Tracey: some more thoughts

Tracey: some more thoughts

There has been a lot of interest, naturally, in the Tracey decision. Some of the comments have been insightful and thought-provoking. Some of them have been neither.

One doctor expressed his concerns about the decision with this sketch:

"Dr Ethic “Now there is something else I have to talk with you about. The High Court and General Medical Council says I must have this conversation with you. It is about cardio-pulmonary resuscitation and do not attempt CPR decisions. Now CPR is a treatment for ventricular fibrillation or ventricular tachycardia or standstill in patients who are having a heart attack. Let me reassure you that you are not having a heart attack. Now CPR is invasive causing in an elderly post menopausal woman like you, multiple painful fractured ribs and sternum. Also CPR does not work in people over 80, only in really exceptional circumstances, and certainly not on a general ward. A failed CPR results in death.

Now a recent study from Scotland shows that at your age and having been in hospital once, you have a one in three chance of death in the next year. I have to discuss with you that CPR is not going to be used when you come to die. In the meantime as I said we are going to do all the treatments that are wise and likely to work. So I am going to sign your DNACPR form and Fergus will see you tomorrow.

That’s OK then? Everyone happy, let’s move on, we have 23 more cases to see before patients’ protected lunch time, the lung MDM and my two week cancer wait clinic at 1pm, which is overbooked by 50%.”

(excerpt but full sketch available at link below)

https://www.dropbox.com/s/ptm8wtyiazgm40t/The%20DNACPR%20Sketch.doc

Obviously this is a parody (although though some po-faced and credulous journalists and nurses didn't realise this), but it illustrates an important point. The courts intervene in the doctor-patient relationship at their peril. 

One naive healthcare journalist commented that the issue was simple, it was about having compassion and respect. Thus speaks someone who has no idea about the realities of medical practice. For many frail people near the end of life, forcing a conversation on them about an intervention which would be futile is not remotely compassionate. One healthcare lawyer argued that Tracey does not entail forcing such discussions on patients. That is very much arguable. It must remembered that Mrs Tracey herself avoided the discussion of CPR.

The court ruling does not (and would not) force doctors to provide inappropriate care. So nothing about this ruling will prevent the decision being made after cardiac arrest by a junior doctor (possibly only after some undignified and painful CPR). Neither will it prevent the use of code words that signify the inappropriateness of CPR. We may just see the return of the bad old days of very few people being designated as DNAR, and having to undergo an undignified rite of passage which amounts to an assault prior to death. It would be much better to have a consistent doctrine for this invasive procedure, namely requiring informed consent for it to be provided. Why should CPR be considered as the default position for all patients of all ages in all states of health? 

Another day, another depressing story

Another day, another depressing story

Another story of a tragic death of a young person was aired on the midland news today. It involves Amy Carter, who was admitted to Worcester Royal Infirmary and discharged with a diagnosis of glandular fever. She returned to the hospital in multiple organ failure due to bacterial sepsis, and died shortly after. The trust accepted out of court, without accepting liability - in fact they issued a statement that "At all stages of her hospital stay, Amy received appropriate care".

http://www.bbc.co.uk/news/uk-england-hereford-worcester-28020357

Amy's parents appeared on television expressing their outrage. They were angry that the hospital has not apologised. They also felt that an internal review was inappropriate.Her father said:
"You want somebody who’s outside, who’s got nothing to do with the NHS or the trust or anything like that, somebody totally independent, to make them suffer and have to feel like we do now, for the rest of our lives. Somebody needs to pay for what they’ve done, and I don’t mean monetary, I mean pay emotionally and physically, the way we  [have]."
Perhaps understandable in the circumstances, although it is not the reaction I would have. No one set out to harm their daughter. No one deserves to be hurt for simply doing their job to the best of their ability. 

I have commented elsewhere about the failure of the tort system to provide satisfactory resolution for victims and relatives of medical negligence. We don't know that there was negligent care here. This is one of the problems with out-of-court settlements. Of course the Carters didn't have to accept an out-of-court settlement. Certainly if their main aim is to get at the truth, then going to court would be much preferable. Sadly the system does not accommodate this. It may well be that the hospital has nothing to apologise for. Medicine is full of uncertainty. It has been known for a patient to drop dead in the corridor after being pronounced fit in the cardiology clinic. 

The saddest aspect of this saga for me is the desire for retribution expressed quite clearly by Amy's father. It is a scenario that occurs with monotonous frequency. Can this bitterness be reduced by a different way of approaching these cases? Not in all cases I suspect. We need to recognize and understand this. 

Observer story about the war on drugs

Observer story about the war on drugs: "The war on drugs killed my daughter"

I am not a reader of the Guardian, because although I agree with many of its stated values, I know from personal experience that it is totally hypocritical in practice. So I don't know what its stance on drugs is, but I'd take a shrewd guess it's in favour of legalising recreational drug use. The chattering classes in North London are quite fond of a bit of Charlie at their dinner parties after all. It seems the only explanation for the massive leap it makes in this story where it is claimed that the war on drugs killed someone's daughter. 

