Dying at home 498 \200 Don \200\231t touch me! Don \200\231t question me! Don \200\231t speak to me! Stay with me! Estragon; Wait- The UK death rate is 12 : 1000/yr, or 30 deaths/GP/ yr. 65% die in hospi tal, 10% die in hospices, public places, or on the street, and 25% die at home. Of these de aths at home over half will be sudden. In the remainder, the GP and the palliative care tea m has a central role to play in enabling a digni \201 ed death in the way the patient choo ses. Pain relief and symp- tom control are the central preoccupations of death in hospices, where death has already been somewhat medicalized, but in those who choose to die at home there often runs a \201 erce streak of independence, so that their main aim is to carry o n with the activities of normal living, come what may. This may cause distress to relatives who feel that the dying person is put- ting up with unnecessary pain. An open discussion i s often helpful in harmoniz- ing the family \200\231s aims. A key step is to \201 nd out what a patient wants \200\224and then to enable him to do it. Be aware that aims change ove r time. The next step is to \201 nd out about his hopes and fears and how they interact w ith those of the family. Is your patient dying? This is a key question. Failure to ask it, and to discuss with the mulidisciplinary palliative care team, may consign your patient to a painful unplanned death. Break this question into 6 parts: 1 Is there a fatal disease tha t is advancing? Check histology; any rising LFTs etc? 2 Is the patient \200\231s response w eakening? Comatose? Obtunded? Cachexia? Un- responsive? Unable to swallow? Labored breathin g? Assess over time (min- utes, hours or days). Don \200\231t base decisions on a single sn apshot. ing for Godot Helping agencies \200 Family \200 Community nurse \200 Hospice/night nurses \200 Fr iends/neighbors \200 GP/health visitor \200 Pain clinic \200 CRUSE (self-help group) e r a c y r a m i r P 3 Have reversible causes been \201 xed? (eg drug overdose Ca2+, OHCM p690). 4 Is he in \200\230do not resuscitate \200\231 territory? Dialog (family & patient) is wise. This helps stop inappropriate monitoring, such as blood glucose tests. 5 What does your instinct say? Spend time with the dying to hone our instincts. 6 What do o ther members of the palliative care team (and the family) think? Pain See p500. Morphine is the standard choice. Fentanyl has a role (good in renal failure; doses don \200\231t accum ulate). Skin patches last 72h. It may cause less sedation and constipation than morphine. T rans-mucosal lozenge forms exist. 133 Bereavement is the process of adapting to a loss whic h is causing sorrow. When trying to help bereaved people bear in mind where they are on Wor den \200\231s journey: 1 Numbness and denial until the fact of loss is accepted 2 Experienc - ing grief, yearning, and pain1 ( somatization) 134 3 Adapting to a new environ- ment wi thout the deceased 4 Redirecting the positive feelings towards the deceased in building a b righter future. It is often tempting to try and \200\230do some- thing \200\231 by giving psychotropics, but it is known that most bereaved people do not want this, and there is no evidence that drugs reduce problems. Empathy and helping the patient to shed tears is proba bly the most valuable approach, especially when losses are covert or hard to acknowledge. C ounseling after bereavement is eff ective. 135 After bereavement, risk of death in spouses rises in the 1st 6 months (men) or in the 2nd year (women). Men and younger bereaved are at greatest risk. It is not known whether this is due to shared unfavorable environments or t o psychological causes (eg mediated by the immune system). The main causes of death are vas cular, cancer, accidents, and suicide. 136 1 \200\230There is in this world in which everything wears out, everything perishes, one t hing that crumbles into dust, that destroys itself still more completely, leaving behind st ill fewer traces of itself than Beauty: namely Grief \200\231. 137 M Proust 1925 Albertine Disparue. NB: Proust \200\231s view is clear enough for grief surviving down generations \200\224which it does not. But what of one person \200\231s grief? Surely this can last a l ifetime, and Proust is wrong? No: we must assume that Proust had in mind an image from G r ard de Nerval (p397, the man with the pet lobster) who describes grief as being carved into us, not like lettering on stone, which may be worn away by time, but like those initials w e carve into the bark of a living tree. As the tree grows, the lettering sinks ever deeper, so that it seems to disappear, but really it has been embodied (Richard Holmes on G rard de Nerval in Footsteps 1996 HarperCollins, p222). Activities which we should try to avoid 138 \200 Distancing tactics: \200\234Everyone fe els upset when there is