Monday, 23 September 2013

Empowerment of endings

Last week, just before he was cut short by the intractable problems that the Today programme has with its telephonics, David Attenborough said that 'old age is not for sissies.'

Rather than be affronted that an interview that was supposed to centre on his new show was inelegantly redirected towards euthanasia and quality of life in old, he expressed great temperance and dignity in beginning to address the issue. The phone line dropped before he could make his full point, but it was ramping up to be considered and eloquent.

His qualification for questioning on the issue was predicated on the fact that he is old. But he did not pretend to be an expert. In fact, he seemed a little bemused. He is after all in very good health, and sustaining an enviable professional output. For him, the issue of frail old age may well be as distant to him as it is to us, as it is simply not his experience of the world.

It can be difficult to empathise with something of which you have no direct experience, and what he did so well was to illustrate the need for circumspection. There is no right or wrong answer in the issue of euthanasia in old age (for that is what Justin Webb was rather insensitively asking him about). In fact, most of the headline cases of people seeking assisted suicide involve younger individuals with predictable progressive neurological illnesses, for whom the manner and timing of their own deaths is the last defiant act they can take, towards a disease that has robbed them of so much.

By asserting that old age is not for sissies, David Attenborough made exactly this point. Your individual reaction to the aches and limitations of old age is not predetermined, and it is not universal. There can be no universal answer to the problem of what we should do with or for our frail and elderly.

He is a good example of what good old age looks like. He is also an example of how well the elderly can do when they have purpose, respect and opportunities. Often the discussion around euthanasia and the elderly takes place in a climate of negative assumptions about the role that they have in society. The question of whether the elderly should have access to assisted suicide, or the right to die, is perhaps underlined by the implication that they have no broader role in society, and the implication that the best that we can offer them is the choice of when they die.

The question will always remain, and it will always remain a matter of collective judgement and value. I repeat, there is no right answer. But there is a sense in which we are still not ready to progress the debate: the risk of allowing assisted suicide or euthanasia is the risk that individuals will be coerced, in a variety of ways, both well-meant and sinister, to end their lives when they would not have otherwise done so.

This risk would be tempered if the role of the elderly in the day to day functioning of society was more embedded. David Attenborough may be in his late 80s, but we all respect the work he has done, and continues to do. But is his success the product of some rare talent that he has, or is he simply the rare individual who has continued to have opportunities, where other elderly folk do not.

Until we can satisfy ourselves that the role of the elderly in society is better embedded, and that their participation in the communities and the work place is limited only by their ability or willingness to take part, then I would rather see the discussion centre on how we can involve them more, not on how we can help them end their existences.

The issue here is one of empowerment. Euthanasia and assisted suicide are issues that have at their heart the empowerment of an individual who is losing, or has lost, their reason to live. A discussion around its application to our elders can only meaningfully take place in a society that has done all it can to empower those individuals who are experiencing the waning of their physical and cognitive abilities. Until we can satisfy ourselves that this is something that we do well, then further discussion is premature. I worry that the repeated emergence of the euthanasia debate in the media portrays our collective ambivalence to the role of the elderly in the smooth functioning of society.

I have no doubt that the kindest action we can take right now for our frail elders is to involve them better in the decisions around their medical care, while at the same time working tirelessly to involve them better in the daily functioning of our communities. There must be a great many David Attenborough's out there who are not given the chance to shine.

Old age is not for sissies, partly because it can be tough, but also because we make it tough.

Monday, 16 September 2013

Induction with a difference

I trudged along to the induction at my new Trust. This was the 12th organisational induction I have attended, a number which says more about the nature of my training than it does about me.

It's difficult to get too excited about hearing a new version of fire training, or information governance. But this induction was different.

After coffee in the morning, and the session about the organisational values and aims, there was a session labelled something like 'The perspective of the service user.' An inauspicious title perhaps, but one which had a huge impact on me, and made me ask why out of all 12 Trusts I have worked in, this was the first one to place the perspective of the patients and their carers on centre-stage.

It was a powerful experience. Watching the nervousness of the man who told us about his journey through the system, dealing with treatment-resistant depression made it clear, that we were not just being offered an insight, we were being given a privilege. Mental health will only lose its stigma when we learn to talk about it openly, but it takes some brave individuals to lead that charge.

