Derek Willis

BMJ is not always impartial about the advertisements it includes

The BMJ prizes impartiality and is the official journal of the BMA. As the ethics committee of the Association Palliative Medicine, we were interested to see that the 16 November print issue of the BMJ contained an insert from Dignity in Dying promoting physician assisted …

Grumpy old ethicist

I am aware that I have picked two strands of Medicine that seem to have an image problem. As I discussed in the last piece, I deal with patients who I know are not going to get better. The second strand is ethics. Some say that medical ethics is just opinion, and rather than producing anything ‘useful’, ethics is accused of muddying (already muddy) waters and so, is inherently ‘useless’. Medical ethics is a branch of philosophy, and at its heart, philosophy attempts to describe good ways to live. Over 2000 years of thought have gone into this, and if the conclusions it reaches are complicated, it is because life itself is tricky, messy and complicated. Specifically for doctors, an ethicist would want to say that there is a right way to understand and to practice medicine. An ethicist has …

Tracey judgement and hospice DNACPR orders: steady as she goes or seismic change?

Objectives The 2014 Court of Appeals decision with respect to Tracey vs Cambridge University Hospital (‘the Tracey judgement’) changed the requirements for discussing Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions with patients. This study is a retrospective case note review aiming to identify any changes in practice around discussing DNACPR decisions in hospices following the judgement. Methods 150 case notes from 2013 (before the Tracey judgement) were compared with 150 case notes from 2015 (following the Tracey judgement). These notes came from five hospices in the West Midlands. The notes were analysed to determine if the judgement resulted in changes to how frequently DNACPR decisions were discussed with patients and their families, as well as whether there were any changes in the documentation of reasons for not discussing such decisions. Results Discussions with patients around DNACPR decisions increased from 31% to 60% and with relatives from 29% to 59% following the Tracey judgement. Prior to the judgement the most frequently documented reason for not discussing was to avoid distress (23%), whereas after judgement it was patients lacking capacity to engage in such a discussion (40%). There was a lack of consistency and clarity in defining the concept of ‘physical or psychological harm’. Conclusions Although DNACPR decisions are being discussed more frequently with patients and families following the Tracey judgement, clarity on what constitutes ‘physical or psychological harm’ caused by these discussions is still required. Future research must examine whether the judgement is delaying or preventing DNACPR decisions being made.

Conscientious objection—a way out for assisted suicide or a non-starter?

International Journal of Palliative Nursing 2017, Vol 23, No 6

P-189 Hospices working with commissioners – mutually beneficial or a necessary evil?

Background Hospices’ value within the third sector is in their specific strategic organisational capabilities. It could be argued that this potential is unrecognised and untapped. The specialist nature of the services that hospices provide and their financial independence and freedom to develop and invest in services place them in a strong position to influence NHS commissioning of services. This study uses the VRIN model to assess the organisation’s resources and to demonstrate the hospice’s specific strategic capabilities. (Barney & Hesterley, 2010). This study demonstrates how one hospice has successfully challenged commissioning intentions and evidenced a counter proposal which resulted in the funding and delivery of an enhanced Hospice at Home service. Aim To prove that increased provision of spells of Hospice at Homecare 24/7 would improve care and support the choice to be cared for and die at home and reduce hospital admissions. To demonstrate that patients who fit the criteria for Hospice at Home also fit the criteria for CHC funding and secure that funding for the expansion of service. Method Through semi-structured interviews we set out to evidence the true gaps in community palliative and end of life care and the approach to commissioning hospice services. Scoping of the views of the below: Phase 1 – Local GPs, community nurses and community. Phase 2 – Commissioners from 2 CCGs Phase 3 – Wider group of hospice directors (Survey Monkey) Results Counter proposal accepted Joint funding of Proof of Concept Increased numbers of patients supported at home. Hospital admissions avoided Engagement of CHC and funding agreed. Conclusion This study demonstrates the potential of hospice strategic organisational capabilities and the value of good relationships with commissioners that place hospices as equal, influential partners within a struggling economic and healthcare environment. This study demonstrates how one hospice has successfully challenged commissioning intentions and evidenced a counter proposal resulting in the funding and delivery of an enhanced Hospice at Home service.