The value of silence when a patient dies

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25 October 2011 Last updated at 06:07 GMT Surgeon and columnist Pauline Chen suggests doctors and nurses should be obliged to pause for silent reflection when someone they are treating dies. It would be good for them, she says, and may make them better carers.

On hospital wards, in the operating room, in clinics and in the intensive care unit, there should be a mandatory five-minute silence when a patient dies.

The doctors, nurses and all who had been caring for the patient at the end would gather around the bedside for those five minutes and reflect in silence on that patient's life and death.

In my experience, there's a moment right after the patient dies when most caregivers, particularly doctors, will scatter - if not in presence then in mind.

We immediately think about going to see the next patient, cleaning the room, getting the body ready to go to the mortuary. Anything to avoid confronting the reality before us because, for those of us who practise in wealthier countries, a patient who dies represents our professional failure.

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One reason we don't do a better job caring for the dying is that we hardly ever acknowledge our own responses to those who have died”

End Quote Several years ago, I took care of a young woman who had had a transplant a decade earlier but who was now hospitalised because of a series of infections.

She was slender and blonde, and I can recall how she loved talking about the novels she had read and the way she raised her right hand to her forehead, palm facing outward, to pat her hair.

But on the night she bled to death from an infection that had eroded into a major artery, none of us stopped to remember the lively conversations about literature.

Instead, as soon as she was pronounced dead, we became preoccupied with seeing the next patient, removing the stains from blood that had gushed up to the ceiling and disposing of the used needles and syringes strewn on her bed.

We did not talk about her, the woman who had just died in the room.

Weighed down

I have often thought back to the fact that I did not stop to remember her or acknowledge her impact on me. There was no closure to our relationship, no acknowledgment of her life or my grief.

Continue reading the main story Dr Pauline Chen laid out her idea on The Forum, on the BBC World Service, and discussed it with literary editor Diane Athill and poet Paul MuldoonThe Forum presents ideas from the world's biggest thinkers every week Broadcast on Saturday at 09:05, 22:05 and Sunday at 02:05 and 15:05Had I lived those moments around her death differently, perhaps the details of her death would not be frozen in my mind as they are now, a few minutes replaying over and over again.

Perhaps by acknowledging her passing I would not be as weighed down by what was lost, even as I continued to care for other patients.

I believe that instituting the five-minute pause for silence after a patient dies will change the way doctors, nurses and other caregivers approach death.

First, it will give closure, as well as respect, to the relationship between that patient and his or her caregivers.

Second, the conscious pause, the act of taking time out, will establish a ritual. And rituals, consistently practised, offer great comfort at difficult moments.

Finally, the five-minute silence will allow caregivers to acknowledge their own feelings.

I am convinced that one of the reasons doctors and other healthcare providers don't do a better job caring for the dying is that we hardly ever take the time to acknowledge our own responses to those who have died. We deny those feelings only to end up constrained by them.

A five-minute pause for silence would allow us to attend to our own grief about a patient who has died and free us to commit ourselves fully to those who will follow.

Pauline Chen is a liver surgeon and author of Final Exam: A Surgeon's Reflection on Mortality. She also writes the Doctor and Patient column for the New York Times.

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CNN: Steve Jobs Was a Difficult Patient

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Former Apple chief Steve Jobs was notoriously difficult, not least as a cancer patient, it turns out.

After discovering in October 2003 that he had a pancreatic tumor, he put off the surgery that doctors recommended to see if a "few other things would work," Jobs told his biographer Walter Isaacson (TIME's former managing editor): "other things" like a vegan diet, acupuncture, herbal remedies and other alternative therapies, even psychic consultation.

Jobs relented to surgery in July 2004, but afterward, refused to adhere to recommended care when it came to his diet. Offering fascinating excerpts of Isaacson's book, CNN's Elizabeth Landau notes that Jobs had unconventional, obsessive eating habits — he routinely fasted or ate extremely restrictive diets, sometimes refusing to eat at all — which he maintained, despite that fact that "standard of care [for pancreatic surgery patients] is to have frequent meals and a diet with a variety of proteins from meats, fish and milk," Landau reports.