bad news, but you \200\231ll 499 soon get used to it. \200\235 False reassurance: \200\234I am sure you will feel better; we have good antiemet- ics these days. \200\235 Selective attention: \200\234What is going to happen to me? I \200\231m beginning to think I \200\231m not going to get better this time. The pain in my hip is getting worse. \200 \235 Doctor: \200\234Tell me more about your hip. \200\235 Breaking bad news Bad news is any information that drastically alters a patient \200\231s v iew of their future for the worse. Patients have a right to such knowledge, but not a duty to receive it, so negotiation is needed to agree the type of information and the amount the y want to hear at any moment. The advantages of patients being aware of bad news are: \200 It helps maintain trust in those caring for them. Trust is what the bedside manner is all about. \200\234Trust is necessary precisely where we cannot be cer- tain. If we had certa inty, we wouldn \200\231t need to trust. \200\235 Onora O \200\231Neill Reith lecture \200 To reduce uncertainty. \200 To prevent inappropriate hope. \200 To allow appropriate adjustment. \200 To prevent a conspiracy of silence. The central activities in the breaki ng of bad news are:139 e r a c y r a m i r P 1 Preparation \200\224choose a quiet place where you will not be disturbed. 2 Find out what the patient already knows or surmises. 3 Find out how much the person wants to know. You c an be surprisingly direct about this. \200\234Are you the sort of person who, if anything were amiss, would want to know all the details? \200\235 4 Fire a warning shot. \200\234I am afraid I have bad news. \200\235 5 Allow denial. 6 Exp lain (if requested). Share information about diagnosis, treatments, prognosis, and speci \201 cally list supporting people (eg nurses) and institu- tions (eg hospices). Ask \200 \234Is there anything else you want me to explain? \200\235. 7 Listen to concerns. 8 Recognize and encourage ventilation of the patient \200\231s feelin gs. 9 Summarize and make a plan. 10 Off er availability. The most important thing here is t o leave the patient with the strong impression that, come what may, you are with him or her whatever, and that this unwritten contract will not be broken. Useful agents in terminal care1 Useful agents: 1) GI problems Diarrhea (post radiation): Lo w-residue diet. Constipation: Co-danthramer capsules or liquid bisacodyl 5 \200\22310mg at night. Cachexia: Prednisolone 15 \200\22330mg/day or dexamethasone 2 \200\2234mg/day PO may help by \200\200 appetite. Gastric irritation eg associated with gastric carcinoma \200\224proton pump inhibit- ors (omeprazole 20mg/24h PO) or H2 antagonists (eg ranitidine 150mg/12h PO). 500 Itch in jaundice \200\224Ondansetron 4mg/14h PO. Pain with dysphagia or vomiting: Buprenorp hine sublingual 0.2 \200\2230.4mg/8h. Not a pure agonist. \200\230Ceiling \200\231 eff ect s negate dose increases. Foul rectal discharges: Metronidazole 500mg/8h PR. Vomiting: Cycli zine 50mg/8h PO, IM, SC. Haloperidol (p360) 0.5 \200\2232mg PO. If this fails, try levomepr omazine, below If from inoperable GI obstruction, try hy- oscine hydrobromide 0.4 \200\2230 .6mg SC/8h or 0.3mg sublingual. Octreotide, max 600 g/24h SC via a syringe driver may avoi d the need for palliative surgery, IVIs and NGTs. If from gastric stasis: Metoclopramide 10 mg/8h PO/SC. If this fails, try domperidone 60mg/12h PR. Herbal remedies (eg ginger) may be tried. 2) Lung problems Optimize COPD care (eg tiotropium 18 g/d via Handihaler ) Air hu nger: Chlorpromazine (eg 12.5mg IV). Rattles: Hyoscine 0.4 \200\2230.6mg/8h SC or 1mg/72h a s Scopoderm TTS patch. Glycopyrronium 0.6 \200\2231.2mg per 24h by syringe driver \200 \201 secretions and helps colic. Dyspnoea: (hypoxic) \200\224Table fans supplemental hum idi \201 ed oxygen. Haemoptysis: Diamorphine, above; IV if massive. Pleural effusion: Thor acocentesis (bleomycin pleurodesis). Pleural pain: Intercostal nerve blocks may bring lasti ng relief. 3) Cardiovascular problems Distension from ascites often causes distressing symp toms. Try spironolactone 100 \200\223200mg/24h PO + bumetanide 1 \200\2235mg/24h PO. 4) GU problems Foul vaginal discharges: metronidazole vaginal gel. 5) Psychological problems Agit ation \200\224Try lorazepam half a 1mg tablet sublingually, or haloperidol (p360) 1 \200 \2233mg PO (may help nightmares, hallucina- tions, and vomiting too). Or midazolam in syrin ge drivers (eg 20 \200\223100mg/24h SC) \200\224or levomepromazine 12.5 \200\22350mg IM sta t or 12.5 \200\223200mg/24h SC via a sy- ringe driver. NB: some drugs cause local skin irri tation when used with a sy- ringe driver: avoid chlorpromazine, prochlorperazine, and diaze pam. 6) Others \200\224Coated tongues may be cleaned by 6% hydrogen peroxide, chew- ing pin eapple chunks to release proteolytic enzymes, sucking