Monday, July 15, 2013

The Way We Die Now

May I quote this case reported in a respected medical journal? This happened in a metropolitan English hospital.


A 92-year old lady with multiple comorbidities was admitted to hospital from a residential home with community-acquired pneumonia.

She was judged to be at high risk of aspiration and was made nil by mouth (NBM) pending review by a speech and language therapist (SLT).    ....
She was given intravenous (IV) antibiotics at a rate that cannot be determined by retrospective examination of the medical notes.
On day 4 of her admission she was reviewed by an SLT, who advised keeping her NBM and consider an alternative mode of feeding.
On day 9, the patient was reviewed by a dietician.

The physiotherapist who treated her commented that she had grossly oedematous arms and legs.
On day 10 the patient received nasogastric tube feeding (NGTF) and was started on a low-energy feeding regimen (30 ml/hour for 16 hours) to avoid refeeding syndrome (RFS).
Intravenous fluids were continued for 1 day, and on day 2 of NGTF, serum magnesium was found to be low; 8 mmol of magnesium were given intravenously.
On day 3 of NGTF , the patient's respiratory function deteriorated, her antibiotics were changed and the feeding rate was increased to 75 ml/hour. The patient's phosphate had fallen to 0.5 mmol/L.
A further 6 days later, the patient pulled out the her feeding tube on the day she was judged clinically to be dying.
Intravenous fluids were discontinued and the LCP (Liverpool Care Pathway) was used to support her care.

Within 4 days she she had dramatically improved, was no longer oedematous or breathless, and was asking for a cup of tea. The LCP was discontinued.
However the patient continued to be at high risk of aspiration, so she was again kept NBM; as she refused NGTF, IV fluids were restarted to avoid dehydration.
Two days later, the patient deteriorated again and seemed clinically to be dying. She was again supported by the LCP and IV fluids were stopped.

Ten days later, the patient had improved so much that she started to eat and drink for pleasure - despite the high risk of aspiration.
The patient was eventually discharged to a nursing home, where she died 10 months later.


This is defensive protocol medicine as practised in NHS hospitals. This old patient suffered the misery of all this intervention because the admitting doctor followed a protocol which said nothing by mouth - not even water or tea - until the risk of aspiration was evaluated by a speech and language therapist, who came 4 days later.
Note that her gross oedema was reported by a physiotherapist. Where was the ward sister, where was the house physician, where was the consultant in charge of her case? Was there any continuity of care, or was she managed by a succession of doctors on the "Medical Team"?
But the doctors did pick up her low serum magnesium. And no doubt all the boxes were ticked on the "Care Plan".

Words fail me. Is good, intelligent medical practice now made obsolete by fear of responsibility?
I'm glad I'm out of it.