by the 14th day).

    The way EoL death at home is treated at the moment, the patient who the GP considered to have a 1-in-10 chance of dying on every day, would be 'expected death'. A patient with a 1-in-11 chance of dying would be 'unexpected death'. Even if the GP could be certain of the chance of dying [which the GP cannot be] - HOW DOES THAT MAKE SENSE ?

    If the GP believes his patient has a 1-in-10 chance of dying, then the patient's death is treated 'sensitively', the police are kept away from the death, and the live-with relatives are treated with care and consideration. If the GP believes the patient has a 1-in-11 chance of dying, then it is quite likely that the live-with relatives will be confronted by police officers, who far from being 'sympathetic and caring' tend to treat them 'as if they were potential suspects in a murder case'. This is CRAZY and it treats the 'early but known EoL death of a patient' as if it is very similar to 'the unexpected death of a thought-to-be-healthy 25 yr old'.

    The obvious way around this - to me - is for GPs to record that 'I would no longer be surprised statement':

    'I (the GP) would no longer be surprised by the natural death of this patient, but I would need to attend post-mortem before deciding whether to certify the death'

    AND FOR THE RELATIVES TO KNOW THAT. Then, if police 'start to interrogate the relatives', the relatives can say 'why do you seem to be surprised by my husband's death - the GP wouldn't have been surprised that he has died, so why do you seem so surprised ?

    I have no objection to police attending these 'earlier deaths', nor for the body to be retained by the coroner until the coroner has been satisfied about the cause of death, nor about the police asking relatives ONCE 'what happened'. But I object HUGELY to the police behaving as if these just-bereaved relatives are 'primarily suspects', repeatedly and insensitively questioning them at length when there is NO ACTUAL INDICATION of any wrong-doing, and seriously interfering with the relatives in the hours after the death (when, in my opinion, long-term memories are being formed, and when 'messing just-bereaved people about' leaves them with 'strengthened, which means worse, memories of the death of their loved one'. Not only, in my opinion, does that type of overly-intrusive police questioning leave bad memories of the questioning, but the lengthy and intrusive questioning stops the bereaved person's mind from 'distracting itself from the death', and you are consequently left with stronger memories of the death itself - and NOBODY 'wants to remember the death itself').

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