ice, or butter. If oral thrush use \202 uconazole 50mg/24h for 7 days. Superior vena cava or bronchial obstruction, or lymphan gitis carcinomatosa \200\224Steroids; dexamethasone is most useful: give 8mg IV stat. Tabs are 2mg ( \211\210 15mg prednisolone) NB: dexamethasone given at night can prevent sleep. Appetite low, or headache due to \200\200ICP \200\224Steroids; most useful is dexa- methas one, eg 4mg/12 \200\22324h PO to stimulate appetite, reduce ICP, and in some patients induc e a satisfactory sense of euphoria. \200\207Before leaving the bedside Have I diagnosed all symptoms? Are the bow- els working? Is hypercalcaemia present? What is plan B, eg if h e cannot absorb MST, are patches (eg fentanyl) in the house? Are parenteral anti-emetics av ail- able (eg cyclizine 50mg)? Have you asked for hospice and district nurse help? e r a c y r a m i r P 1 UK patients and relatives may get much support via BACUP (Brit Assn of Cancer United Pati ents, 3 Bath Place, Rivington St, London, EC2A 3JR, tel. 020 7613 2121). cancerbacup.org.uk /home. In the UK, Social Services can fast-track applications for \201 nancial help in th e form if prognosis <6 months 501 Examples of dose ranges and how to provide total sedation Pain has physical, emotional, and spiritual components: all aspects need ad- dressing. What follows assumes that the patient is dying from an incurable disease, and that they want to be at peace, with no suff ering, and that total se- dation is preferred. Know your patient \200\231s desired place of death well in advance. \200 Prescribe within established guid elines (such as the Liverpool Care Path- way Gold Standard). Document that each dose increase is proportionate, and plans have been dis- cussed with an experienced colleague, and take into account GMC guidance. \200 Be proactive: diagnose an d monitor each pain separately. The prescriber (you?!) must take charge, and be responsible for complying with patients \200\231 wishes, the law, and making judgments about patients \200\231 capacity to take informed decisions. e r a c y r a m i r P To comply with patients \200\231 wishes to be kept peaceful, doses may need to be at least doubled every 12h (if on a pump, increased by 5 \200\22350% every few hours). 140 Active ma nagement of death may need these geometric increments to avoid suff ering. If you start wit h 10mg morphine/12h, and the need is for 200mg/12h, you are consigning your patient to week s of misery if you use 5 \200\22310mg increments, but if you double doses every 12h while y our patient remains distressed, control takes a few days at most. Your prescription must al low for this, and nursing staff must be brought in on decisions, with the rationale agreed at each handover. \200\234This is what the patient wants \200\235 not \200\234This is wha t the doctor says \200\235. Don \200\231t be frightened to use big or very big doses if smaller doses are not working. It \200\231s whatever is needed; this is very variable. While \201 nding avoid transderma l drugs (dose escalation is slow and ineffi cient. 141 \200 Non-opiate analgesia may espe cially help bone pain (ibuprofen 400mg/8h PO or diclofenac + misoprostol (Arthrotec ), 1 t ablet/12h PO.) Pamidronate may also relieve pain from bony secondaries (OHCM p672). Nerve d estruction pain: Amitriptyline 25mg PO at night clonazepam 0.5mg/24h, increased to 1 \200\2232mg/8h. Resistant pain: nerve blocks may help. \200 Opiate dose equivalence: Diam orphine PO: 2mg \211\210 3mg morphine. SC: 1mg diamorphine \211\210 1.5mg morphine. Susta ined release morphine is available, eg MST-30 or MXL (lasts 24h). Use syringe drivers SC or suppositories if dys- phagia or vomiting make oral drugs useless. If crystallization occ urs with drugs mixed in syringe drivers, either \200\200 dilution, or use 2 syringe driver s. \200 Transdermal patches are also useful, eg fentanyl (last 72h: typical start- ing do se for someone needing the equivalent of 90mg morphine/day would be one fentanyl-25 patch (the 25 means 25 g fentanyl/h; 50 \211\210 135 \200\223 224mg MST, 75 \211\210 225 \200 \223314mg morphine/day and 100 \211\210 315 \200\223404mg morphine/ day). Use non-irritate d, non-irradiated, non-hairy skin on trunk or upper arm; remove after 72h and replace by an other patch at another site. \200 Modi \201 ed-release morphine sulfate: 10 \200\223260m g/12h. 140,142,143 Oxycodone is an alternative, eg Oxycontin . In one study, the mean dail y OxyContin dose was 80mg/d. 20% need at least 3 times as much. 144 \200 Parenteral mo rphine: 2.5 \200\223100mg/1 \200\2234h SC. For larger doses use a pump or diamorphine (very soluble, so volumes can be very small). If the problem is distress or dyspnoea, midazolam (5mg/4h sc) + morphine rescue doses may be best. 145 On demand doses are typically 25% of t he background dose. If many rescue doses are needed, increase background analgesia by \200 \20650%. 