stripping the willow

‘I’m so sorry to disturb you, Jeffrey. My name’s Jim. I’m with the Rapid Response Team and I’ve been sent in to see how you are.’
‘That’s all right, mate,’ he says. ‘You do what you have to.’ Then he closes his eyes and falls immediately back to sleep.
Jeffrey is a hundred and one years old. He’s lying in the foetal position in bed, his left hand crooked under his head, his right hand resting on the outside of the duvet up near his face, like his thumb just slipped out of his mouth. Jeffrey was discharged from hospital this evening after investigations for a GI bleed. He’s been in a fair bit recently, what with one thing and another. They’re still not sure about the bleed. They’ve booked him in for more tests. For now, he was discharged back to his warden controlled flat earlier this evening, carers four times a day, one late at night.
He’s been referred to us to keep an eye on things.
‘Do you have any pain, Jeffrey?’
He opens his eyes again.
‘Only you,’ he says. ‘I’m kidding, mate. I’m grateful for all you’re doing.’
‘Any more vomiting?’
‘Nah. They jabbed me in the arm with somink. It seems to have done the trick.’
‘Great. I’ll be as quick as I can so you can rest.’
‘You carry on,’ he says, and falls asleep again whilst I feel his pulse.
All his obs are south of where they should be, and it’s frustrating not to have a record of his baseline. I’d guess he’s probably stable, but it’s tricky when I’m the last clinician to see him. When I’ve finished the examination I write up the results and wake him up one last time.
‘I’m a bit worried about you, Jeffrey.’
‘Me? I’m all right.’
‘Your oxygen levels and your blood pressure are a little on the low side….’
‘I just want to rest. That’s it.’
‘I know, but – would you mind if I called the out of hours nurse to come in and see you later?’
‘Nah. I’m all right. I’ve got the carers at ten. If anything happens in the meantime I’ll press my button. Just let me sleep now.’
‘Okay, Jeffrey. I’ll have to let my boss know what’s what, but I’ll clear off now and let you rest.’
‘Thank you. Could you put that light out when you go?’
I close the door quietly.

Back out in the car I phone the Co-ordinator and tell them what I’ve found.
‘He’s worn out,’ I say. ‘He doesn’t want anyone else going in. He just wants to rest.’
‘I don’t think so. Not with obs like that. We’ll have to get the out of hours in.’
‘He’s got a DNACPR,’ I add, hopelessly.
She makes a note. A DNACPR is specifically about resuscitation, of course, and has no bearing on whether or not he receives treatment for anything other than cardiac arrest. She doesn’t suggest a night sitter because they’re in huge demand and mainly for falls risks. Jeffrey won’t be getting out of bed, so at least he’s safe in that respect. It’s a shame, though. I don’t know what the OOH will do when they go in. With obs as poor as Jeffrey’s, it’s touch and go whether he’ll simply be readmitted. Not because the hospital will necessarily do anything, but because the OOH won’t feel able to leave him at home. I don’t know why he’s been discharged knowing all this – but then, of course, I really do. The relentless squeeze on bed space at the hospital means something has to give. In this case, it’s Jeffrey.

I don’t know what his family situation is. Coming in cold like this, it’s difficult to get much more than a snapshot of his care provision, family circumstance. I have no idea who might be available to come and sit with him in a chair by the bed, to hold his hand, or smile at him when he opens his eyes, another human being to be with him in the small hours of the morning. I don’t have the space, the time or the wherewithal to do anything other than report the bare, clinical facts of his observations. And all the Co-ordinator can do is pass them on to the OOH. And so it goes on, the dance of Clinical Responsibility, Stripping the Willow in a particularly fraught and exhausting Ceilidh, where you don’t link arms but swap obs sheets, person to person to person, all the way to the hospital and back again, with no-one able to break the chain, to step aside and sit down next to Jeffery and say ‘All right, mate? Let’s sit this one out.’

2 thoughts on “stripping the willow

  1. Tricky isn’t it Jim.All of you in the NHS have an over-riding desire to make everyone better.That,combined with paper work and the fear of blame leaves common sense out of the window.Jeffrey’s stats are bound to be a bit iffy at 101,but he’s made it through many a night before and will no doubt continue to do so.

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  2. What strikes me most is the lack of continuity in his care. The NHS is so fragmented, so many different agencies doing much the same thing. I don’t doubt his obs were as poor as I found, but without a clear note to that effect, with guidance on what the plan is, he’s doomed to have a succession of clinicians worrying about whether he should ‘go in’ or not. A combination of wanting to do the best for the patient and a fear of litigation. It’s not a situation that’s conducive to good patient care, though. And it’s very expensive….

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