So I read an article recently about making ‘do not resuscitate’ (DNAR) orders an opt out policy, rather than opt in.
The current situation is that if it is felt that resuscitation would be unsuccessful, or would lead to a quality of life that is unacceptable, a DNAR form is completed by their doctor. Generally speaking, this should be discussed with the patient and their family. However, it is always their doctor that has the last say as to whether it is completed. More often than not there is an agreement between the doctor and patient (and relatives) before this is put in place.
So why to opt out? The article discussed the rates of survival from a cardiac arrest – approximately 20% in hospital and 10% outside of hospital (success rate being that they are discharged from hospital following an arrest). It also discusses how traumatic CPR is and that often a DNAR order is not discussed until too late in a patient’s illness. Therefore meaning that sometimes a meaningful conversation cannot be had with everyone involved.
From my perspective I find the DNAR order one of the hardest parts of the job. I find it to be one of the hardest discussions to have with patients and their relatives. Most people understand what you are asking and why, and most say they would not want to be resuscitated. I have also seen it from the other side. My mother had a DNAR put in place. I realised how non-medical individuals interpret it – you are placing a time limit on the life of their loved one, and it’s presumed to be a short time frame. Realistically speaking, this is often the case.
On the other hand, I have been at many resuscitations in my career. I have seen how undignified and traumatic it can be. I have thought to myself that this is completely inappropriate and unfair.
But should it be opt out? Because then you are actively making people to face their own mortality, and from an early age. People’s thoughts, and ideas about what they want will change with age, and illness, and their social circumstances.
I think that rather than opt out, we should be open about resuscitation and be open to discussing it. We should inform people, and allow them to think about it in their own time. I’m talking practicing holistically. It is important that people get to thinking about it in advance, and before they are too sick to contribute to the decision. I also think that if we were more open to entering this type of discussion, it wouldn’t make it such a difficult topic for the doctor to broach.
This is going to be short I think!
I realised that I am slipping in to old habits and giving up too early! So I thought I would write something, albeit short, just to keep going and try to get back into the habit.
So I thought something quick to scribble about was how I have always disliked Monday! I think it’s multifactorial:
1) it’s the first day of a new working week – the biggest reason!
2) as a result of number 1 it always ends up being the busiest day of the week as things have built up over the weekend (in my line of work for sure).
3) after two days of freedom, where I’ve had fun, I don’t feel like getting back into a routine. I think I would prefer an extra day off to recover from the weekend.
But then I get to wondering………….what if I didn’t work Monday’s? Would Tuesday become the new Monday? Or would it seem less painful if you had to work a shorter week?
With Monday always being the prominent day of the week, right from playgroup days aged 3yrs I think its psychologically the worst day, and I think it’d take a good few years before Tuesday became the new Monday, and Wednesday the new Tuesday!
The only think I can say with certainty is I love Fridays………..apart from those when I’m working the weekend!!
Does anyone else feel the same?
I am sorry for the rant I am about to impose on your eyes! Today has been the most frustrating day of my current job (now 6 weeks in) so far. I can hardly think about anything else so I must get it off my chest!
So, let me introduce you to my current job. I am training to be a General Practitioner (or family doctor as some may refer to the role as). This involves rotating around several specialities (every 4 months) to gain further experience in each are of medicine that I rotate through. My current job is Psychiatry. I have been allocated on the elderly dementia ward. Since starting the job I have found it to be fairly unsatisfying, and it does not really enrich my learning with respect to being a GP.
The biggest problem has been adjusting to the role of psychiatrist. I have found that they have little medical knowledge (because they don’t necessarily need it) and are very risk averse when it comes to making medical decisions (really good at the mental health decisions though). So I have dropped into this job as a medical doctor pretending to know a lot about psychiatry. I’m struggling to get to grips with it really. Because by swapping jobs, literally overnight, I am now deemed not to be able to give a medical opinion. Thus meaning that I cannot manage patients medically unless it is something really straightforward. This is not my decision. It is the nursing staff who work on my ward. Essentially they will ask me to review someone, I will, and I then make a decision about how to manage the patient. If they are not happy about this as they think its ‘too medical’ I have to give in and send them to the emergency department for a ‘medical review’. Hence it feels like I have lost my autonomy and all medical knowledge overnight!