146 In one study, 91% needed 5 \200\223299mg of morphine/day), 7% needed 300 \200 \223599mg/ day, and 2% needed \200\206600mg of morphine/day. 147,148 Morphine doses SC via a syringe driver range from 0.5/h to 300mg/h. 149 Example of dose escalation: if 10mg/h is not working, give a bolus of 10mg, and then increase the rate by \200\20650% (15mg/h). If distress continues, re-bolus with 15mg, and \200\200background to 22mg/h and so on until full comfort is achieved. 150 It often helps to add mida- zolam 0.8 \200\2238mg/h; 151,152 the buccal route works too: 153 Buccolam 5mg/mL. NB: validated protocols for dose escalat ion are absent. 154 ! ! e g a r u o c n o B \200\235 ! m e h t h t i w y l p m o c n w o n k e r a s w e i v s \200\231 t n e i t a p e h t f I \200\234 : m i x a m g n i d n u o s - c i t a r c o p p i H ) ? ( e l b a t u f e r r i t n e i c n a e h T Records, computers, and decision support \200\207We cannot make ourselves better people by using a system or a machine: re \202 ection, dialog, and action are more likely routes to self-improvement. From 2015 all UK patients will have the right to view their primary care records on-line. Problem-orientated records \200\224List problems as \200\230inactive \200\231 Eg \200\230breathlessness \200\231 (not \200\230?bronchitis \200\231 \200\224or \200\230Down \200\231s syndrome \200\231, which may be un- problematic to the individual, but a problem to us \200\230normals \200\231. Use \200\230SOAP \200\231: Subjective inter pretation: How the patient and/or carer sees the problems. Objective: Physical examination and results of tests (not always objective!). Assessment: Social, psychological, and physic al interpretation. Plan: Do the following tests \200 \200\231 or \200\230Wait on events \200\231; treatment: eg \200\230Start psy- chotherapy \200\231 and explanation \200\224not e what the patient has been told. Internet records Could our health records be like Faceboo k? Yes. We allow various specialists to be friends and join in conversations, so that our r ecords are under our control and always available. See www.patientsknowbest.com. Computers with limited connectivity These give faster links (lab, hospital, GP). Computers automatica lly scan patients \200\231 records so that we are alerted via pop- up boxes, eg \200\230No BP in last 3yrs \200\231 or \200\230Has heart disease & chol. >5 & not on statin \200\231 etc. 155 This development, linked to payment by results/quality markers in the GP contract uk of 2004, has improved care in asthma, SCR may be good if you are: diabetes, and heart di sease (MI rates are is fall- \200 Needing emergency care ing faster in the UK than in any other European \200 On complex treatments country). 156 \200\223158 \200 Being seen ou t-of-hours \200 Demented/confused/deaf NHS extranet/summary care record (SCR) The \200 Fed up with repeating idea is that NHS staff anywhere can access data held centrally on the \200\230NHS spine \200\231 to \201 nd out about current drugs, allergies major illne sses. These are updated nightly via GP and other sources. \200 Security is untested \200 \224a major problem. Record access is logged, and NHS staff using smartcards to access reco rds without need may be \201 red. 502 \200\230active \200\231 or e r a c y r a m i r P name, date of birth.etc, etc Disbelieved by doctors \200 Wanting 2nd opinion (you can print off your records) Public unease with SCR \200 Malicious access \200 Mistaken identity \200 Blackmail \200 Staff errors could lead to Consent is presumed: opt-out is by discussion with the GP who adds code 93C3 to the record. Decision support 35 webmentorlibrary.com (WML) is part of EMIS systems, with >25,000 key-w orded facts connected by an intelligent index 160 linked to the medical record via Read/SNO MED codes to en- able explanation of apparently unrelated phenom- ena \200\224such as RASH & DEPRESSION & CONSTIPATION. See BOX below. gross inaccuracies NHS may sell data for cash \200 Incomplete if secret items omitted (eg HIV statusetc) Expensive to maintain \200 No tangible health bene \201 t \200 Bias against those who don \200\231t register with a GP Mentor gives this reasoning to explain why sarcoidosis is one match \200 Sarcoidosis freq uently results in rash. \200 Depression is commonly a feature of sarcoidosis. WML explana tion: sarcoidosis can result in neuropathic pain neuropathic pain can result in depression. Constipation is commonly a feature of sarcoidosis. WML explanation: sarcoidosis can result in hypercalcaemia hypercalcaemia can result in constipation. Other matches HIV, Whipple \200\231s disease, adrenal metastases, Cockayne syn \200 To sup port or \200\230refute \200\231 these, look for: arthritis, dactylitis, ptosis, ascites, d ementia, premature aging, splenomegaly, failure to