He was followed by another man, who told us of his experiences of looking after his wife, who suffered from bipolar disorder, with all of its incumbent challenges. The problem for them was that it took her years to be diagnosed with bipolar: every doctor she saw told her she had depression, because she only presented when she was low, and they refused to include her husband in the consultation.

Both of them had reason to be upset: they had both at times been disappointed by the response of the service, by the response of individuals. But they had both seen it all improve, and they both had met people who did little things that made a big difference.

They wanted us to know that what we do makes a difference to the lives of ordinary people, and that what we do is important. They wanted us to know that they way we do our jobs makes a difference to the lives of people who are suffering. We all have the power to make a difference in a job like ours, and I think that they simply wanted to remind us of that.

I asked them whether they had any advice on what we should do to help ourselves and those around us be as good as we could be; to avoid being the people who lacked empathy, or made them feel that they didn't matter.

I was struck by what they said. They said that we need to remember that what we do isn't just a job, it is more than that.

They also said that patients need to remember that we are people too, and that we can also have bad days.

It's a simple message, but it's a good one.

There aren't many induction sessions that I remember clearly, but I think I'll remember this one. 12th time lucky, I suppose. And at least it's for a Trust that I hope to be working in for a long time.

Monday, 9 September 2013

Sharing the load

It's amazing what you can learn from a different perspective. My new job has me working in the community, where I sit at the interface between the acute hospitals, and the GPs. Put alongside my role within the organisation, it is a fascinating mix.

The challenges that face healthcare delivery in the future can be hampered by giving too much air time to one's own particular challenges. For example, the pressures being faced by the acute sector can be managed in a number of ways. The solution chosen really depends on where you are viewing the problem from. For example, if you choose to view the issue purely from the operational perspective of the acute hospital, then your solutions will be directed towards capacity, efficiency and crisis management.

If however, a more system-based view is taken, then your solutions may well centre around how the rest of the system can take some of the strain for the acute hospitals.

The reality of healthcare at the moment is that Emergency Departments and acute pathways are under pressure. There are no doubt a host of reasons for this. But we can boil it down. More people go to A&E, where they perhaps present late in their disease process. They are seen by junior doctors, working in departments that are struggling to manage the throughput of patients, often functioning without a full complement of consultants (many departments have struggled to appoint and retain A&E consultants). The fallout is that the decision to admit or refer is influenced by the late presentation of the patient and the need to ensure that clinical risks are not taken. This is understandable. And, I suspect, inevitable. When you place a health system under strain, staff will take actions that reduce the strain on them, but will also try to minimise the risk to patients.

Under different circumstances, things could be different. If the staffing levels were higher, or if the patient numbers were lower, then doctors could take the time to ensure that they have assessed patients as thoroughly as their presentation allows. Take out the pressure of time, and staff have the breathing space to apply their best thinking to the patient. If there were more consultants, then junior doctors would benefit from easy access to expert opinions, and a better training experience.

But can we imagine significant changes in staffing levels, patient numbers, or consultant presence? Of those factors, the issue that seems to be most remediable is patient load: by ramping up the system in other places to take on some of the work currently done by Emergency Departments, we might start to make headway.

The solution to acute sector strain may well therefore reside in the ability of the rest of the system to improve pick up patients earlier in their illness, and closer to home, or to implement successful policies to maintain wellness.

Viewed in this way, the stress on the acute sector should be viewed as a symptom of the illness, not the illness itself.

Our actions to treat the illness must involve some symptom relief, but they must also treat the underlying illness. This involves understanding the mechanism of disease, and understanding what aspects of the process can be modified.

I never meant to make a medical allusion, but it seems to fit. We need Emergency Departments that provide excellent care, and we need nurses and doctors to be happy working there. Without their job satisfaction, maintaining safe and expert level of staffing will always be a challenge.

The whole health sector needs to think about what it can do to help out its ailing colleague. The involvement of the whole health service needs to be committed and meaningful, or we risk running a system with great care in lots of place, except at the front door, where it often matters the most.