Jobs' disordered eating contributed to his striking 40-lb. weight loss in the spring of 2008 as the cancer spread from his pancreas to his liver. In 2009, he had a liver transplant, but by that time, doctors thought, the cancer had likely spread to other parts of his body. Landau reports:

Jobs again went against doctors when he insisted that they not pump out his stomach when they needed to perform a routine procedure. That led to pneumonia, and he might have died. But he survived, and didn't lose his stubbornness, even while deeply sedated. He thought the oxygen monitor on his finger was "ugly and too complex," and offered ideas for making the design simpler.

By Christmas 2010, Jobs was down to 115 lbs. and still eating unconventionally or refusing to eat. "Cancer curbs appetite, but Isaacson suggests Jobs had a deeper complication from his psychological attitude toward food," Landau reports.

Read the full CNN story here.

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Patient data lost from hospital

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5 October 2011 Last updated at 06:13 GMT A hospital has admitted losing a memory stick containing the confidential medical details of 800 patients.

The unencrypted device went missing from the East Surrey Hospital, run by Surrey and Sussex Healthcare NHS Trust, in 2010 and has never been found.

Details of patients names and operations were on the stick.

The Redhill hospital has been warned by the Information Commissioner's Office (ICO) that any repeat of the action may result in formal regulatory action.

The loss, in September 2010, came to light in the NHS trust's annual report.

Michael Wilson, chief executive of the trust, said there had been no reports of the stick being found by a third party.

He said when the stick was lost it was the trust's policy that all staff should use encrypted memory sticks when transferring patient data.

Further training

"It is regrettable that this didn't happen on this occasion and since then we have put in place new measures that mean that now only encrypted memory sticks can be used with trust computers," he said.

He added the trust had contacted the ICO itself to receive advice shortly after the memory stick was lost.

A spokesman for the ICO said the hospital had subsequently been warned that the trust's policy covering personal data must be followed.

"The trust was also warned that any repetition of such an incident may result in formal regulatory action," he said.

According to the trust, the member of staff who lost the stick has been taken through disciplinary procedures and has received further training.

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Warning over heart patient drugs

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28 September 2011 Last updated at 13:44 GMT The report reviewed cardiology services across Scotland More than half of heart patients in Scotland at high risk of stroke are not receiving the most appropriate treatment, according to a new report.

Scrutiny body Healthcare Improvement Scotland has published the "most comprehensive picture yet" of cardiology services across the country.

It found 53% of patients who should be getting a blood thinning drug were not.

Meanwhile low-risk patients are being given more powerful medication when they should just be taking aspirin.

The report paints an in-depth picture of the strengths and weaknesses of heart disease services in Scotland, and includes detailed plans for how improvements to services can be made.

Cardiovascular disease is the leading cause of death in the UK and coronary heart disease results in nearly 10,000 deaths every year in Scotland.

The report raised concerns about treatments prescribed to people with atrial fibrillation, a common heart rhythm disorder with a high risk of stroke.

While nearly 80% of people with this diagnosis receive some form of blood-thinning drug, less than half (47%) of higher risk patients are receiving the most appropriate treatment, Warfarin.

At the same time 31% of low-risk patients, who should be treated with aspirin alone, are receiving a blood-thinning drug which exposes them unnecessarily to a higher risk of bleeding complications.

Vital services

Dr Martin Denvir, clinical lead for the heart disease improvement programme, said: "Within three years of starting this improvement programme we are now publishing a groundbreaking report which sets out in detail just what has been achieved in Scotland - and what is still to be done.

"This is the most comprehensive picture yet of heart disease services in Scotland.

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There is some way to go until every patient has the correct treatment every time”

End Quote David Clark Chest Heart & Stroke Scotland "The journey towards perfect care for all patients is by no means over, but our findings clearly identify what is already being done well, what needs improvement and how we can measure our improvement and progress towards best quality of care."

The report also found that although all health boards have risk assessment programmes in place to identify people at high risk of heart disease and stroke, these programmes are not provided comprehensively for all high-risk groups in the general population.

It also said the Scottish Ambulance Service provides a well-trained and rapid response to emergency calls and reaches 71% of patients with suspected heart disease within eight minutes.

The report makes a number of key recommendations to improve patient care, including a review of the prescribing of blood-thinning drugs.

It said patients at low risk of stroke should not routinely be prescribed Warfarin.

Andy Carver from the British Heart Foundation (BHF) welcomed the report and said: "It is an important step in improving the accountability of NHS boards for the delivery of vital services for heart patients.