thrive, weight loss \200 (If one is pre sent, click it to add it to the search, and so narrow the \201 eld.) This page intentionally left blank Medline 14 million abstracts & full text links free at www.ncbi.nlm.nih.gov/entrez We all n eed to know about Medline \200\224it \200\231s a skill as basic as taking blood \200\224but easier. The lucky-dip method is good, but undiscriminating: just enter any- thing in the s earch box, and press the \200\230go \200\231 button. A natural-language inter- face (AskME DLINE) also exists at www.askmedline.nlm.nih.gov/ask/ask.php. 161 If this is all you want a nd you want full-text, the best site is www.highwire.stanford.edu. 504 \200 This page aims to help if you want to be sure you are not missing some- thing (and want to cut down irrelevant hits). If Medline is new to you, \201 nd an Internet connection and a n experienced friend and try the searches below in GREEN CAPITALS. When you click the \200 \230go \200\231 button, the system tries to match your search to a nomenclature of medical subheadings (MESH terms). To ex- plore alternative therapies for angina: type ANGINA AND TH ERAPY (use capitals; \200\207check your sfzpelling!); click \200\230go \200\231, then the \200\230details \200\231 button to show that this is mapped to (( \200\230angina pectoris \200\231[MESH Terms] OR angina[Text Word]) AND (( \200\230therapy \200\231[Subheading] OR \200\230therapeutics \200\231[MESH Terms]) OR therapy[Text Word])). There are >45,000 hits . Adding AND RANDOM* to the search phrase (a star gets randomized, randomized, etc but also authors whose name starts with Random ) narrows these to <7000; adding COMPLEMENTARY bef ore the word THERAPY gives <400 hits. Square brackets The contents of these limit or expand the search. Most- ly, let Medline do this for you, as in the above example. But there are some square brackets it \200\231s useful to add to the search yourself. For example, ANGINA AND BMJ gives (( \200\230angina pectoris \200\231[MESH Terms] OR angina[Text Word]) AND BM J [All Fields]). There are <90 hits; but searching on ANGINA AND BMJ [JOUR- NAL NAME] (exac tly like that) automatically maps to (( \200\230angina pectoris \200\231[MeSH Terms] OR ang ina[Text Word]) AND ((( \200\234BMJ \200\235[Journal Name] OR \200\234Br Med J \200\235 [J ournal Name]) OR \200\230Br Med J (Clin Res Ed) \200\231[Journal Name]) OR \200\230BMJ \200\231[Journal Name])) This yields >500 matches, ie MESH expands as well as limit your se arch. Other useful things to put in square brackets relate to authors [AUTHOR], publication dates [PDAT] and publication types [PTYP] \200\224eg entering ANGINA AND RANDOMIZED CONTRO LLED TRIAL [PTYP] AND BLACK DM [AUTHOR] 1996 : 2013[PDAT] gives a search which doesn \200 \231t include articles using common words such as black, and goes from 1996 to now. Using R andom* may be more inclusive than using RAN DOMIZED CONTROLLED TRIAL [PTYP], but will inclu de sentences such as \200\230there are no randomized trials \200\231. Finding MESH heading s You can make search terms more certain by select- ing them via the MESH browser button \200\224look carefully: it \200\231s in the left-hand blue margin, half way down. Typing in to the search box yields MESH terms which need no mapping. If no exact term is found, choos e a likely one from the list off ered, and press the \200\230browse term \200\231 button. Click the \200\230Add \200\231 button to add this to your search. Try this with SMALL VESS EL ANGINA. This is not a MESH term, but the MESH browser off ers angina, microvascular, amo ng a host of other less helpful possibilities. Con \201 rm this for yourself. Other ways o f lim- iting searches: Click the \200\230Limits \200\231 button to explore this, or add a word such as HASABSTRACT (one word, no space, added to the search phrase) to retrieve only articles having abstracts (this excludes editorials and correspondence items). \200\234HUM ANS \200\235 [MESH] excludes animal research). An example of Boolean logic: try NIFEDIPINE AND (AMLODIPINE OR FELODIPINE) NOT PRINZMETAL ANGINA [MESH]. This excludes studies of Prinz metal \200\231s angina. EBM Try ANGINA AND COCHRANE NOT COCHRANE[AUTHOR] or ANGINA AND META -ANAL- YSIS , or try the clinical queries button. Choose \200\230sensitive \200\231 to avo id missing possible hits, or \200\230speci \201 c \200\231 if you are getting too many hi ts. Exercises Now you \200\231ve got the idea, recall your last 6 patients and \201 nd me ta- analyzes relevant to them. Why are my searches going wrong? \200 Mis-spell- ings? \200 Not using capitals (AND, OR, NOT)? \200 Using the wrong search box? e r a c y r a m i r P \201\201 Premonitions In the limelight we have the world of evidence-based medicine (p489) , Med- line, and the whole enterprise of objective science. In the shadows we have our prem onitions. It is