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Government commits to ‘high quality’ end of life care by 2020

  • 48 Comments

NHS and care professionals will be expected to “reflect” six new commitments in their work surrounding end of life care, the government has announced.

Made in response to an independent review of end of life care, they include having “honest discussions” with patients who are dying, better care planning and more “informed” choices on care.

The Department of Health set out the six commitments yesterday, saying they were intended to end “variation in end of life care across the health system by 2020”. In full, the commitments are:

  • honest discussions between care professionals and dying people
  • dying people making informed choices about their care
  • personalised care plans for all
  • the discussion of personalised care plans with care professionals
  • the involvement of family and carers in dying people’s care
  • a main contact so dying people know who to contact at any time of day

New measures will be developed to ensure local health and care leaders are meeting the standards expected of them, added the government.

It said plans were already underway to ensure experts could provide specialist support on end of life care by acting as a first point of contact for anyone who needed them, as part of urgent and emergency care hubs currently being developed in all local areas.

“Every person nearing the end of their life should expect a good death”

Ben Gummer

The experts would be available 24 hours a day, seven days a week to help with symptom control or deteriorating conditions late at night or at the weekend, as well as clinicians who had questions or needed additional support.

In addition, there will be a “focus” on improving the training for clinicians, including a national plan aimed at sharing best practice among NHS staff, said the DH.

Pilots in Southend and Airedale will be launched to trial new ways to support clinicians to initiate meaningful conversations with dying people about serious illnesses.

Department of Health

DH moves to quicken FtP process and end midwife supervision

Ben Gummer

A potential new role, a care coordinator, will also be tested with the aim of helping patients have more choice and control at end of life.

Meanwhile, innovative community care pilots, including 24/7 specialised nursing services for end of life care, will be tested in a number of areas.

Announcing the measures, health minister Ben Gummer said: “Our commitment is that every person nearing the end of their life should expect a good death: attentive, dignified and compassionate care.

“To do this, we will address poor care where it exists and accelerate improvement across the health and social care system in England,” he said.

The announcement by the DH was made in response to report – called What’s important to me: A review of Choice in End of Life Care – which was published in February 2015.

Published by an independent board chaired by Claire Henry, chief executive of the National Council for Palliative Care, it offered a blueprint for how greater choice in end of life could be achieved.

“I’m pleased by the overall vision set out in the government response”

Claire Henry

Among its recommendations were that each patient should be offered a care coordinator who would be their “first point of contact”, as well as a named senior clinician who would have overall responsibility for their care and their preferences.

In addition, it said there needed to be “more honest and open” communication about end of life issues, with better support for healthcare professionals and increased awareness among the public.

It also called for a new right in the NHS Constitution for everyone to be offered choice in the end of life care, and for these choices and preferences to be recorded in a personal plan of care.

Responding to the DH, Ms Henry said: “I’m pleased by the overall vision set out in the government response. They have clearly acknowledged our report, and taken its recommendations seriously.

“It will be vital that we continue to work with the government to ensure all these commitments are realised as part of all future care delivery,” she said.

However, another report, also published this week, warned that an overload of policy recommendations is making it harder for nurses and other health professionals in England to deliver quality end of life care.

Written by Sheffield Hallam University, the State of the Nations report looked at policy on terminal illness in all four UK nations. It found 76 different government publications relating to the subject had been published in England since 2004.

Meanwhile, draft guidance from the National Institute for Health and Care Excellence has outlined what the best palliative care for children looks like.

The draft emphasises the need for infants, children and young people to be treated as individuals and highlights the importance of children and their families being involved in decisions about care.

  • 48 Comments

Readers' comments (48)

  • Not before time, now we have posative quidance, now all we need is Nursing Homes paid the same as Trusts and Hospices.
    Why is there the massive disparity I wonder. CCGs do not seem to have an answer.

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  • The vision seems helpful.

    Does this mean then that elderly people with complex needs will be communicated with adequately on a daily basis in line with their personal needs instead of being treated as objects then dosed up inappropriately with anti psychotic drugs when they retaliate?

    When will this vision materialise? -because it is so distressing to see so-called carers delivering negligent treatment to vulnerable people because they are following orders from the so-called "Responsible Individuals" in charge of care homes who are cutting costs on the recommendations, I believe, from Clinical Commissioning Groups, who are, I believe, being too enthusiastic about keeping costs for care of the elderly low because they are advised mainly, I believe, by people like accountants and doctors who have not a clue usually about how to deliver cost effective residential care?

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  • michael stone

    I only just found this - so I've not yet read it properly, nor have I followed up the links. But this seems to be almost identical to what I've been 'banging on about' for some years, and with a slight reservation, I really like this list:


    honest discussions between care professionals and dying people
    dying people making informed choices about their care
    personalised care plans for all
    the discussion of personalised care plans with care professionals
    the involvement of family and carers in dying people’s care
    a main contact so dying people know who to contact at any time of day

    My reservation hinges on the difference between 'what has to be offered' and 'what has to happen', For example:

    'personalised care plans for all'

    Patients must be OFFERED the chance to 'construct a personalised care plan' - but, it has to be the patient's decision as to how far to go along the 'care plan' route: some patients might (and I think with good reason) say 'sorry, this 'planning' seems too prescriptive. because I have not died before, and I suspect that as it is a new experience to me, my decisions and wishes might change day-to-day and in ways that I cannot foresee - so I'd prefer to explain my decisions and wishes, in a much more real-time way as things happen, rather than trying to make guesses about what they would be in a 'care plan''.

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  • michael stone

    Just started to read the actual PDF - what NT reported was a simplification, and the PDF itself does say 'given the opportunity to' (on its page 10):

    Our commitment to you is that as you approach the end of life, you should be given the opportunity and support to:

    have honest discussions about your needs and preferences for your physical, mental and spiritual wellbeing, so that you can live well until you die;

    make informed choices about your care, supported by clear and accessible published information on quality and choice in end of life care; this includes
    listening to the voices of children and young people about their own needs in end of life care, and not just the voices of their carers, parents and families;

    develop and document a personalised care plan, based on what matters to you and your needs and preferences, including any advance decisions and your views about where you want to be cared for and where you want to die, and to review and revise this plan throughout the duration of your illness;

    share your personalised care plan with your care professionals, enabling them to take account of your wishes and choices in the care and support they provide, and be able to provide feedback to improve care;

    involve, to the extent that you wish, your family, carers and those important to you in discussions about, and the delivery of, your care, and to give them the opportunity to provide feedback about your care;

    know who to contact if you need help and advice at any time, helping to ensure that your personalised care is delivered in a seamless way.

    ALTHOUGH 'there is a lot in that, which will be 'a challenge to deliver'.

