Category Archives: guest blog

My first time.

Claire Donohoe (@clairedonohoe6), Editorial Assistant BJS, Consultant Oesophagogastric surgeon, Dublin

(a follow-on to “With the End in Mind”1)

Who was the first patient you discussed their own death with? 

For me, it was my grandmother. I was a medical student and she was slowly declining from heart and renal failure. During her last admission to hospital, she was clearly fearful of impending death – she told me that she felt better when I sat with her as she slept – which she did more frequently than, previously  – as she feared that she might not wake up from her nap. 

I assume that the medical staff noted our relationship. It was suggested to me that I might discuss resuscitation orders with her. I agreed that this was a timely discussion for her. Having participated in resuscitation during my rotation in the Emergency Department wanted to spare her this futile treatment.

I can only imagine how bumbling I was in that conversation. My mother had noted when I started medical school that I would have to work on my “bedside manner”.

On reflection

I definitely lacked the requisite vocabulary to not frighten her more. However, I do remember trying to reassure her that this was to prevent harmful treatment, that wouldn’t help her. And I would have loved to have had the phrase “It’s an order so that we hold your hand when you are dying rather than pound your chest”( see here2 and here3 for more).

I would have loved to have known better to narrate the process of dying to her; to relieve her of her fear that slipping away would be painful and something that she should fight. That her increasing need for sleep was normal and it differed from slipping into unconsciousness so that she could sleep more easily.

An ending

In the end, I failed her. As her medical team predicted, she had a cardiac arrest watching a soap on TV a few weeks later. And I failed her, because I hadn’t had that delicate conversation with her wider family. In my naïve medical student approach, she was the patient and I and the medical team knew her wishes. But I forgot that she existed surrounded by a devoted family who wanted to keep her forever. 

She arrested, panic ensued, an ambulance was called, CPR was commenced and she had cardiac compressions en route to the hospital where she was pronounced dead. Family members arrived to the resus bay to sit with her and hold her hand. With better communication, we could have done that in her own home. 

What I wish I’d known

In the world of surgery, we are always learning4. I regularly wish that I had already mastered all of the communication skills that I need. In a recent blog post1 I wrote about an approach to end of life communication entitled “Difficult Conversations – Why we need to talk about dying”. Dr Lara Mitchell has produced resource materials with Open Change, an educational design company, to give healthcare professionals a visual approach to support these difficult conversations  around dying with compassion and honesty. It aims to give framework, concepts and phrases to support these conversations for health and social care.

She has now produced a video discussing the framework in more detail and with references to other sources5. I found it useful and hope that you do too. In the meantime, I’ll continue to work on my bedside manner, aiming to communicate with openness, compassion and empathy.

References

1. Donohoe C. With the End in Mind. 2020.

2. Mannix K. 2020. Available at: https://ne-np.facebook.com/DrKathrynMannix/posts/today-i-was-asked-a-great-question-about-deciding-whether-or-not-a-ventilator-is/2949195348436749/. 

3. Mannix K. Dot MD talk. 2019.

4. Chamberlain C, Blazeby JM. A good surgical death. BJS (British Journal of Surgery) 2019; 106(11):1427-1428.5. Mitchell L. Difficult conversations- we need to talk about dying. 2020.

Prioritising Surgical Treatment in Coronavirus Pandemic “Salford Score”

Prof Gordon Carlson CBE FRCS

Background

In light of the need to assess priorities of surgical treatment in a resource-limited environment, NHS England have set out clinical priorities for cancer surgery. However, these priorities do not take into account the vulnerability of the patient to excess morbidity and mortality in the event of Covid-19 infection. It seems evident that, particularly when undertaking elective surgery, the vulnerability of a patient to Covid-19 related morbidity and mortality might be equally important to considerations of the timing of surgery as the underlying disease for which surgery is proposed.

The resource allocation system currently in use at Salford Royal NHS Foundation Trust (which has since been adopted throughout other hospitals at Northern care Alliance) takes both of these factors into account, by producing a score based upon the need to prioritise treatment on purely disease related grounds and also the vulnerability of the patient to Covid-19. The aim is to generate a score which can be used to determine the overall surgical treatment priority of a group of patients, possibly from different surgical subspecialties, when surgical resources have become limited as a result of the Covid-19 pandemic. The score allows different groups of surgeons and hospital management to objectively determine how temporarily limited resources might be allocated. It is meant to help guide collective discussions, not to be a rigid indicator of those patients for whom surgical treatment should be deferred, and it should be used to support, not to replace MDT discussions.

Cancer Surgery Priority

The NHS England Suggested Priority for Cancer surgery is summarised in table 1 below.

PriorityDescription
Priority level 1a• Emergency: operation needed within 24 hours to save life
Priority level 1b• Urgent:operation needed with 72 hours
Based on: urgent/emergency surgery for life threatening conditions such as obstruction, bleeding and regional and/or localised infection permanent injury/clinical harm from progression of conditions such as spinal cord compression
Priority level 2Elective surgery with the expectation of cure, prioritised according to:
• Surgery within 4 weeks to save life/progression of disease beyond operability.
Based on:urgency of symptoms, complications such as local compressive symptoms, biological priority (expected growth rate) of individual cancers

NB. Local complications may be temporarily controlled, for example with stents if surgery is deferred and /or interventional radiology.
Priority level 3Elective surgery can be delayed for 10-12weeks with no predicted negative outcome.
Table 1: NHS England Suggested Priority for Cancer surgery

However we could make resource allocation easier if we devised a simple, objective and consistent way of summarising the two variables which influence decision making – clinical treatment priority and risk of COVID-related adverse outcome, into one numerical score;

The “Salford Score” simplifies this to:

  • Priority 1a = score (P)1
  • Priority 1b = score (P)2
  • Priority 2 = score (P)3
  • Priority 3 = score (P)4

Vulnerability

A second component of this relates to vulnerability of the patient in case of a COVID infection (see table 2).

Vulnerability scoreOutcome in case of COVID infection
Vulnerability level 1• Unlikely to have excess mortality (compared to a completely fit individual < 70 years old) in the event of Covid infection
Vulnerability level 2• Likely to have significant excess mortality compared to a completely fit individual < 70 years old in the event of Covid-19 infection, but would ordinarily receive invasive ventilation in that eventuality
Vulnerability level 3• Extremely likely to succumb to Covid-19 infection and would not ordinarily receive invasive ventilation in that eventuality
Table 2: Vulnerability score

Salford Score

A resource allocation score of PxV, is then calculated so that a fit patient at high risk of imminent death of underlying disease (P1or 2) and unlikely to have excess Covid mortality (V1) would score 1 or 2 (and get urgent surgical treatment), whereas a patient with a non-immediately life threatening condition (P4) for which surgical treatment could be safely be delayed for 12 weeks and who would not, as a result of severe pre-existing medical comorbidity, be intubated etc. should they develop Covid and respiratory failure (V3) would score 12 and we would not proceed to offer surgery until the current resource position changes.