Story here: http://www.theguardian.com/society/2014/jun/22/mother-fights-against-war-on-drugs-anne-marie-cockburn-martha-fernback

Normally I avoid reverse snobbery, but it seems quite remarkable that this mother doesn't blame her daughter, the dealer, or even the maker of the drug. She blames the government. Personally I am against the legalisation of recreational drugs, but for some limited tolerance and improved treatment for drug addictions and better access to problem-solving courts. Whatever your feelings about legalisation though, this narrative makes no sense. If middle-class kids can run foul of illegal drugs, what about poor kids? 

The reference to khat is slightly baffling. The drive to criminalise khat has come from the Somali community, concerned about the zombification of many young Somalis:

http://www.coventrytelegraph.net/news/coventry-news/coventry-campaigners-welcome-government-crackdown-4873433
All in all, it seems a rather desperate attempt to make a personal freedom issue into a public safety issue.

The problems with EBM

The problems with EBM

Evidence-based medicine (EBM) is a philosophy of the practice of medicine which may seem like motherhood and apple pie, obviously true and pointless in arguing against. However, many medical practitioners have issues with EBM. Proponents of EBM might argue that none of these criticisms are valid reasons not to practice EBM in its purest form, but certainly EBM as it is practised has several issues.

Trisha Greenhalgh wrote in the BMJ recently of a "movement in crisis". The reasons for such a crisis include:

• The evidence based “quality mark” has been misappropriated by vested interests
• The volume of evidence, especially clinical guidelines, has become unmanageable
• Statistically significant benefits may be marginal in clinical practice
• Inflexible rules and technology driven prompts may produce care that is management driven rather than patient centred

• Evidence based guidelines often map poorly to complex multimorbidity
Source: http://www.bmj.com/content/348/bmj.g3725

Much evidence is not a good fit for the individual patient with a complex set of interacting problems. EBM potentially reduces the importance of patient preference and shared decision-making. There is also a tendency to excessive confidence in prospective randomised controlled trials, despite all the problems and limitations of the scientific method. There is always an element of interpretation of scientific results and social construction of theories, but this aspect of the sociology of scientific knowledge is apparently neglected. 

The "groupies" of evidence-based medicine (not doctors generally, but so-called "skeptics") feel empowered to bully providers and, worse of all, patients who opt for medicine that is not evidence-based. There is an element akin to religious fundamentalism, although most of that movement is avowedly humanist. The reasons for this connection are not clear, but there seems to be a parallel with the trolling of the religious by the followers of Dawkins.

The recent decision at the Court of Appeal on DNR/DNACPR orders

The recent decision at the Court of Appeal on 'do not attempt resuscitation' orders

The Court of Appeal have ruled that Janet Tracey had her Article 8 rights infringed by Cambridge University Hospitals NHS Foundation Trust when they failed to consult with her and inform her of a decision to designate her as not for attempted cardio-pulmonary resuscitation (DNAR [do not attempt resuscitation] order). 

It has been recommended for some years now that good medical practice requires that doctors discuss such decisions with patients and families. As the court in this instance restated, there can be no legal requirement to provide a patient treatment that is not medically indicated, although the clinician should refer the patient for a second opinion if necessary.

This decision now imposes a legal duty to consult and inform patients about these decisions - not as one BBC newsreader stated that doctors have to get permission for DNAR orders. There are circumstances where doctors can omit this discussion, where they think this will harm the patient. This exemption is in some ways curious, given the particular facts of this case. It states in para 19:

'Dr Simons said that Mrs Tracey did not wish to engage in discussions about her care and prognosis. Every time she initiated a discussion about resuscitation, Mrs Tracey would either say that she did not wish to discuss the issue or that she would speak to her family about it.'

Further at para 25 & 26

'He submits that, if Mrs Tracey did not wish to discuss her prognosis with Dr Simons (described by one of her daughters, Kate Masters, as “sympathetic and a good communicator”) there is every reason to think that she was not willing to discuss it with any other doctor. Indeed, according to the evidence of Mr Tracey (para 57 of the judgment), Mrs Tracey felt “badgered” by the attempts of the doctors to discuss her end of life treatment with her.

Lord Pannick also draws attention to passages at paras 4, 9, 11, 13 and 14 of the witness statement of Dr Simons. For example, at para 11 she says:

“Mrs Tracey did not wish to engage in discussion relating to her care and prognosis. On occasions when I attempted to initiate discussions with Mrs Tracey regarding her treatment and her future she did not want to discuss these issues with me.”'

This decision will result in much more "badgering" of patients in the end stages of life - unless ample use is made of the exemption in para 93 that the doctor:

“thinks that the patient will be distressed by being consulted and that that distress might cause the patient harm”

The courts have been very reluctant in the past intervene in the clinician-patient relationship. I fear this decision may prove why this was a wise policy. Further, this decision is likely to legitimise and perpetuate misconceptions about CPR and the effect of DNAR orders.