absurd that we spend so little time thinking about them, when they govern a nd control so much of what we do as clinicians. Carl Jung said \200\234My increased knowle dge gradually permeated or repressed the world of intuitive premonitions \200 \200\235 \200\224and so it often seems. The more we know, the more we have to use our premonitions, in deciding how to use that knowl- edge and on whom. Often the objective world yields con \202 icting instructions such as \200\234Get this patient \200\231s blood pressure down \200\235 or \200\234Falls here might be fatal \200\224 we must avoid falls at all costs, a nd reduce blood pressure treatment \200\235. Our premonitions tell us which of the voices f rom the objective world to listen to. What is a premonition? Premonitions are warnings or f oreknowledge of as yet unspeci \201 ed events. They are the means whereby our subconscious noti \201 es us of danger. Listening to one \200\231s premonitions is an example of intui tive thinking. Intuition is a non-linear process of knowing, per- ceived through physical a nd emotional awareness, and its methodologies entail making subconscious physical or spirit ual connections. 162 Some premonitions we are born with (such as our expectation of monster s under the bed); others we acquire slowly during our clinical lives. These premonitions ar e worth billions to health services, which could not operate without them. Without them w e would have to be guided by blind pessimism. We would have to think: this pain in the toe could be due to ma- lignancy, and we must investigate accordingly. But if we grant our prem oni- tions full play, and combine this with statistical probability, we can become much mor e useful physicians. The above thinking can be reformulated as: it \200\231s very rare for toe pain to be the presenting sign of cancer so we can default to never thinking about this (so our minds remain uncluttered) \200\224until our premo- nitions send us a warning messa ge: \200\234I don \200\231t like the look of this \200\224I \200\231ve got a bad feeling \200 let \200\231s analyze this more \200 \200\235 There is nothing occult or paranormal a bout this: think of it simply as being eff ortless learning from experience. How can we hon e our premonitions? Some people object that this is like asking how we can sleepwalk more e ff ectively; but consider these methods. \200 Take every opportunity for feedback. What h appened to Mr Jones with non- cardiac chest pain which you thought might be cardiac after a ll, after seeing him smother his \201 st with his dominant hand while describing the pain ? \200 Ask yourself \200\234What did he mean \200 \200\230I \200\231ve never had pain l ike that before \200\231? \200\235 \200 Take time after every dozen consultations and ask yourself \200\234What clues did I respond to; which did I ignore? Am I feeling uneasy? \200\235 If you are, go back over the patients \200\224 \201 nd out what it is that is mak ing you uneasy, and con- sider re-contacting the patient for further exploration. 505 e r a c y r a m i r P Fig 1. Subclinical premonitions. Clinos is Greek for bed, so subclinical means, literally, under the bed. Don \200\231t stick to your guns \200\224come what may. Be \202 exible in revising your o pin- ions. Have a low threshold for admitting the possibility of error when you are detecti ng something moving in the shadows. Don \200\231t shun silences in consultations: this may be when we hear our premoni- tions b est. Try \200\234Let me re \202 ect on what you have said for a few moments \200\235. \200 Figuratively speaking, turn out the lights on all the workaday world of col- lecting and assembling data, so you can adapt to darker, less de \201 ned areas. \200 You can gi ve yourself thinking time or time for re \202 ection by taking longer than strictly necess ary during auscultation, say. By catching up with your feelings, you give your premonitions a chance to declare themselves. Audit Audit comes from the Latin audire \200\224to hear; and the term was once used for ver bally presented veri \201 ed \201 nancial accounts. Audit in clinical practice involves quality control by systematic review of an aspect of practice, implementing change and veri fying that the desired eff ect was produced. Its purpose is as a tool to achieve best quali ty clinical care. Audit means asking questions such as: \200\234Have we any agreed aims in medical practice? \200\235 and \200\234Are we falling short of these aims? \200\235 and \200\234What can we do to improve performance? \200\235 Audit is a part of the Summative As sessment required for all UK GP registrars/ST3 to pass before they can be principals. An 8- point audit is required. [See examples] 1 Title: When selecting a topic think: is it releva nt; common or important; measurable; amenable to change? For a registrar audit, is it simpl e? For other audits, is it worth the investment (of time and money)? Say why you chose the particular topic. [Does exercise improve diabetic control?] 