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  • Stone, I hope it occurs to you that every single individual patient is different and so are all their very different circumstances surrounding their process of dying which I will not waste my time spelling out to you. All those surrounding them and involved in their care are also individuals and professionals come together as a team to reach consensus on a plan in order to provide in all measure possible continuity of care. This care is informed by a very complex combination of different elements, which I have no time to detail, but include background training in the areas of medicine, nursing and everything surrounding these disciplines as well as philosophy, spirituality, the law, various healthcare policies and the care needs of the whole person from the day they are born and very much more. As well as the above, clinicians also bring their own personal elements and in addition their professional and personal experience, expertise, evidence based knowledge, empathy, and an understanding, where possible, of the life and wishes of the patient and above all their highly developed capacity for both deductive and intuitive thought. Guidelines have been drawn up by a panel of these experts and those around the world taking all aspects of dying patients into consideration. It is the duty of clinicians to consult these guidelines and intelligently adapt the recommendations to the needs of each and every patient according to their own unique set of needs and any problems confronting them. Professionals, however, are fully autonomous in their own right and work together with others and their patient to make the best possible decisions to inform their care. Not every single clause in the guidelines is relevant to the care of every patient and trying to follow them blindly does not lead to high quality or safe care and can be highly detrimental to the patient. Nurses are not robots but sentient human beings like those they care for and are very well trained and qualified in alll of the skills for the job they do. Please therefore stop trying to tell them how to do their job and persistently trashing the profession and this site.

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  • I failed to get much sense from the previous comment. I do hope that verbose person with no time to spare is not the one doing my end of life care.

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  • And I hope you are fortunate enough that he or she is. The comments are thoughtful, intuitive and above all, compassionate. Perhaps also a little ideological, but if we don't aim for the best, how can we hope to achieve it?

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  • I agree with anon. just do it

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  • JULY, 2016 7:34 PM

    Thanks for your kind comment. Mine is ideological maybe but based on my own experience and practice I had the privilege to be involved in for over 20 years in a 1,000-bedded state of the art university hospital In Europe which is a model of clinical excellence where staff work together in interdisciplinary teams to provide the best individualised care for each and every patient which is becoming increasingly challenging in a world of rapidly developing clinical advances, changing demographics due to shifting populations and economic uncertainties. End of life is the one certainty facing us all where there is only one chance for those accompanying the individual to endeavour to get it right for each and every individual and it is imperative to 'manage' it well.

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  • 7 JULY, 2016 6:53 PM

    It is difficult to condense such a broad and important topic into the space of a comment in a limited time and it was addressed to another reader.

    When my end comes I would like to be looked after by caring staff like my my former colleagues in a hospital such as I worked in with this excellent and compassionate model and philosophy of care and where a staff of autonomous and highly qualified and experienced professionals all worked together with the patient to find the optimal solutions to offer them the very best quality of care. Obviously this also relied upon excellent communications at every level which also required a certain degree of time and verbosity to make sure everything was very clear and well understood and agreed upon by all involved and and with the chance to discuss ideas or any objections raised which is always a good way of eliminating misunderstandings and avoiding potential conflict. Other languages do not have such an extensive vocabulary as English so communications are often more repetitive for emphasis and to try and ensure this clarity.

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  • michael stone

    ANONYMOUS 7 JULY, 2016 6:53 PM

    There is some sense in that 'have a go at me' comment, but more 'Stone knocking'. It certainly doesn't make sense as a critique of my position - which is based on 'patients are individuals'.

    But I write about EoL at home - and the things that bother me, are outlined in my recent BMJ piece promoting 'law not ethics':

    http://www.bmj.com/content/353/bmj.i2230/rr-7

    I would like to understand these things, which are in that piece:

    The reason I am so keen on people sticking to the informed consent described in our English law, is not that I am ‘against happy endings’, nor am I sanguine about young adults, ‘exercising their legal right to kill themselves’. I am so insistent about the application of informed consent, because I became involved not in a general ‘ethical debate’, but in a debate about end-of-life behaviour. And the ethics which many professionals seem to apply during end-of-life, offend me. I am offended that most guidance seems to imply that if a terminal patient has clearly expressed a refusal of a future treatment to a member of his family, ‘somehow this counts less than if he had expressed it to a GP’. I am offended that even if I write a very clearly worded Advance Decision refusing cardiopulmonary resuscitation irrespective of why I arrest, if I arrest at home and the death could not be certified, attending 999 paramedics would be likely to ignore my instruction and would probably attempt CPR. I am offended that for known end-of-life but not yet ‘expected’ home deaths, the police tend to become involved, and to treat the family as if they are suspects – but I feel sure that deaths which happen in identical clinical situations, but in hospital, do not result in the police attending and interrogating the nursing staff. These things all offend me, and they also ‘offend my ethics’. My ethics include things such as ‘no accusation without some evidence’: people should be assumed honest until proven otherwise; decent end-of-life support for patients requires that clinicians and family carers should be working together; etc. So my ethics, appear to be different from the ‘ethics’ of 999 paramedics, police officers, etc.

    If my [hypothetical] 82 years old, but seemingly ‘healthy’, father had made it very clear to me that under no circumstances would he want CPR to be attempted, I might not think he was making the ‘right decision’ but I would respect it because it is his life, and he would experience the consequences if he arrested and CPR was attempted – if he collapses, I tell 999 paramedics that he had made it clear to me that he would never want attempted CPR but the paramedics attempt CPR, ‘then I’m not happy with the ethics of 999’.

    When EoL patients are at home, and capacity has been lost, discussions about ‘what should happen’ can lead to disputes, for example between a GP and a family carer. The only thing I am 100% certain of, is that a family carer’s ‘well, I’m not going to do that, because my dad made it perfectly clear to me he would have refused [that course of action]’, is legally (and in my opinion morally) correct. It has to be legally correct: because it follows the fundamental ‘a person is sovereign over his or her own body’ legal principle. There is no such clarity, once ‘professional ethics’ [and professional objectives] are applied to disputes between relatives, clinicians and police officers: and while ‘arguing the ethics’ with a GP is one thing, ‘arguing with police officers about ethics’ is a wholly unsatisfactory experience (for a live-with relative), immediately after a death, and when ‘the police officer is confused’.

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  • Why do we need another six (6) list of how to give good care at end of life? Do any of these expert panels look at what is already 'out there' as far as initiatives and policies and guidance? We have had the '6 Steps for End of Life Care (2008) from the NEoLC strategy. We have had the 6 C's for care from the NMC (as a response to the Francis Report 2005-2013). We have the 5 Priorities for Care of the Dying Person (Leader Alliance for Care of the Dying, 2015). We have the 6 Ambitions for Palliative and End of Life Care (National Palliative and End of Life Care Partnership, 2015-2020) Do we really NEED another set of six statements???? Let's just start to DO the Care and Change the culture of care!!!!!