Panorama and expert witnesses

Panorama and expert witnesses

The recent Panorama programme on expert witnesses apparently showed that at least some expert witnesses were willing to be experts for the party, rather than experts for the court. I note that the programme involved parties going straight to the experts, and I think this is probably very significant. I would imagine that instructing lawyers usually organize the assumptions on which they wish the expert to base his or her report on. Also I note that no medically qualified experts were involved (nor any with a definite professional body and/or register). 

Is this Panorama exposé a mortal wound to the status of expert witnesses? I'm not so sure it is. I think any decent advocate worth his salt probably assumes that the expert witness instructed by the opposing side may be consciously or subconsciously biased. Any opinion based purely on details (false or true) from the party would be ignored as effectively hearsay, and amounting to oath-helping. Thus a psychologist or psychiatrist who relied purely on a sleepwalker's accounts of his or her sleepwalking would not be fulfilling their role as an expert witness correctly. 

If the Panorama programme injects a note of suspicion in the justice system towards expert test, that would seem to be healthy. I suspect that scepticism is already present in abundance. All expert evidence requires examination by advocates who understand about science. That is far more important and relevant than any register of expert witnesses, which would not prevent bias occurring.

'Reliable Witness': 'Doctors', dementia, and confessions

'Reliable Witness': 'Doctors', dementia, and confessions

Watching in passing an episode of the BBC daytime serial drama Doctors entitled 'Reliable Witness', one of the storylines was about a man with dementia who confesses to the murder of his wife. The very vexing issues of the punishment of people with dementia could not be explored in depth in one episode, but there was some coverage of the neuroethical problem of holding someone to account whose mental capacity is severely reduced. 

There are a number of reasons related to mental conditions for not holding someone to account. In the case of sufficiently advanced dementia, the basic problem is that it may be impossible to hold the person to account in the truest sense. The person with advanced dementia cannot own their actions nor answer for them.  If they cannot understand the reasons why they were being punished, and therefore to punish them would be truly Kafka-esque. Instead of reflecting on their crimes, they would be constantly perplexed by their predicament.

If dementia was apparent at the time of the proceedings, the defendant might be found unfit to plead, and so be spared a trial. However, they would still be liable for the disposal options available under the Criminal Procedure (Insanity and Unfitness to Plead) Act 1991 - either an absolute discharge, outpatient supervision, or a hospital order. In the case of homicide, a hospital order would be mandatory for a mental disorder.  

The obsession with excellence

The obsession with excellence

I read a Tweet that was re-Tweeted with apparent approval by a number of those involved with patient safety initiatives - it stated 

Not OK to be average. Executive responsibility for safety - need to listen to human story of effect of safety incidents.

If it's seen as unacceptable to be 'average', this explains the reaction to a hospital being below average. One can only imagine the headlines the Daily Mail might make out of 50% of hospitals being below average. There have already been sensationalist headlines on the same lines surrounding mortality statistics. Sadly, this reflects the surrender of common sense or even basic numeracy to the current absolutist memes of patient safety. 

The population in more rural areas would prefer an open, average hospital within easy reach, to a magnificent centre of excellence, an hour's drive away (for those who have cars), almost certainly overburdened due to closure of local hospitals. 

Skeptic trolls bullying patients and doctors

Skeptic trolls bullying patients and doctors

The internet sadly is full of trolls. A small minority, but omnipresent. I don't mean "troll" in the facile sense that is often used, which is simply a label for anyone who disagrees with one. I mean people with serious personal issues who have to bully, insult or harass for their own entertainment. Any number of pretexts will do, including the apparently honourable and reasonable one of "fighting quackery". 

There are a number of skeptic trolls, who like all trolls are nobodies, who are extremely vocal on the subject of alternative medicine etc. Their activities in some cases amount to plain bullying of people who have different views from their own. I think most alternative medicine is complete bunkum, but it is a matter of personal freedom that people can seek whatever treatment they wish, no matter how bizarre. What's even stranger is that most of these skeptic troll have no proper scientific credentials at all. Truly the Dunning-Kruger effect personified. Like most trolls, they are willing to resort to lies and other tricks to try and "win" an argument. One skeptic troll was getting very exciting because someone alleged that Pfizer was funding the Saatchi Bill. Palpable nonsense, but the truth matters little to trolls. Another skeptic troll wrote that the consultation on the Saatchi Bill was conducted by the campaign. Again, a failure of the most basic research.

I won't name the individuals. They are nobodies, trying to be somebodies. They pretend to be "rationalists", but instead they are just bullies and trolls. 

Another example is the campaigns against alternative medicine providers. Again, I have no problem with combating false claims about treatments where necessary. However, the orchestrated campaign against certain alternative medicine providers has been accused of racism through the focus on one particular individual. It is easy to see why these accusations have arisen. Even registered medical practitioners have been the focus of disciplinary proceedings, despite their unorthodox practices meeting the needs of their patients and having the full support of those patients. Should the GMC be acting when no patients have complained? Arguably not.