506 2 What criteria were chosen: State why the criterion/criteria were chosen. [HbA1c will be used as a marker of diabetic care] 3 Setting standards A standard is a statement of a criterion of good quality care. A target should be set (the degree to which the criterion will be met). Choose a realistic and obta inable target. Aim for standards to be evidence based. [HbA1c <7.5% re \202 ects adequate control. Target to have >50% patients with HbA1c <7.5%] e r a c y r a m 4 Planning and preparation What have you done? For example, what lit- erature has been cons ulted (essential). [Consulted NSF (p523) for diabetes (literature): put all HbA1c results o n computer as they came in] i r P 5 First Data Collection Gather the evidence. Observe current practice. Com- pare this with the standard. [40% HbA1c <7.5%] 6 Implement changes [Implement vigorous exercise program] 7 Second Data Collection Compare with the standard and the \201 rst data col- lection. [Check patients received intervention? 45% HbA1c <7.5%] 8 Conclusions [Exercise works; target not reached] Use these to formulate your next title t o complete the audit cycle. [Better exercise intervention] Other people \200\231s audits ca n seem boring. It is only when a practice engages in audit itself that interest is aroused, and it can be satisfying to watch one \200\231s practice develop through a series of audit s. With computers, audits can be done on many aspects of care, to answer questions such as \200\224Is our care of diabetics adequate? Are all our fertile female patients rubella-immu ne? The practice manager can have a central role in running an audit exercise \200\224 eg by re lieving doctors of the burden of data collection and is able to commu- nicate the results o f the audit in a practice \200\231s annual report. Possible dangers of audit (No interventi on is without side eff ects.) \200 It takes time away from eye-to-eye contact with patien ts. \200 In becoming the province of professional enthusiasts, it can alienate some practice members, who can then ignore the results of the audit. There is no guarantee that audit will improve outcomes. \200 It may limit our horizons \200\224from the consideration of the vast imponderables of our patients \200\231 lives in a world of death, decay, and rebirth \200\224to a preoccu- pation with attaining tiny, spec i \201 c, and very limited goals. Some doctors fear that in espousing audit they risk transforming them- selves from approach able but rather bumbling carers and curers who per- haps don \200\231t know exactly where t hey are going, into minor administrative prophets, with too much of a gleam in their eyes a nd zeal in their hearts. 507 New ways of extending primary care: two models As we move away from providing care in expen sive high-technology hospi- tals, more is expected of primary care, with implications for c apital expendi- ture, acquiring new skills, and local access to procedures needing expensiv e equipment, eg endoscopy or ultrasound. Whole specialisms such as derma- tology and day-ca se surgery may move out of the secondary sphere, as the distinction between primary and sec ondary care becomes redundant. Antico- agulant clinics are another example of a hospital se rvice which \200\230might as well be done in the community \200\231. How are these develop ments to be structured (taking the NHS as an example)? What are the dangers and opportuniti es? Market-led models Well-capitalized companies take over running general practices, after winning provider contracts from primary care trusts. Such companies create free-standing p olyclinics (eg the Riverside Medical Center1). Alternatively, large supermarkets/pharmacies create in-store health centers. In both, GPs become salaried employees of the company prov iding services. Federated GP-led models General practices club together to purchase equipme nt and consolidate the new skills required. This is the model favored by the Royal College of General Practitioners (Roadmap) \200\224as providing the most \202 exible model which can rapidly adapt to local priorities 32 \200\224and cause the least disruption to existing services \200\224and maintain continuity of care. 163 Under this model GPs develop special interests and \200\230portfolio careers \200\231 play- ing to their strengths in both the clinical and administrative spheres in an increasingly complex health environment \200\224 in which they both commission and provide care. e r a c y r a m i r P Various kinds of federated GP models exist, from informal alliances to lim- ited companies owned and run by GPs, who hold shares in the company. 