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  • michael stone

    ANONYMOUS 8 JULY, 2016 10:52 AM

    I'm not entirely sure - but I think your 'It is doubtful you have in depth knowledge of CPR and its consequences ..' was aimed at me.

    No, you are quite wrong - I am perfectly aware of the consequences of attempted CPR [which is why I'm angered that our 999 paramedics still seem to default to CPR even when patients are known terminally-diagnosed]:

    http://www.bmj.com/content/352/bmj.i26/rr-13

    I'm also a little unclear, how much of this thread is a discussion of behaviour here, and how much in Europe:

    'I had the privilege to be involved in for over 20 years in a 1,000-bedded state of the art university hospital In Europe'

    There is no reason to believe that behaviour is identical across national boundaries - and national laws [which DO affect the behaviour of clinicians] relevant to EoL differ even within the UK.

    JANE MARQUESEN: A very good question - but the new DH one, is not actually 'a new set of instructions'. What it claims to be, is effectively a response to things such as 'the 6 Ambitions for Palliative and End of Life Care' and it is the DH's explanation of how it intends to promote the things the earlier reports called for.

    But the DH is not promising to support all of the 'recommendations' in those earlier 'way forward' documents. For example, in 'Annex A' number 20 in response to:

    That the £130 million additional investment identified as needed to enable the national choice offer in end of life care to be made by April 2020 be identified in the next spending review.

    the reply in this new 'promises by the DH' document is:

    We are committed to improving quality and choice in end of life care as an intrinsic part of creating a modern fit-for-purpose NHS that delivers what people need from their health services. In our Mandate for 2016/17, we explicitly refer to end of life care and ask NHS England to improve significantly patient choice and quality in end of life care, including on people’s choices about where they would like to be cared for and die.

    Our plan for end of life recognises the changes underway in the NHS over this Parliament and ensures that end of life care is firmly embedded in the major problems NHS England is putting in place to deliver a transformed NHS.

    As a result, we do not believe that the specific costing proposals set out in the Review, which do not take into account the wider transformation agenda, represent the best way to ensure improvements in end of life care.

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  • michael stone

    By the way:

    ANONYMOUS8 JULY, 2016 10:52 AM

    8 JULY, 2016 10:12 AM

    It is doubtful you have in depth knowledge of CPR and its consequences which can be highly traumatic for a patient and their loved ones. It is not always successful, appropriate or in a patient's best interests and especially if there are clear informed instructions from the patient that this is not what they want.

    No - wrong ! In England, and it seems post-Montgomery, our law is unequivocally Informed Consent. If there is a clearly-expressed DECISION from the patient that CPR has been refused, then attempting CPR is unequivocally an assault on the patient.

    And I wish that people would stop 'muddling' 'best interests' and Informed Consent - mentally-capable patients 'just make their decision and express it' (they are NOT required to 'act in their own best-interests') and during mental incapacity, if best-interests decision-making becomes necessary (it isn't invariably necessary) then there is no legal concept of 'consent' because it has been replaced by a legal duty to satisfy section 4(9) of the MCA.

    I've explained this to BMJ readers at:

    http://www.bmj.com/content/352/bmj.i222/rr-0

    It is staggering, as a 'lay outsider', to have discovered how many clinicians seem to struggle to understand sections 1-6 of the MCA! Even setting aside the ones who understand the MCA, but are resistant to applying the Act - see also:

    http://www.bmj.com/content/351/bmj.h6575/rr-0

    I'm very happy to argue the toss, about whether I've made any legal errors in either of those 2 pieces, with whomever it is who keeps telling me on this website 'that you've no idea what you are writing about'. Provided the person can provide a half-way competent rationale for his/her position.

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  • michael stone

    Proof reading - should have said above:

    No - wrong ! In England, and it seems post-Montgomery in the UK as a whole, our law is unequivocally Informed Consent.

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  • michael stone

    ANONYMOUS 9 JULY, 2016 11:18 AM

    Lots of truth in your post, unlike in some others. And lots of incorrect assertions, about my level of understanding, as well.

    Yes, you cannot ask a patient in CPA, if he would want CPR to be attempted. So, you must ask, or he must tell you, in advance - see:

    http://www.bmj.com/content/350/bmj.h2640/rr-2

    Part of your comment, fits in with my '999 paramedics cannot make defensible section-4 MCA best-interests decisions whatever documents you aim at them' argument: but, family carers, could make defensible best-interests decisions. Look at 'poser no 11' in my series at:

    http://www.dignityincare.org.uk/Discuss_and_debate/Discussion_forum/?obj=viewThread&threadID=692&forumID=45

    If you can get the link to work in NT. Links sent to BMJ always work - but not invariably here on NT.

    But what really raises my hackles, is that many professionals seem to consider that family carers can legitimately be distrusted by default:

    http://www.bmj.com/content/353/bmj.i2230/rr-7

    http://www.dignityincare.org.uk/Discuss_and_debate/Discussion_forum/?obj=viewThread&threadID=859&forumID=45

    As for 'then you might understand what you are talking about' well - I do understand, what I'm talking about:

    http://www.bmj.com/content/352/bmj.i1494/rr-3

    http://www.bmj.com/content/351/bmj.h6575/rr-0

    http://www.bmj.com/content/352/bmj.i222/rr-0

    And I do 'argue about ethics' - see the very contemporary:

    http://www.bmj.com/content/354/bmj.i3806/rr

    which was posted on theBMJ only yesterday - and which is an invitation for a discussion about law and ethics 'I've been having with' David Oliver to continue via BMJ rapid responses.



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  • michael stone

    There is something unedifying, about anonymous name-calling.

    Anyway, getting back to end-of-life.

    It is clear – and I base this not on NT but on much wider observation – that either contemporary judges and I (we usually seem to agree about the law), or else a lot of clinicians, have got things wrong. It isn’t all that easy, to contend that as a body most judges have got the law wrong: the simplest contention, is that for various reasons, the beliefs of many clinicians have not yet caught up with our law.

    I’ll get to CPR as a special case (actually, ‘the easiest to analyse’ case) later, but the law is basically very simple, and very clear in what it does tell us, and what it doesn’t tell us. The appropriate law is the Mental Capacity Act, and what we know about the MCA is:

    1) Mentally-capable patients make and express their own decisions – the role of clinicians is to inform the patient of clinical factors such as prognoses. This is described in section 3 of the MCA – you can call it Patient Autonomy or Informed Consent, or Considered Refusal. It is NOT ‘shared decision-making’ if by that term there is any implication that the decision is made by more than one person – the decision [about whether to accept or refuse any offered treatment] is unequivocally made by the patient. The MCA is only law in England and Wales, but the Montgomery ruling applied informed consent in Scotland [and from a time before the MCA].

