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Hospitals and the ‘Bad’ Death

Medical Director for NHS Dumfries and Galloway talking about bad death and hospitals (Video)
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Dr Marian Krawczyk: We’re here with Dr. Ken Donaldson, medical director for the NHS Dumfries and Galloway in Scotland. Ken has been kind enough to share some of his experiences of being a medical director that includes an acute care hospital in Dumfries. Ken, why do you think hospitals are equated with a bad death?
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Dr Ken Donaldson: Going back maybe 20, 30 years, to come into hospital and spend a week, two weeks was really normal. These days, the best rule is to have just a matter of days, and then either back home or out to a setting in the community. But our demography has changed, and patients have multiple comorbidities. They may have heart failure, kidney failure, other organ failures. And when they present, they are complex. But the way the hospital is set to work, we’re still looking for a diagnosis, something we can treat, some way we can make people better. But often, that’s really not possible.
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These patients then end up staying in the hospital for a period of time, perhaps having many tests and different treatments, but actually, they are reaching the end of their life.
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Dr Marian Krawczyk: How has this continued to change in the last decade or so?
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Dr Ken Donaldson: We have an ageing population of people who have multiple comorbidities. And that makes their presentation in an acute hospital more complex than it was, say, 15, 20 years ago. I can remember myself when I was doing medical receiving, the patients who came in when I was a junior doctor had a heart attack or a stroke, or exacerbation of a COPD. And I think this has changed over the last 15 years for many factors. There’s a lot of good secondary prevention that’s preventing death at an earlier age. People are living longer, but they can have this burden of comorbidity. Along with a change in demography, we’ve seen a change in our workforce.
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And we are struggling to– well, for a while and still is doctors, but also nurses and HPs and pharmacists. So there’s a difficulty in recruiting all these health care professionals, and that puts an extra strain on our staff, in that they perhaps don’t have the time to really get into some of the detail with patients. And with numbers increasing through the front door, that can lead to just trying to process patients quickly to get to the problem, move them on, and we’re not really dealing with the actual heart of the matter which might be somebody who’s reaching the end of their life.
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Dr Marian Krawczyk: I’m wondering if you can speak a bit about what specific characteristics might make a death bad or good from the patient and family member perspective in the hospital.
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Dr Ken Donaldson: Often, I’ve seen many families in particular, speaking from the bereavement phase. And the anger is that we didn’t know Mum or Dad was dying until the day before, when they told us then she died. But we looked back and we realised she’d been dying for weeks, but we didn’t have the time to say goodbye and process that. And I think that that’s that important, that palliative approach, which can still– you can still be doing the odd test and be thinking about treatment. But if you’re thinking, well, perhaps this patient is reaching the end of their life, you can have an honest conversation with both patient and family that can aid that journey.
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Dr Marian Krawczyk: Clinicians can have a hard time because individualising care can be challenging. So I’m curious from your perspective, for you to talk about some of those differences and how clinicians and the system negotiate that.
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Dr Ken Donaldson: Everybody has a different take on what they perhaps see their own death being like, and I think that can often change through time, as well, that people may say, oh this is– you know, I want to die at home and I want this, but actually as it comes nearer and there perhaps is a bit of fear of it being at home, then it may change. The important thing for our clinical colleagues is recognising that individualism and treating every patient as that single person, what it is that they want, what matters to them? And the difficult bit, and I feel this myself, having done it for many years, is getting beyond what I think is the right thing.
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It is what they believe is the right thing, and ensuring that we share a bit of each other so that I know what it is matters to them, and they perhaps understand what my specialist experience in this area is, so that we can do the right thing for each individual patient and their loved ones.

Here are some of the key messages that emerge from this topic. What do you think? Did you pick out any others? Please share your thoughts with other learners in the comments below.

Key Messages:

  • A key theme unifying the concept of a bad death is the dying person’s loss of control over the dying process.

  • It is often difficult for hospital care providers to judge when someone is sick enough to die.

  • Hospitals are often equated with a bad death.

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