"We will continue to watch closely and help ensure that these standards are implemented to help people prevent heart disease and make sure services for heart patients are the best possible in all parts of the country."

Chest Heart & Stroke Scotland's chief executive David Clark said "We recognise that there has been real progress as a result of the Heart Disease Improvement Programme and that Scotland has some world-class centres for the treatment of heart disease.

"However, we also have to recognise that there is some way to go until every patient has the correct treatment every time."

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'Dire' care for patient who died

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28 September 2011 Last updated at 05:51 GMT Paul Ridd's sister Jane Nicholls and brother Jonathan Ridd talk about the care he received after leaving intensive care, saying it was a "catalogue of errors"

A patient with severe learning difficulties who died in hospital may have survived if he had received better care, a watchdog has found.

Paul Ridd's nursing care at Morriston Hospital in Swansea was called "abject" and "dire" by the Public Services Ombudsman for Wales.

Mr Ridd, 53, died of respiratory issues after transfer from intensive care.

His family welcomed the report. Managers said procedures had been improved.

Awareness training for all doctors and nurses has been ordered at the hospital.

The ABM University Health Board, which runs the hospital, also said it had already started implementing the recommendations made in Peter Tyndall's report.

Mr Ridd, from Baglan near Neath, had severe learning difficulties as a result of brain damage at birth.

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It greatly concerns me that the dire level of nursing care to which [Mr Ridd] was subjected on the ward, could have happened in the 21st Century”

End Quote Peter Tyndall Public Services Ombudsman for Wales He was admitted to Morriston Hospital on 31 December 2008 with a serious bowel problem and underwent surgery.

But following his death on 23 January 2009 his brother and sister complained about many aspects of the way he was looked after.

In particular they were concerned he contracted pneumonia while in intensive care and was transferred prematurely to a general ward, where they said his care was poor in the days before he died of respiratory problems.

His brother Jonathan Ridd said: "When Paul was in the intensive care unit, he had top quality care, like a five star hotel, and when he was moved across the corridor, it felt like we were in a Third World country in terms of care, cleanliness.

"There was no leadership and his observations were not done as instructed."

Mr Ridd said in the last four hours of his life, his brother's carer was "constantly begging" the nursing and medical staff to examine him as his condition had steadily deteriorated.

In a report published on Wednesday, Mr Tyndall said concerns about Mr Ridd's condition after he was transferred to the general ward were raised with staff.

But among his findings were:

A failure of supervisionInadequate examinations by doctorsA failure to ensure Mr Ridd's care complied with the Disability Discrimination Act.

"Nursing care on the ward was abject," said Mr Tyndall.

"It greatly concerns me that the dire level of nursing care to which [Mr Ridd] was subjected on the ward, could have happened in the 21st Century.

"It is vital that change is robust and long lasting.

Paul Ridd (centre) received 'abject' nursing care on his ward in Swansea

"I consider it vital that nursing and clinical care providers respond appropriately to the challenge that patients with learning disabilities present. This did not happen."

Wayne Crocker, director of the learning disability charity Mencap Cymru, said the case should be a "wake-up call" for health professionals in Wales.

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We would wish to reiterate our sincere apologies to them for failing to meet the needs of this patient”

End Quote ABM University Health Board "It's a disgrace that someone can go into a hospital, a place where they should be looked after, and see their chances of survival reduced because they have a learning disability," he said.

'Tragic event'

"Currently, people with a learning disability get sub-standard healthcare compared to those without - it's as simple as that."

The ABM University Health Board said it investigated and identified shortcomings following Mr Ridd's death and swiftly took action to make improvements.

These included increasing the number of nursing staff, appointing a new ward sister and ensuring staff completed an education and training programme.

It said procedures had also been tightened and improved in all its hospitals.

"As a result we want to assure the public that the ward today has improved significantly from the way it was over two years ago," it said.

'Sincere apologies'

"We can also give assurances that we have used the experience of this tragic event to improve our practices across the health board.

"Whilst we fully recognise that this can be of little comfort to the family it is important that they know that the concerns that they have raised have improved care for others.

"We would wish to reiterate our sincere apologies to them for failing to meet the needs of this patient."

His sister Jane Nicholls told BBC Wales: "Paul couldn't communicate like you or I can, so you had to pick up on the signs.

"I find it really difficult because I don't know quite how Paul felt and he died from excess secretions in his upper airways, which is like drowning, and he was unable to communicate to us."

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