    Many clinicians seem to think that informed consent is only valid if the patient is fully informed – this simply isn’t the case. The law is based not on the patient ‘knowing everything’ but on the premise that the clinician must, to have obtained valid consent, have told the patient about all clinical factors (which the clinician is aware of) which might have affected the decision the patient reached. An identical concept can be found in section 25(4)(c) of the MCA. Conceptually, you can imagine a doctor offering a treatment, and the patient saying ‘no’. The doctor can keep adding a series of ‘are you aware that ...’ bits of information, and the patient can after every new bit of information just say ‘no – I’m still refusing that offered treatment’.

    Mr Justice Peter Jackson explained in one of his rulings:

    "JB is not required to understand every last piece of information about her situation and her options; even her doctors would not make that claim.”

    Mr Justice Jackson also made clear the distinction between the law, and the ‘ethics’ which doctors usually prefer to law:

    "The temptation to base a judgment of a person's capacity upon whether they seem to have made a good or bad decision, and in particular upon whether they have accepted or rejected medical advice, is absolutely to be avoided.

    That would be to put the cart before the horse or, to put it another way, to allow the tail of welfare to wag the dog of capacity.”

    It isn’t at all obvious – there are in my view strong reasons to believe that the opposite is legally true – that a patient ‘is required to explain why he/she decided as he did’. I think there is absolutely no requirement, for a patient to explain ‘why I decided as I did’ (and that is interesting, and challenging, as soon as such a patient loses mental capacity – think about 4(6)).

    2) The patient autonomy of 1), can be projected into future periods of mental incapacity anticipated by the patient, for refusals of potential treatments by means of Advance Decisions, or the patient can appoint a Welfare Attorney to make any required best-interests decisions.

    3) Welfare Attorneys and Court Deputies are the only people the MCA gives legal POWERS to re best-interests decision-making – the Act imposes a legal DUTY on anybody who makes a decision to satisfy 4(9). But I cannot find anything in the Act itself, which restricts who can make any best-interests decision (most clinicians disagree with me – they can never prove by pointing at the Act, where I’m wrong).

    4) The MCA covers ALL ‘consent law’ for adults: it is Informed Consent during mental capacity, and section-4 best interests during incapacity [unless the patient has already made and expressed the necessary decision]. This doesn’t – interestingly – cover all LEGITIMATE decision-making, but it DOES cover all ‘consent’ law. The bit it doesn’t cover, is the ‘we couldn’t afford to offer you a potentially effective treatment, because it would cost too much, and the NHS ‘has to be fair to all’’ aspect.

    5) Unlike patient autonomy during capacity, nobody is at sure sure about ‘the rules’ for best-interests decision-making in terms of any analysis of ‘the ‘correctness’ of the decision’. The law isn’t framed in those terms (i.e. it doesn’t describe decisions as either good or bad) – all we really know about MCA best-interests decision-making is:

    a) the decision is very strongly connected to the patient’s personal (not clinical) individuality;

    b) whatever satisfactory best-interests decision-making involves, a typical layperson must be able to arrive at satisfactory best-interests decisions (this immediately logically follows from the provision for Welfare Attorneys to be appointed – and it follows from the provision, not whether or not there actually is a welfare attorney appointed).

    If you think I’m right, or might be right, the following elaborate a bit – and if you think I’m wrong, you won’t follow up any of these

    http://www.bmj.com/content/353/bmj.i2452/rr3

    http://www.bmj.com/content/352/bmj.i1494/rr3

    http://www.bmj.com/content/353/bmj.i2926/rr

    http://www.bmj.com/content/351/bmj.h6631/rr-0

    http://www.bmj.com/content/352/bmj.i26/rr-5

    http://www.bmj.com/content/348/bmj.g4094/rr/703333

    What is special about CPR, is that the clinical outcome of an arrest and CPR which does then re-start the heart, is so uncertain that it cannot be usefully described by any clinician in advance: this makes it much easier to think about whether you would decide to forbid future CPR, than if for example you were thinking about a stroke which might happen in the future.

    The thing clinicians seem to find the most difficult to accept, is the logical consequence of Informed Consent:

    http://www.bmj.com/content/350/bmj.h2877/rr-7


    FOOTNOTE: the earlier links to my Dignity in Care pieces do not work in NT. But the ‘guts’ of one thing I tried to link to, is so thought-provoking that I’ll copy it here:

    Should decisions be made by whomever is logically the best-qualified to make the decision, when several potential decision-makers are present at the same time ?

    I was recently sent, as part of a longer e-mail from a consultant hospital doctor, and in the context of a wider discussion hinging on the differences between patients who are at home and patients who are in hospital, the following:

    'The common law already provides for the "necessity principle" where doctors can apply life saving treatment to people acutely ill and at serious risk without knowing whether or not they would consent because the patient is too ill to do so and they don't have time to find out or anyone to ask (e.g. in someone bleeding to death or with dangerously low sugar readings or fitting repeatedly)'

    Now, I agree about this principle, but I'm usually discussing behaviour for patients who are on some sort of 'end-of-life register': and, I often discuss the situation of patients who are at home, 'collapsed and unconscious', and when 999 paramedics and family carers are involved. The question, is rather more complex than 'does 'necessity' exist ?' - the question, is 'when is 'necessity' justifiable ?'.

    The legal defence of 'necessity' is based on 'justifiable ignorance'.

    The legal protection the MCA offers to a decision-maker, is based on the application of an 'adequate understanding of the situation' and the ACQUISITION OF THAT UNDERSTANDING is an 'implied duty' within the Act.

    If an unconscious patient arrives at A&E unaccompanied, necessity has to apply.

    If an unconscious patient arrives at A&E accompanied by a family carer, the question is does the family carer's understanding of the situation make an application of 'necessity' inappropriate ?

    If a patient who is on some sort of 'EoL register' collapses at home, and a family carer calls 999 to be more certain of the medical situation, isn't the family carer's decision about what should happen next (a decision, which the carer MUST defend in terms of the MCA's test - as a long-term carer for the patient, a failure to satisfy 4(9) of the Act 'would be negligence') logically 'better' than any decision made by a 999 paramedic which would be defended by 'necessity' ?

    PUT SIMPLY, isn't a decision made by the person who understands the situation best (there, the family carer – providing the paramedic provides details of the medical situation) the best decision available ?




