Search the hub

Imagine... You are 80 years old. You live independently and have a full social life with friends of similar ages. You have no close family; your friends are your family. You are very much part of the community and enjoy life. Every winter you get a ‘bad chest’. You visit the GP when this happens and get antibiotics. This is your only health issue. Being locked down hasn’t been an issue for you. Life is different, but the village you live in has a great support network, you can get shopping delivered, you are connected via the internet to your activity groups – even tai chi on zoom! You receive a phone call from your GP. They state "...with your chest, it's unlikely that you will survive this virus. So, I need to ask you... do you want to be placed on a ventilator and do you want to be resuscitated?" They expect an answer while they are on the phone to you. You have less than 5 minutes to respond. "Errrrrr, yes… I have lots to live for, please do everything you can" is your reply. You put the phone down and cry. You are scared. What now? This is a real case that was told to me this morning. ‘Difficult conversations’ are needed. They have always been needed. Whether that be in primary care or secondary care, these conversations are important. It is important to find out what patients and families wishes are, important to offer informed choice of what treatments will be of benefit and important to manage expectations from both, patient, families and clinicians. Much has been written on how to have these conversations, when to have these conversations and by whom – this advice has been written in a non-pandemic time where people have the time, have up to date, clear information that patients and families can discuss the issues. Some GPs are using the RESPeCT document, its been slow to adopt and spread, but if completed makes the world of difference. Having an open conversation about dying may feel taboo, but you only get to die once (usually)… you may as well do it well. Where I work clinically, all patients who are suspected COVID-19, have a treatment escalation form completed as they are admitted. This informs other clinicians what treatment that patient can receive during their admission. If a patient doesn’t have a treatment escalation discussion, patients may experience unnecessary pain, suffering or futile treatment that they didn’t want, but were unable to say. The treatment escalation form and process we are using has transformed and streamlined our care. We are now able to give the right care to the right patient at the right time. Patients and families are fully informed and are grateful for having the conversation. But what happens during the pandemic in primary care? GPs are unable to wait for their patients to turn up to the surgery to have these conversations. Many of their patients are the most vulnerable, in care homes, the homeless and often difficult to reach. Is a telephone call, out of the blue the best way of having this conversation? GPs have hundred, if not thousands of patients on their case load, how are they to have meaningful conversations during this pandemic with the most vulnerable? This blog is not to highlight the bad practice. It is not a time for naming and shaming. We are learning together. Are you doing things differently? Do you have a solution? Are you a patient and have an idea on how we can do this better?

Key recommendations Ask the patient if they would like to have the conversation and how much information they would want. All healthcare professionals reviewing patients with chronic conditions, patients with more than one serious medical problem or terminal illness, should initiate shared decision making including advance care planning in line with patient preferences. Conversations about the future can and should be initiated at any point. The conversation is a process not a tick-box, and does not have to reach a conclusion at one sitting. Be aware of the language you use with patients and those they have identified as being important to them, and try to involve all the relevant people in agreement with the patient.

This guidance recommends the following: Suspend initiation of new treatment cycles, including ovulation induction, intrauterine inseminations (IUIs), in vitro fertilisation (IVF) including retrievals and frozen embryo transfers, as well as non-urgent gamete cryopreservation. Strongly consider cancellation of all embryo transfers whether fresh or frozen. Continue to care for patients who are currently “in-cycle” or who require urgent stimulation and cryopreservation. Suspend elective surgeries and non-urgent diagnostic procedures. Minimise in-person interactions and increase utilisation of telehealth. Note: This guidance will be revisited periodically as the pandemic evolves, but no later than March 30, 2020, with the aim of resuming usual patient care as soon and as safely as possible.

Ten days ago, *Mark developed a mild headache, minor fever and sore throat. He is in Denver and we are in Mexico. We Face timed him every day and his aid, *Sandy, was coming to see him every other day. But then Sandy's husband became ill and as she has been exposed to whatever her husband has, she has to now self-isolate at home with her husband. Mark has had no helper now for 7 days. Mark has access to the US government assistant programme, but unfortunately there are no other aids available right now. So we are trying to get him home as soon as possible, but we can’t until he is symptom free. I am getting ready to jump on a plane. Being isolated and without an aid has caused him periods of considerable paranoia and anxiety. Disabled people at home who rely on home healthcare are now at risk of no help. Fortunately Mark is very good at ordering out food for delivery and is able to walk with his walker to the pharmacy for his medication, but I worry about all the other disabled people who may inadvertently get abandoned in this pandemic due to low workforce. *Names have been changed in this blog to ensure confidentiality.

The document covers five key topics: when are video consultations appropriate? how can a practice get ready for them? how can clinicians conduct high-quality video consultations? what can patients do to prepare for and take part in them? what is the research evidence for their quality and safety?

It includes information on: symptoms advice on staying at home when and how to contact 111 advice on your immigration status how to stop the spread of the virus.

In a blog in the Patient Safety Movement newsletter, James Titcombe talks about his son's death and how speaking out can save lives.

Key facts The occurrence of adverse events due to unsafe care is likely 1 of the 10 leading causes of death and disability in the world. In high-income countries, it is estimated that one in every 10 patients is harmed while receiving hospital care. The harm can be caused by a range of adverse events, with nearly 50% of them being preventable. Each year, 134 million adverse events occur in hospitals in low- and middle-income countries (LMICs), due to unsafe care, resulting in 2.6 million deaths. Another study has estimated that around two-thirds of all adverse events resulting from unsafe care, and the years lost to disability and death (known as disability adjusted life years, or DALYs) occur in LMICs. Globally, as many as 4 in 10 patients are harmed in primary and outpatient health care. Up to 80% of harm is preventable. The most detrimental errors are related to diagnosis, prescription and the use of medicines. In OECD countries, 15% of total hospital activity and expenditure is a direct result of adverse events. Investments in reducing patient harm can lead to significant financial savings, and more importantly better patient outcomes. An example of prevention is engaging patients, if done well, it can reduce the burden of harm by up to 15%.