164 One thing held in common is that they are part of the NHS family, and share core NHS values of inclusivity, fairness and dis tributive justice. The primary motive for their creation is to maintain general-practice-ba sed primary care \200\224and the system whereby patients can see the doctor of their choice near where they live who stands a good chance of having known them for years. Pros and con s The RCGP cautions against developing polyclinics that focus on diseases and technical car e \200\224but it commend the value of co-location of services to reduce fragmentation. What ever models are adopted, the cardi- nal values of general practice such as interpersonal ca re and continuity of care based on de \201 ned populations must be given full weight. Support for registration of patients at multiple primary care outlets \200\224or even regis tration at A&E clinics or urgent care centers is occasionally fa- voured by some NHS and ot her governmental bodies. This may be desirable for some patients working away from their pr actice based location \200\224but such arrangements are bound to lead to expensive and frag mented care (this is why it is not RCGP policy). Also, registering patients with a single g eneral practice allows longitudinal care, lifelong medical records, con \201 dentiality, a nd team-based care to feed into a viable gate-keeping role. This gate-keeping role keeps co sts down and protects patients from over-medicalization. Quality control2 If a service such as INR testing is taken out of the lab and fragmented to a number of smaller community-bas ed clinics, quality control becomes problematic. Ditto for the validation of GPs with speci al interests. Con \202 icts of interest If a GP federation is a for-pro \201 t organizati on (with funds \202 owing from the NHS) and if the doctors are sitting on boards deciding on which services are to be commissioned, there is a con \202 ict of interest. The NHS is establishing procedures to minimize risk from this possibility \200\224but nev- ertheless, probity is a vital issue, for doctors as well as other NHS staff . 1 Clinics may share wit h \200\230sister surgeries \200\231 and provide on-site gynae, mental health, surgical, an d other clinics. 2 If a batch of reagents is faulty, the lab will be onto this at once, but who would know in the communi- ty if a batch of INR test strips was faulty? Perhaps only a fter a series of bloody deaths was investigated. Appraisal, assessment, and revalidation \200\207Appraisal isn \200\231t the same as assess ment. For NHS doctors (yearly appraisal is required) peer appraisal is moving beyond a chat about one \200\231s professional development. 5 areas to address (with data) are: How do I know my clinical care is good? Do I keep up to date? How do I come across to my colleagues and patients? Am I in dialog with my peers to ensure good use of resources (eg prescribing ; referrals)? What have I done about what I have learned? What form does UK appraisal take for GPs? There are 2 administrative forms (Forms 1& 2); then there is Form 3, needing thoug ht and data gather- ing (in protected time) \200\224with a commentary on your work, an acco unt of how it has developed since last year, your view of your developmental needs, and cat aloging of factors that constrain you in achieving your aims, eg: \200 What are the main strengths and weaknesses of your clinical practice? \200 How has the clinical care you pr ovide improved since your last appraisal? \200 What do you think are the clinical care de velopment needs for the future? \200 What factors constrain you in achieving your aims fo r your clinical work? \200 What steps have you taken to improve your knowledge and skills ? \200 What have you found successful or otherwise about these steps? \200 What profess ional or personal factors constrain your skills and knowledge? \200 How do you see your j ob and career developing over the next few years? \200 What are your main strengths and w eaknesses in your relationships with patients? How have these improved? What would you like to do better? What factors in the workplace (or more widely) constrain this? 508 e r a c y r a m i r P What are your main strengths and weaknesses in your relationships with colleagues? How have these improved? What would you like to do better? What factors in the workplace or more wi dely constrain this? Do you have any health-related issues which might put patients at risk? Other areas: Teachi ng; \201 nancial probity; research; management activities. During the appraisal Form 4 is completed and signed by both parties. Form 4 feeds through to Clinical Governance Leads, w ho identify trends and make re- ports to the Trust \200\231s chief executive. Form 5 is a n on-obligatory form containing background ideas supporting Form 4 which may be used to infor m other ap- praisals. Finally there is supportive follow-up (eg a further visit or phone ca ll).