Today really just puzzled me. Having completed my ward jobs, I retreated to my office to complete some paperwork. ‘Over-the-top’ (OTT for short – the most prominent healthcare assistant on my ward), came to the office and asked to to see a lady as she had a red, dotted rash spreading across her back. This lady had returned from the medical ward the previous afternoon. She was one of these ‘examples’ of where my word had not cut it, and I’d been forced to send her for a medical review. She had fallen off the sofa 4 days prior to them asking me to send her to the hospital. Since the fall she had been much less mobile and uncomfortable. She also had 2 big black eyes. I’d been pretty certain that there was nothing serious going on – all superficial. Anyway, I had been right about there being nothing wrong. Having called the medical ward the day after her admission they had explained that all tests were normal, and they would try to improve her mobility, but would send her back in a day or two.
I walked back to the ward and had a look at the lady’s ‘rash’, which to me looked like dry skin with a bit of itching having taken place. From a medical opinion just some moisturiser was required. When telling ‘highly annoying’ (the most annoying nurse I may have ever met) that I thought the lady looked better, she proceeded to disagree and suggest that perhaps she shouldn’t have come back from the medical ward. I explained, with my medical hat on, that there had been no reason for them to keep her. The conversation spiralled into a heated discussion about how she expects me to go over to the medical ward and check that someone is medically fit before they return to the dementia ward. I explained that this essentially contradicted everything, since she went for a medical review as I wasn’t deemed to have enough medical knowledge to make a decision. So how come I all of a sudden had enough to say she was fit to come back – and potentially go against the medical teams decision. I felt it was complete nonsense. So I made that point. This is where over-the-top decided to to get involved. As she sat down in front of me, with wide eyes ” let me tell you how it is…….”
This is where I reached boiling point. I knew that either I would have to stop this speech or I was going to storm out. I responded with the salient points “I heard what you’ve said, I’m not psychic and no-one told me this is what you expect, I disagree with it, In the end I’m not going to send the lady back to the hospital so I can go over there and check she’s medically fit for return, So thats how I’m ending this conversation”. And that was that – I completed writing in the notes about the ‘rash’ and then left the ward never to return! (well for today)
Now, back to the title of this entry, respect. I truly believe that the best relationships – professional and private – are based on mutual respect. This is what was lacking between myself and highly annoying. Since I started working with her I have felt like she doesn’t respect my opinions and suggestions regarding the management of patients. I have worked hard to prove my worth, and yet I feel that she rather tell me what she thinks or what she expects, that listen to me, and take my word for it. I appreciate, and communicate that my psychiatry experience is minimal but have always made my medical decisions with conviction ( I will be a fully qualified GP in 18 months). But due to the way she makes me feel I am always on edge around her, and lack respect for her now.
I don’t know how you feel about mutual respect, but I think it is a crucial factor in developing and maintaining a relationship with someone else. In fact I would rate it as the most important, and without it there cannot be a successful relationship………..
Today got me thinking about behaviour and morals…….
As I walked into the ward today, the lovely receptionist (who always sounds bright and breezy) greeted me with ‘female colleague (as I will refer to her) has called in sick today. Therefore it would leave me to cover my patients’, female colleagues patients’, and long-term holiday’s (as I’ll refer to him) patients’.
Fine I thought – at least I wont be bored today! But I couldn’t help but boil over inside. Female colleague was off yesterday after an on-call. She’d shown no sign off illness on Monday. I couldn’t help but wonder how genuine it was. Especially since the previous day I’d been talking with big jolly giant (BJG – a fellow GP VTS trainee). He had told me how his November had been very busy doing my now/his then job. Female colleague had developed pneumonia and had most of the month off. On the one day she’d come in she had spread it to long-term holiday, who also had most of November off sick. This conversation was ringing in my head, alongside a flippant comment a nurse had made at the start of the job, about the doctors always being off sick.
