A personal response to the Francis Report (Part 1)

7 Feb

Form filling and tick boxes

Do Not Attempt Resuscitation [DNAR] Form


End of life care is an important part of primary health care and general practice. There are strong ethical and moral arguments going back to biblical times to refrain from postponing inevitable death with futile treatment. For example, consider patient who is 93 years old and no longer recognises anyone because of dementia, and is always curled up in bed and seems to survive on vapours only because feeding is challenging. When this poor person has a cardiac arrest it is not ethically right to commence CPR.  Common sense supports this attitude too. However in our ever increasing secular world with fear death such a patient as this is too often treated aggressively because of fear of upsetting a relative. To avoid such conflict, “DNAR” orders now prevail throughout the health service.  The Liverpool Care Pathway for End of Life tells us how to use the DNAR properly because there have been concerns about abuses.  A standard form has been developed in NHS to further reduce any misunderstandings and permit even better deaths with fewer futile resuscitation efforts.

Figure 1

Source – Mt Vernon Cancer Centre

The problem – another form

The mission creep with forms should not countenanced.  We have enough to worry about without the insistence by jobsworths that their form MUST be used for whatever it is they are responsible for.

Doctors, especially General Practitioners already have allowed ourselves to be forced to use official forms for suspected cancer, chest pain clinic referrals, district nurse referrals, hospital transport requests, community COPD clinic, community diabetes clinic, dermatology Clinical Assessment and Treatment Service and many more.

I believe any referral a doctor writes the words matter more than whether or not they are written on a particular form. The words on a sheet of paper and signed by the doctor is a legal document.  In my opinion, anyone who fails to act on our request is interfering with patient care and ought to be penalised. This is supported by GMC guidance “Good Medical Practice: Duties of a doctor”.

Figure 2

Source – GMC Guidance on Good Medical Practice

Who or what will stand up for doctors to halt the onslaught of forms from all directions before my profession drowns under the weight and has even less time to do what doctors do best which is assess people who come to the Doctor for help with clinical problems?

My concerns are covered by Recommendation Number 5 of the Francis Report

Figure 3

Source – The Mid Staffordshire NHS Foundation Trust Public Inquiry

The Francis Report is nearly 1700 pages long; it was published on Wednesday 6th February 2013.  The Inquiry is established under the Inquiries Act 2005 and is chaired by Robert Francis QC, who will make recommendations to the Secretary of State based on the lessons learnt from Mid Staffordshire.  It will build on the work of his earlier independent inquiry into the care provided by Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009.

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