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  • michael stone

    Apologies - a combination of an annoying office programme, and my own inattention, means some of those BMJ links are faulty. The first 2 should have been:


    http://www.bmj.com/content/353/bmj.i2452/rr-3

    http://www.bmj.com/content/352/bmj.i1494/rr-3

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  • michael stone

    Will you PLEASE stop doing this NT - it appears (again !) that you have been removing posts from this thread, WITHOUT leaving a 'comment removed' marker!

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  • michael stone

    Even better - will NT please leave alone comments which are 'having a go at me' because I don't them removing: and as I seem to be the target, if I'm not bothered, why is NT taking them down ?

    'Leaving gaps' where there used to be comments, destroys the coherence of the discussion thread - sometimes it really 'screws up any attempt to follow the debate' and it needs to have a really good justification in my opinion (and insulting me, isn't a good enough justification, in my opinion).

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  • Dear Michael. I enjoy coming here to read insightful comments from other nurses and learning from their different viewpoints, and yours, if you have them, and they're relevant. However, you are turning this forum into some sort of outlet for your own self interest and I honestly think this upsets people who feel this is an unwelcome obstacle in our ability to engage effectively with each other. Please can you consider this when posting in the future.

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  • Michel, are you taking over the whole site or just monopolising certain pages? It should be quite clear by now what is thought of your constant interference. When you have finished perhaps we can have our once highly esteemed nursing journal back.

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  • Michael stone. Think about the meaning of the nouns 'user' and 'name', you can use a good quality dictionary of English to help you if you find it difficult. you can then look up the term 'username' and its uses on the Internet. There you will learn that as a 'username' you can use your own name, make one up yourself or use an online generator to create one for you. to log in to most sites you need one of these or an e-mail address. once logged in, you can chose to post anonymously if the option is available, as it is here and as a number of professionals do, and their right has to be respected. It is entirely your own responsibility to familiarise yourself with all the website rules and as you are not the only poster permitted to post here we request that you do so.

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  • michael stone

    12 JULY, 2016 6:31 PM & 12 JULY, 2016 6:31 PM

    This NT article was about end-of-life guidance, and it is the correctness or otherwise of EoL guidance which is my main interest, and my main reason for attempting to engage nurses, doctors and others (social care staff and police, for example) in discussion of them. Naturally, an article such as this one, will attract my attention.

    My other main reason for trying to get that lay-professional debate started, is that things frequently look different from different perspectives, so 'the issues that seem the more important' often look different to the professionals and the service users: the consequence is that when left largely to their own devices, professionals 'create biased guidance'.

    13 JULY, 2016 9:49 AM

    I feel certain that NT allows people to post with their real name, or with a name they have made up to post under [which I was referring to as a 'username'], or as Anonymous. It is comparatively simple to link together a series of posts which are tagged as 'Fred Jones' or as 'Nice Nurse', but much more difficult, or even impossible, to do the same if people decide to post under Anonymous. The point is both clear and irrefutable - playing verbal games around the word 'username' is out-of-place, in connection with that issue.

    And I really do wish that NT would desist from removing posts which are having a go at me, without leaving a place marker - and even better, as I've said before, would be for NT to leave the posts where they are.

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  • Michael, for the umpteenth time it is not up to you to dictate to the NT, or to other posters commenting within the community rules, how to comment here. If you wish to start a lay discussion please go to the appropriate website for that purpose. As has been pointed out to you on many occasions this is a professional journal for nurses which your comments are dominating to the cost of any sort of reasoned and purposeful discussion between professionals.

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  • One problem with this is, even when one endeavours to exchange views with colleagues, it cannot take place without the persistent intervention of M. stone, desperate to join in and attempts to show he knows best but in the absence of any professional experience. This only serves to block any further meaningful discussion and is a considerable waste of time and effort.

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  • michael stone

    12 JULY, 2016 10:13 PM & 13 JULY, 2016 10:31 AM

    I'm wondering, if you have read the DH piece which this NT article was discussing ?

    On page 13 of the DH document you will find:

    'We will continue to work closely with our voluntary sector partners including on specific projects to improve end of life care in hospital and out-of-hospital settings, promote a national conversation about death and dying ..'

    That says the DH 'will promote a national conversation about death and dying'.

    I've asked the people who are tasked with doing that, to confirm that they will be trying to promote a national conversation between everyone - patients, nurses, current and bereaved family carers, doctors, police officers, 999 paramedics and EVERYONE IN THE NATION [who wishes to contribute to that conversation] - and how they will achieve that object of 'a single conversation about death and dying inclusive of all who wish to contribute'.

    It appears that some nurses - ' If you wish to start a lay discussion please go to the appropriate website for that purpose' 'when one endeavours to exchange views with colleagues' etc - do not agree with the DH and me (and with most EoL experts) that we ALL need to DISCUSS EoL TOGETHER !

    Which is rather the point - 'living in silos' doesn't help, when discussing EoL !

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  • Michael stone. Please take you thoughts to the appropriate platform for that purpose.

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  • care planning needs to be incorporated when people are well, its needs to be reviewable, involve others at the request of the indvidual .It should stand as a seperate document in a care plan and not placed beside "elimination" as a sub heading , filled in once and left . I've been working on a webtool to allow this to happen, see www.lastsay.co.uk.
    We need to make a start and not wait until people are in denial of death and already feel out of control and helpless.

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  • Here here Tony , absolutely spot on !

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  • michael stone

    I wrote this at home, and I'm copying it in without having read any of the posts more recent than my previous comment (I will read them, but I'm not online at home - I want to post this one and move on to other online stuff, then I'll look at this thread later in the day).

    The fundamental issue, which I am angered by, is that many clinicians seem to consider that 'whether a treatment should be administered' is 'a clinical decision' and falls to be made by clinicians: it IS NOT and DOES NOT. That is a 'consent issue' and all of the law (setting aside for now 'necessity' which is in my view also affected by the MCA - needs 'thrashing out' like many issues) for 'should a treatment be administered or not' is within the Mental Capacity Act, and 'consent' is very clearly NOT 'a decision the clinicians make - they have to ask for consent'.

    HOW THE TREATMENT IS ADMINISTERED is a 'clinical decision' - but 'SHOULD A POTENTIALLY SUCCESSFUL TREATMENT BE ADMINISTERED' is NOT.

    The pre-prepared post:

    This ‘National Conversation about Dying/Death’ was originally called for in the Neuberger Review of the Liverpool Care Pathway, in its Foreword:

    ‘Whatever decisions are made about the LCP (our recommendations are listed on page 52), we believe there needs to be a proper National Conversation about dying. Otherwise doctors and nurses are likely to become the whipping-boys for an inadequate understanding of how we face our final days.’

    The recommendations did not unequivocally deal with that National Conversation – the recommendations were more about ‘increasing understanding of dying and death’.

