Posted by: ayrshirehealth | September 11, 2013

Whose needs are being met? by @kendonaldson

Let me tell you about two elderly ladies….

Helen

Helen was in her mid-eighties and had been attending the pre-dialysis clinic for several years. She had decided that she did not wish to have any form of dialysis treatment and would therefore have ‘conservative management’ – all medical therapies, symptom control and supportive care.

She was admitted through medical receiving on a Tuesday morning with severe shortness of breath and chest pains. She was reviewed by a colleague of mine who found her to be desperately unwell – her lungs were full of fluid and she was gasping for breath. Helen was desperate for anything to be done to help her and was pleading for dialysis to remove the fluid. My colleague found herself in a difficult situation, Helens family thought dialysis wasn’t the right thing to do but the patient herself was adamant. My colleague discussed Helens case with me. I asked her what she thought and she said that she felt we should go ahead and dialyse her. So I agreed and we arranged to get a dialysis line inserted, I left my colleague to sort this.

About 30 minutes later I popped into the renal unit to see how things were going. I found a very distressed patient and clinician and no line yet in place, this was proving to be a difficult procedure. My senior charge nurse was present and gave me a look that said “This isn’t good.” So what to do? I took over and, with difficulty, got the line in. Helen was attached to a dialysis machine and started her treatment.

The following morning I went straight to our High dependency unit to see how she was. The nursing staff told me that Helen was a little brighter and had managed her breakfast, I was encouraged. I then went in to see her and found her slumped on her side and barely breathing. She passed away peacefully 5 minutes later.

Mary

The other lady I wish to tell you about is Mary. She was also in her mid-eighties and was admitted with acute on chronic kidney injury following a diarrhoeal illness. On admission the team had treated with intravenous fluids but, despite some improvement in her blood pressure, Mary didn’t pass any urine and her blood tests were poor – a decision had been made to inform the renal team and start dialysis.

When I went to see Mary I found her curled up in bed dozing and reluctant to communicate. She had pulled out all her cannulas and her catheter. All she said to me was “Go away.” The nursing staff had set up a trolley for line insertion and were ready to go. So what was I to do? I thought of Helen and stepped back.

Hardly an advanced directive… but very useful information!

I managed to track down Mary’s daughter and had a long chat. It sounded like Mary was a feisty soul who didn’t really like hospitals and doctors and managed independently at home with a small care package.  I explained what the situation was and that it was possible she may die. We could dialyse her but this wasn’t without risk and may not be successful but seemed the only choice. She was unsure but left the decision to me.

I then spoke to Marys GP. She knew her well and was clear that Mary would not want any of this. She had had a heart attack in the spring and they had managed her from home as she refused admission. Mary had made it clear many times that she didn’t want any heroics should she be poorly. Hardly an advanced directive but very useful information. So what to do?

I decided not to insert a line and moved Mary to a side room pending her family visiting (they lived some considerable distance away) and I discussed her with my palliative care team. The family, on seeing Mary, agreed that we should not dialyse her. We arranged transfer to a community hospital near where she lived with a plan for palliative care.

I received an email 3 weeks later from Marys GP. She had started passing urine 2 days after transfer and had made a full recovery. She had just discharged her home.

Values

So what had happened to me between seeing these two ladies? On reflection it was clear that Helen had been dying when she was admitted and that dialysis had not been in her best interests – it had merely ‘medicalised’ the end of her life.

Values

I discussed her with a colleague who suggested using her case in a process called Values Based Reflective Practice. This involves presenting the story to a small group and answering some simple questions like Whose needs were being met?, What does this tell me about my caring Ability? and What does it tell me about Me and my Values?  The group then ask questions always framing them with the phrases “I notice” and “I wonder.” A facilitator ensures that the focus is on learning and reflection and not blame.

I learnt an enormous amount about myself during this process. I will not go into detail but by far the most important question I learnt to use was “Whose needs are being met?” My decision making around Helen, I now realised, was about my needs and those of my colleague. When it came to Mary I stepped back, thought and asked the question. Once I had spoken to the right people and got the information I required I was able to answer it and NOT dialyse. Having reflected ON practice I was now reflecting IN practice.

Just because we can…

Dialysis decisions can be tough in our ageing and increasingly co-morbid population. This is the same throughout medicine as we develop more complex drugs and machines that can support desperately ill people. But just because we can doesn’t mean we should. My lesson from Helen was to stop, think, step back, accept that not treating might be the right thing to do and, ultimately, try and meet her needs.

This week’s blog was by @kendonaldson, in addition to being a ‘kidney doctor’, Ken is blog master of DGHealth.wordpress.com

Next week @john_nhsfv_qhub blogs for us here on ayrshirehealth

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Responses

  1. this is an incredibly powerful example of how we sometimes rush in with treatment without considering the ‘whole’ person rather than just their symptoms which require the treatment.

    • Thanks Hazel.

  2. It takes great courage.

  3. Very, very difficult in the acute situation. To have said no to dialysis, when Helen (presumably competent to make her own decisions) was adamant that was what she wanted, risks overriding patient autonomy. I guess the ideal is to have in depth discussions about this sort of situation with patients well in advance, however here it sounds as if you’d already done that and she simply changed her mind as she became acutely ill. No easy answers…

    • Always difficult Andrew and its hard to know whether you got it right or not. Its the simple but strong message of “Step back, think, ask for more information” approach before wading in.

  4. How can we get all NHS employees that have a direct, or indirect, influence on patients’ outcome to develop and implement the same attitude? It concerns me that there is a greater focus on processes than values in some of the support groups that assist frontline services within the NHS.

  5. […] Whose needs are being met? by Ken Donaldson on the Ayrshire Health blog […]

  6. […] the Ayrshire Health blog this week in Whose needs are being met? by Ken Donaldson  he tells us of two elderly and frail patients, who both needed care and […]


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