Now today it wasn’t bothering me. The workload was not excessive. I was a bit frustrated as I knew none of the patients’ backgrounds – but that was not a big problem. No, it was really my feelings about people taking sick leave, and my take on sick leave. Now, I have never had to take time off sick. Perhaps its all the mud pies I ate as a child and general exposure to germs. I think this is supported by the memory of my mum. She would not let me have a day off sick unless I had a recordable high temperature. As you can imagine, I acquired a lot of attendance awards during my schooling.
But I really feel that you have to seriously consider things before you call in sick. You have to think about who’s going to cover you, and how busy they’ll be. You have to think about who you’re letting down, etc. Or thats just the series of thoughts I’d have to go through.
This got me to thinking about some mail I’d received over the weekend. The government is planning on changing the pension scheme. It would see us work longer, pay more contributions and draw less pension. This is the deal for any civil servant. Recently there was a large strike involving most professions, including all other medical professions except doctors. People did strike, many didn’t. Through the post had arrived a survey on whether I was prepared to strike and what degree of striking I would support (absolute vs. providing emergency cover vs. not striking). I’m really unhappy about the idea of working until I’m 67, paying more into a pension fund and receiving less pension per year, of my reduced number of retired years. However, I have never really seen the rationale behind striking as I’m not convinced it gets you anywhere. The other issue is, when I qualified as a doctor, I signed up to the hippocratic oath. I’m fairly certain that striking would be going against this, and therefore I’m not sure I can agree to striking. But, again, there I am putting my work responsibilities before my own health and welfare.
I think my extensive ramblings are coming to an end. But I would summarise them by saying that I cannot believe how many, lazy, unreliable, unsupportive, people who lack morals have decided that medicine, and caring for others is the right job for them.
Maybe you would disagree with my thoughts? I’m open to other peoples views and opinions……
I had my washer repaired today. It’s been broken since christmas eve. It has taken this long to:
1) work out that we were covered by an insurance-style home cover policy,
2) arrange a time when someone can be home to let Mr Repairman in and
3) to have one episode where Mr Repairman came and went because, according to the guy on the end of the phone, ‘you left him in a clamping zone’.
Well today really wasn’t a convenient time, but it was the earliest appointment they had, and I really wanted to be able to wash my clothes! I was due to be at work, on a ward round with my consultant (more about this later) and covering another ward as their doctors were both off.
After much discussion with him indoors (my fiancé who also has a full time job), we made a plan – I would go in late and hope Mr Repairman came dead on 8am, with our window of appointment being 8am – 1pm.
Anyway I went into work late for no reason. He didn’t arrive by 9.30 and I just couldn’t stay waiting any longer. Plan B – when Mr Repairman called to say he was en-route him indoors would send his cleaner from work over. This effectively killed two birds with one stone – a repaired washer and a clean flat, thus making for a clean, albeit delayed, start to the new year.
My major issue with the whole scenario is you have two options with repairs/deliveries – a morning or an afternoon slot. They cannot be anymore precise (well ocado can and that makes me a loyal shopper of theirs). They also cannot give you any details to contact Mr Repairman directly, and it is always your own fault when they are late or don’t turn up at all. Now, how many people with a full time job can drop work at short notice to spend half a day waiting for someone to turn up. I feel discriminated against for having a full time job! If I worked part-time, or not at all my washer would have been repaired 2 weeks ago. I cannot understand why, in a modern 24hr society, you cannot have someone to come and repair the washer in the evening, or even more crazy, the weekend!
Enough about the washer. I arrived at work to find the consultant and nurse waiting for me to start the ward round. I must explain what at ward round on the dementia wards entails. It is essentially sitting in an armchair, drinking tea whilst discussing each patient. Generally not much has happened. We have a chat about medications and that’s about it. If I didn’t bring it up myself, we wouldn’t discuss any medical problems they’d had or when the patient may be discharged. The majority of patients have been resident on the ward for months (one will be at the year mark in february!), and there seems to be no eagerness (other from myself) to have them discharged. This ward round will last about an hour, and generates very little work. So off I trek to the ward next door. All they ask of me is to write up some gaviscon and a steroid cream for a patient. Therefore, from 11am my jobs were done. I was later highly excited when remembering I had my GP VTS teaching (something I’m sure I will come to discuss later) this afternoon. Something to do!!!