    When Professor Bee Wee became the lead for End-of-Life at NHS England in 2013, and the Department of Health disbanded its EoL team previously led by Tessa Ing, I sent an e-mail to Bee asking about her new role (and her leading of the LACDP group which was to consider how to replace the LCP). One thing I asked about, was that National Conversation, and in a November 2013 e-mail Bee answered that question with:

    ‘In your email of 8th Oct, you asked if my intention was to try and establish a national conversation about dying (as per Neuberger report) or a national consultation about dying. The answer is the former, though I wouldn’t claim it to be something as grand as a ‘national conversation’.’

    The new DH ‘response/promises’ which the NT article is discussing, ‘Our Commitment to you for end of life care’, includes a foreword by Ben Gummer MP, Parliamentary Under-Secretary of State for Care Quality. He writes in his foreword:

    ‘Providing the opportunity of a good death lies at the heart of this document – our commitment to you for end of life care. It is born of HM Government’s response to the Review of End of Life Care, a report presented in 2015 at the request of Ministers concerned at the state of care for the dying person in our country. The Review was a seminal piece of work, a culmination of many years of research into the components of providing exceptional palliative care to the dying person. I am very grateful to all the partners who contributed to the Review, in particular the End of Life Care Coalition of charities and the Ambitions for End of Life Care Partnership, led by the National Clinical Director for End of Life Care, Professor Bee Wee. We accept the recommendations of the Review, which form the basis of the broader commitment we give in this response.’

    So it isn’t surprising – whether or not anybody has so far worked out how to achieve it – that the support for a National Conversation about Dying and Death, and the necessity of somehow getting that conversation started, is an ongoing theme within reports about EoL.

    You cannot properly join together understanding, beliefs, perspectives and behaviour for end-of-life, if you have nurses talking to nurses, doctors talking to doctors, family carers talking to family carers, etc: you NEED to get everyone talking to everyone.

    And the reason is simple (and it is why ‘go away and talk to other laymen’ so annoys me ‘as a clinical attitude’) – it is this (the final bit, below), as pointed out in a summary note published by the DH about an MCA ‘listening event’ held earlier this year (the summary note can be downloaded from the SCIE website – I’ll not bother with the url, because long urls seem to often fail to work here on NT):

    The National Mental Capacity Forum (NMCF) seeks to bring together professionals from a range of sectors to seek to improve awareness of the rights and responsibilities contained within the Mental Capacity Act (MCA). Further details on the Forum can be found at the following link: http://www.scie.org.uk/mca-directory/forum/

    To ensure the work of the Forum is informed by what really matters to individuals affected by the MCA, the NMCF held a “Listening Event” on 8 February 2016, to hear the experiences – good and bad – of service users, their family members and carers.

    In the words of one contributor:

    “I really do think it is important for patients, family and friends to get their experiences and perspectives to Baroness Finlay’s group, because otherwise professionals end up discussing the problems which seem more important to them: and the most important problems can seem different depending on whether you are a patient, a GP, a nurse or a family member supporting a patient”.

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  • michael stone

    TONY MCKERNAN 13 JULY, 2016 2:37 PM

    'Try to start the discussion and planning early' is a major thrust of recent end-of-life guidance - there is agreement about that.

    The bit 'planning' seems to find problematic, is 'patients can change their minds'.

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  • Stone are you suggesting that every patient going into hospital should discuss an end of life plan? How do you think that would enhance confidence in their care and help their healing? Imagine going under anaesthetic with a belief reinforced by the staff that you may never wake up, which many naturally fear anyway. Not every treatment facility is a mid staffs and some, strange as it may seem to you, do manage to get out alive. I find your attitudes here quite despicable and once again you are not involved in any sort of care and have no idea what you are telling about. Kindly leave all that concerns professional care to those that do and stop hammering them!

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  • michael stone

    14 JULY, 2016 7:19 PM

    Actually I'm less than totally enthusiastic about 'EoL Plans' - my position is that because dying patients are dying for the first time, they cannot necessarily anticipate their future decisions, so 'dying patients must be allowed to make their own choices in real-time'.

    What I am keen on, is the correct and ongoing application of the law around 'consent' - which means for dying but mentally-capable patients they should consent to any intervention, and it also means that decision-making during mental incapacity becomes very complex indeed (because section 4 of the MCA is complex).

    Professor David Oliver has just written a BMJ piece at:

    http://www.bmj.com/content/354/bmj.i3888

    David seems to think that it helps enormously if patients do discuss EoL (and I know this to be true from e-mails with him, even if it is not obvious in that BMJ piece), and his article does point out:

    'Despite concerted campaigns to improve care in the last year of life and get more people to make advance plans, these opportunities are missed.4 5 Only 4% of 9000 patients in the hospital audit had any form of advance plan made before admission.3'

    I can't work out what 'attitude' of mine you so dislike - please be clear, by explaining what you think 'my attitude' is ?

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  • You comments are totally insignificant despite your low opinion of the NHS and its staff. Strange it may seem to you these are compassionate individuals who give their lives to care for others, putting them and their needs, in the limits of the possible their wishes where they are relevant to their care and treatment, first. Obviously they cannot provide the all the extra services of a five star hotel! Outside the MH act which does not apply to the majority of patients and can be excluded from the present discussion for the sake of simplicity, time and space, staff are bound by their ethical codes of conduct and do not just go and 'attack' their patients as you imply but always, for every single intervention, where the patient or a representative is able to give it, seek informed consent in the form of a signed document right down to an informal exchange of words and explanation for the application every sticking plaster or the administration of an aspirin. Professionalism apart, you don't just approach someone and force something upon them without asking first or without offering reasons. I am sure, or at least hope you wouldn't even do that to a guest in your own home when offering hospitality, on the assumption that you do on occasion show some such generosity! Well, in hc where all care and treatment are concerned there are laws, policies and regularly discussed ethics for professionals to abide by, and apart from the occasional criminal you read about in the press, they all do!

    I would suggest you roll up you sleeves and go and work on the wards but unfortunately it would be a breach of confidentiality and judging by your endless comments, for staff and patients, a hindrance. Now please stick to websites for your sort of commentary and stick to something you understand.

    Apologies for any typos and a hasty comment but no time to read through again and repeatedly correct predictive text errors, having already done so several times!

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  • Stone
    ,David seems to think that it helps enormously if patients do discuss EoL ...'

    Of course it can help and any experienced clinician knows that but patients are human beings and high,ply individual and you cannot categorise people like that and decide what every patient needs. That is where the skill of professionals is important in being aware of those who want a discussion even if they don't, or are afraid to express it, and those who don't want such a discussion, some may be highly sensitive or for any other reason and to do so could cause them more harm than good. You cannot simply impose your own will ipon others as you persistently do here and thank goodness we have professional highly skilled in their work. Michel, it is not a subject you should be constantly trivialising over.

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  • Stone

    '...dying patients must be allowed to make their own choices in real-time'. '

    Once again, you cannot generalise very highly individual human beings no matter what their state of health or Steve of their life. You need experience of a considerable number of patients and of care of the dying as perceptions and perceptively about everything in life change over time, as you should know from your own experience, and even with dying and how patients wish to confront it the goal posts can move and as far as care goes need to be very flexible to accommodate that. Until people are dying they have no idea how it will happen nor how it will feel and their ideas if they are still able to express them, depending on their condition, may be quite different from previously the case ane even a few minutes before. It is an evolving situation for each and every which requires constant vigilance and adaptation and skill. In any form of healthcare and especially at the end of life there is never, and never will be, one side fits sl, please get that into your head and lay it to rest and go and take your discussions elsewhere.

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  • michael stone

    There is finally some near-to-sensible discussion going on - and I'm still being traduced but that doesn't surprise me - but despite the more sense in some of the comments, I had pre-prepared this, and I'm going to post it:

    I'll be sending this to NT by e-mail, and as I approve of transparency, I'm also putting it here.


    Thanks for responding to my comment – as I've posted on NT 'your position is a reasonable one'.

    The 'pity in all of this' (in bullying and name-calling instead of discussion) is that for the article at:

    https://www.nursingtimes.net/news/policies-and-guidance/nurses-must-reflect-new-end-of-life-care-standards/7006217.article?blocktitle=Most-commented&contentID=-1

    the nurse who posted at 7 July, 2016 2:37 pm and also I think at 8 July, 2016 9:16 am, clearly has a good deal of understanding of EoL.

    The end of the second post, is spot-on, with the possible exception of that word 'manage' (I see the role of clinicians in EoL as the provision of clinical expertise and the facilitation of options for patients – I don't like the idea 'that patients should be 'managed' by staff'):

    'End of life is the one certainty facing us all where there is only one chance for those accompanying the individual to endeavour to get it right for each and every individual and it is imperative to 'manage' it well.'

    So it really would be interesting, if that nurse would discuss some of the issues I bang on about on BMJ, for example in my pieces at:

    http://www.bmj.com/content/353/bmj.i2230/rr-7

    http://www.bmj.com/content/352/bmj.i222/rr-0

    http://www.bmj.com/content/352/bmj.i1494/rr-3

    In fact, I think it would be better if nurses in general spent rather more time discussing those questions,

    Best wishes, Mike Stone

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  • michael stone

    15 July, 2016 10:31 am

    'despite your low opinion of the NHS and its staff'

    I do not 'have a low opinion' of NHS staff.

    'Strange it may seem to you these are compassionate individuals who give their lives to care for others'

    I am fully accepting of the compassionate nature of most NHS staff – in my opinion, much more compassionate than I am (and probably also 'better people' than I am).

    'Outside the MH act'

    Yes please – the MHA is seriously problematic where it interacts with EoL: but the MCA is fundamental, and applies to every patient.

    'staff are bound by their ethical codes of conduct'

    I am forever arguing over this one: clinicians often think it goes 'ethics then law' and even most of the rest think it goes 'law then ethics' – I insist it should be 'law then a combination of logic and perspective-balance'.

    'but always, for every single intervention, where the patient or a representative is able to give it, seek informed consent in the form of a signed document right down to an informal exchange of words'

    Only the patient can give consent – there is no part of English law for adult patients which suggests that 'a representative of the patient can give consent'.

    'Well, in hc where all care and treatment are concerned there are laws, policies and regularly discussed ethics for professionals to abide by, and apart from the occasional criminal you read about in the press, they all do! '

    I don't doubt it – but clinicians currently tend to get the law wrong (sorry, but that is true – I keep pointing that out on BMJ).


    15 July, 2016 11:03 am

    'but patients are human beings and high,ply individual and you cannot categorise people like that and decide what every patient needs.'

    That is precisely my point – the inherent danger with 'advance planning' is that there is a possibility of 'fitting the patient into the plan' rather than responding to the changing needs and choices of individual patients. That seems to be where the LCP failed – in some places, instead of thinking of 'planning' for EoL as what is should be (a framework of options which ideally the patient chooses from when decisions become necessary) it seemed to be the case that 'the patients were made to fit into a plan'.

    'That is where the skill of professionals is important in being aware of those who want a discussion even if they don't, or are afraid to express it, and those who don't want such a discussion, some may be highly sensitive or for any other reason and to do so could cause them more harm than good'

    That is far too complex to discuss briefly – but you don't need to be a professional to be aware of that issue.

    'You cannot simply impose your own will ipon others as you persistently do here and thank goodness we have professional highly skilled in their work. Michel, it is not a subject you should be constantly trivialising over. '

    I think you are confusing presenting an analysis with 'imposing will' – and I have NEVER 'trivialised end-of-life' !


    15 July, 2016 11:15 am

    '...dying patients must be allowed to make their own choices in real-time'. '

    Once again, you cannot generalise very highly individual human beings no matter what their state of health or Steve of their life.'

    My only generalisation, is the universality of our 'consent' laws – I'm very forceful on the 'patients are all individuals' issue.

    'with dying and how patients wish to confront it the goal posts can move and as far as care goes need to be very flexible to accommodate that'

    I just stated that, above.

    'Until people are dying they have no idea how it will happen nor how it will feel and their ideas if they are still able to express them, depending on their condition, may be quite different from previously the case ane even a few minutes before'

    Yes, I keep saying that !

    'In any form of healthcare and especially at the end of life there is never, and never will be, one side fits sl, please get that into your head and lay it to rest and go and take your discussions elsewhere.'

    You've traduced my position – one-size-fits-all is precisely what I complain about – so what is inside my head isn't what you claim: and because of that misrepresentation of my position, this is exactly where my discussion needs to be !


    http://www.bmj.com/content/350/bmj.h386/rr

    This confusion about the LCP's replacement was predictable (title)

    It was entirely predictable that the LACDP's 'replacement' for the Liverpool Care Pathway, has confused some healthcare professionals. One reason the LCP was heavily criticised, is that it was [apparently] seen by some HCPs 'as a process into which patients are fitted', whereas good end-of-life care involves fitting the treatment provided to the clinical needs and wider-life requirements of individual patients.

    Two patients in identical clinical situations, might have very different objectives and therefore make different choices about which treatments to accept - people are not all alike, 'we are not tins of baked beans'.

    So the LACDP effectively said that end-of-life care has to be based on offering the best treatments which can be provided, combined with individual patients making their own choices about which offered treatments to accept: add in that 'I have not died before, so I can't really predict my future choices', that often dying patients lose mental capacity and there is inadequate agreement about 'the meaning of the Mental Capacity Act' [even among the apparently limited number of people who have actually read the Act], and that it is even more complicated when patients are dying at home, and it is easy to see why some HCPs 'are uncertain'.