So I couldn’t hold back here’s my 2nd ever post.
The job that I currently undertake requires me to do actual work for around 2 hours max. The rest of the day I am trying my hardest to fill, or make it look like more work than I have. It frustrates me that I have to be present in this place between the hours of 9am and 5pm. For the most part I just seem to sit in my office staring out of the window at the generally miserable winter weather and the packed car park that separates me from the main hospital block. If I’m not doing that I am frantically refreshing my emails to see if a new, highly important email has arrived in my inbox (in the last 5 minutes).
You see it baffles me how rotas and shift systems are created. On my current rota there are 24h shifts. I have so far done two, and I must admit they have been very good to me (almost too good). I am waiting for one of these dreadful ones that everyone keeps talking about. I think the point I was trying to make is why have 24 hr shifts which can be so busy, when a day job can be so slow. I really would prefer to have a more regular on-calls with day or night shifts that a 24h on call.
On this 24 hour on-call you are allowed to go home, as long as you are within 30 minutes of the hospital. But it’s not in any way relaxing as you look at your on-call mobile phone just waiting for it to ring (often within 30 minutes of reaching home). The sleep is interrupted by the fear of the nokia ringtone.
Now you might ask – why don’t I go and help my busy colleagues. 2 reasons – 1) most of them are also not busy or pretending to work, and 2) self-preservation. I have learnt over the years that people may thank-you for your help (many will not), but they will rarely return the favour. I have perhaps learnt this to a greater degree than most. I am what you would call the sucker. Always giving in to a sob story, or for an easy life. There are few times when I have not agreed to help someone out, or cover for them. Mostly getting nothing in return. I am therefore trying to avoid all times like this other than those where I am directly approached.
I will take you back to New Years Day 2010. I was due to work the saturday and sunday 12 hour days, covering gynaecology. On arriving at work I was greeted with ‘your mission which you have no choice but to accept’ of finding a locum to work New Years Day night. I was given a list of locums, which I was assured that someone would likely be available. Having completed my ward round I set about making the phone calls. I was greeting mostly with ” I’m really sorry but………”. The closest I got to was someone who could work the next day but not tonight. I made my way to find the consultant, head in my hands as I was pretty sure what was to come – “well could you do it?” As discussed above, my mouth opened to say not really and the words came out as “I guess so….”. By now it was 3.30pm. The other junior on-call was kind and suggested I go home for some rest prior to continuing what would become the 24 hour shift. 45 minutes to home left me with just 3 hours to try to rest, eat and, more importantly, mentally prepare myself for the night to come. I cannot recall much of the shift. My only vivid memory was at around 5am being asked to cannulate a patient. As I opened up all the equipment I found myself struggling, and dropping things. The cannula went in first time but I just remember thinking “This is why the European Working Time Directive came into force”. Also, there was the realisation that should I have made a mistake, I would have been in trouble for working outside the recommendations.
I have decided to set up a blog. I have for sometime considered writing a book about my experiences so far as a doctor. However, knowing me I will never get around to writing this and may just forget all the things I wanted to say. So I have decided to start here and see how it goes.
Luckily for me I have a very quiet job at present so I think I should have the time to update regularly and perhaps go back into the past a little.
More about me first – I decided to study medicine having decided I would be a forensic pathologist. However, during my medical school days I started to think that perhaps I liked to talk to people – a luxury that would be kept to a minimum as a pathologist. So with time my mind changed and I looked to different careers within medicine. Options that arose were obstetrics and gynaecology (O&G) and surgery. I soon realised that O&G wasn’t for me – I hated the Gynae, and following a number of times where I could have cried at work I knew that wasn’t going anywhere. I really liked surgery, and I was pretty good at it. However, relfection from my partner suggested that I may be highly stressed in a hospital environment forever. Plus I have a serious problem with rota co-ordinators. A chance application for General Practice (GP) led me to where I am today – year 2 of my GP training, and in a psychiatry job caring for patients with dementia. There are several areas I will come back to along the way – rota co-ordinators, my past jobs and experiences and general points about the health system in which I work. But for now I am going to thnk about what order I will discuss them all in!