    The LCP seemingly 'failed too often' partly because some of the staff who were using it, had an inadequate understanding of the law for things such as 'best interests decision making', which probably arose because the intention of the LCP, was to try and generate care in non-specialist situations (hospitals) which was more similar to the care in specialist situations (hospices). The LACDP's approach, is in principle better than the LCP was - but, it requires a much deeper understanding in the staff who work with dying patients and with the families and friends of those dying patients.

    As Margaret McCartney has just written in her piece about the prescription of Tamiflu:

    'But guidelines are not always applicable to our patients, and they are meant to guide practice; rarely should they dictate it.'

    I'll stop here: I can either be very brief, or very lengthy, on this particular topic!

    23 January 2015
    Michael H Stone
    Retired non-clinical
    None
    None Private Individual
    Coventry CV2 4HN

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  • Stone

    Considering your position here your commenting has been treated with tolerance and as often as not apparently ignored judging by the lack of responses to it. Do you believe many actually read your lengthy rambles when they have access to an extensive and more reliable evidence based knowledge base and professional discourse?

    Beyond the username stone there appears to be not one single incidence of name calling and the only bullying is yours, where it is not your place, to express repeated annoyance at professionals for reasons that do not concern you chose the anonymous option. You do not run this site even though you have taken it over and do no more than give an impression of somebody totally deluded with ideas of grandeur far beyond your own importance. I would like this site to revert to its intended purpose of hc professionals having an opportunity to exchange views with one another without you constantly butting in. This has been made very clear to you by a number of posters.

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  • michael stone

    Anonymous 15 July, 2016 9:17 pm

    The Nursing Times team - unless I misunderstand them - consider there is 'bullying' and NT has been removing 'bullying comments' aimed at me, somewhat to my annoyance.

    I don't see how I can disrupt a discussion between people who want to discuss something, and who are not interested in my comments: I give you a dinosaur and a name, so surely it isn't difficult to ignore my comments if you wish to do that !

    The lack of analytical reasoning on this website in connection with posting under 'Anonymous' compared to posting under an identifier such as 'SweetyPie 56' is disturbing.

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  • michael stone

    To 15 July, 2016 9:17 PM:

    The NT team have stated that in their opinion there is bullying going on in the comments to:

    https://www.nursingtimes.net/news/reviews-and-reports/policy-overload-affecting-end-of-life-care-provision/7006208.article




    Nursing Times

    Nursing Times11 July, 2016 4:44 pm

    Hi Michael,

    There has been an increase in what we would describe as bullying comments on the site recently. We are therefore monitoring comments more stringently and simply removing anything that is clearly offensive.

    Where possible we're trying not to disrupt the flow of debate but sometimes this is unavoidable.

    Where a comment may by construed as offensive, but this was perhaps not the author's intention, we are including a link to terms and conditions to explain our decision to remove the comment. However the comment you refer to was a clear breach of our terms and conditions and we are confident the author knows this.

    Thank you for commenting!
    Nursing Times

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  • I have been working in Nursing Homes in different capacities for over 30 years and I have been involved in closing down some of the hospital wards for the elderly which had been designed and operated by so called experts. So I am not surprised when the "anonymous" clan congregate on people such as MICHAEL STONE and deride him the way they do.All I can say to Michael is please stick to your stance and keep at it. The people that deride you have not a clue when it comes to discussing and debating ,they are not used to people such as yourself being allowed to express their opinions as this is strictly forbidden in their working environment I still have difficulties getting our Nursing Staff to do this and be proud of what they have achieved.

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  • michael stone

    Hi Gerald,

    Thanks for your supportive comments.

    I gather from the odd thing I've read, that these days people are 'taught' how to construct an 'argument'. I never was - but I suppose you don't acquire science degrees, without being able to cobble together 'a logical argument'.

    I don't think - I've no real evidence to support this - that nurses, despite their claims to professional autonomy - are trained or encouraged 'to argue'. Academics are 'argumentative by nature' and doctors seem to much faster 'to argue' than nurses, in my experience (the arguments on theBMJ {that isn't a typo - the BMJ calls its online arm 'theBMJ'} within rapid responses can be quite 'intense and heated').

    As for those hospital wards for the elderly which were unsatisfactory: I feel sure that some wards were good, some were average and some were awful, and in some cases the awfulness of the situation was not primarily down to the nurses. But is some cases, it probably was. I also think that end-of-life care has been improving in terms of the general picture , although I'm bothered that the current squeeze on resources is going to have a negative effect.

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  • michael stone

    ANONYMOUS 23 JULY, 2016 6:39 PM

    I have just reported your comment to the moderator - will you please supply your evidence that Gerald 'knows nothing about' the things he commented on ?

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  • michael stone

    MY PERSONAL POLICY ON REPORTING ABUSIVE COMMENTS TO NURSING TIMES

    I am more concerned with protecting and promoting the coherence of discussion threads, than with abusive comments directed at me. Consequently, it has been my practice to only very rarely report abusive comments directed at me.

    However, NT has requested that I do report abusive comments, which poses a conflict for me.

    My 'compromise position', will be to do the following:

    1) If an Anonymous 'abusive comment' aimed at me contains within it some point I wish to discuss, then I shall re-post the part(s) of the comment which I wish to discuss;

    2) I will then report such an abusive comment, which was posted as Anonymous, to NT;

    3) I will report - having taken step 1 if appropriate - ALL 'abusive comments aimed at me' to NT if they are posted as 'Anonymous';

    4) If an abusive comment aimed at me appears under either a real name or under a screen name, I will NOT be reporting it to NT;

    5) Irrespective of whether they appear anonymously, I will probably report to NT abusive comments which are aimed at other posters.


    I accept that my position on 5) is slightly at odds with my position at 4) - 'c'est la vie', as some people would say.

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  • Please note: We encourage all users to report any comments they deem to be abusive or spam. We review all comments reported to us.

  • Michael stone, as you were previously informed the matter of your commentary has been taken up with the editor of the nursing times.

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  • ANONYMOUS 23 JULY, 2016 6:39 PM

    I have just reported your comment to the moderator - will you please supply your evidence that Gerald 'knows nothing about' the things he commented on ?
    Dear "Anonymous" I cannot see where Michael suggests anything of the sort, but since when have I delegated advocacy to you, who ever you are ? I am more than able to put my own put of view thank you.

    Please come out of the woodwork and contribute to constructive discussions and stop being a "mous" (anonymous). Thanks to Nursing Times we can do this freely.

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