Do not resuscitate: final word is with medical staff, whatever patient feels
www.guardian.co.uk/society
The case of Janet Tracey who died in Addenbrooke’s hospital after family claims that a "do not resuscitate" order was put in her medical notes will, no doubt, encourage health managers to check how well staff and patients are acquainted with the use of such orders.
They have been given official notice to do so before. In 2000, the Department of Health in England reminded local trusts they must have appropriate policies. This followed warnings from doctors that junior staff lacked proper guidance and training and from the charity Age Concern that older people were being written off.
These warnings came after Jill Baker, 67, from Southampton, who had stomach cancer and was being treated for septicaemia, discovered after leaving hospital that a "do not resuscitate" order had been written in her notes by a junior doctor. Neither she nor her husband had been consulted.
Cardiopulmonary resuscitation (CPR) attempts to restore breathing or blood flow to those whose heart has stopped beating or who have stopped breathing. It can include using electric shocks to try to correct the rhythm of the heart, repeatedly pushing down firmly on the patient’s chest and inflating the lungs with a mask or tube inserted into the windpipe.
But while TV medical dramas may suggest it is often successful, statistics tell another story.
Only 15-20% who have such treatment ever go home, according to the British Medical Association (BMA), which, together with the Royal College of Nursing (RCN) and Resuscitation Council, offers professional guidance on when Do not attempt Cardiopulmonary Resuscitation (DNACPR) orders – to give them their full name – should be prepared.
Rib fractures and brain injury are significant risks, says the NHS’s policy guidance in Scotland while its leaflet for patients, relatives and carers says: "Most patients never get back the physical or mental health they had before they were resuscitated. Some have brain damage or go into a coma."
In an era when nearly seven in 10 people die in hospital – and most have "do not resuscitate" orders – there is increasing pressure for more mentally competent adult patients to help plan towards the end of their lives.
Adults can legally refuse medical treatment, even if that leads to their death. But the medical profession is also clear that doctors cannot be required to give treatment against their clinical judgment, although they should offer patients the chance of a second opinion, if possible.
The General Medical Council (GMC), last year said there was no absolute obligation to prolong life.
In 2005, it won a case on appeal brought by Leslie Burke who had a degenerative brain condition. He had claimed a legal right to artificial nutrition and hydration, come what may, rather than give doctors the ultimate say.
The GMC said the ruling meant that doctors had no legal or ethical obligation to agree to a patient’s request if they consider the treatment was not in the patient’s best interests.
The Scottish government is blunt on the issue. Its patient information leaflet says that while the healthcare team "must listen to your opinions and to anybody you want involved … you cannot demand treatment that will not work".
In England, where successive governments have trumpeted a mantra of patient choice, Andrew Lansley, the health secretary, has stopped short of a national policy.
The Department of Health told the Guardian: "Our end of life care strategy commended the joint statement by the BMA, RCN and the Resuscitation Council as a basis for local policy-making.
"There is a substantial amount of expert guidance available to assist those making complex decisions in discussion with other members of the healthcare team, the patient and their family."
Yet a number of soon-to-be abolished strategic health authorities in England want to harmonise policies across local care settings, including hospitals, hospices and residential homes.
In the words of Mike Richards, the government’s end-of-life czar, this "will minimise future problems with cross-boundary working by encouraging a consistent – or at least compatible – approach nationwide".
A draft East Midlands document, for instance, says that there should be sensitive discussion with patients who want to insist on resuscitation in an attempt "to secure their understanding and acceptance of the DNACPR decision".
It adds: "Although individuals do not have the right to demand that doctors carry out treatment against their clinical judgment, the person’s wishes to receive treatment should be respected wherever possible".
It will be April 2013 before the recently published regional policy in the East of England, where Addenbrooke’s is based, is fully implemented in all its trusts.
It says: "A patient who has capacity has no legal right to demand CPR (or any other medical treatment) if the responsible senior clinician and multi-professional healthcare team judge that it would not be medically successful in achieving medical life."
It says that when a "do not resuscitate" decision has been made: "Opportunities to sensitively inform. patients and relevant others should be sought unless it is judged that the burden of such a discussion would outweigh the possible benefit for the patient."
It also says that "where death is unavoidable, [a patient] should be allowed to die a natural death and it may not be appropriate in these circumstances to discuss a DNACPR decision".
NHS Scotland made quite clear why it had adopted a national policy last year. "The increased movement of patients and staff between different care settings makes a consistent approach to this complex and crucial area a necessity," it said.
In addition, there was uncertainty about the process of making decisions that CPR should not be attempted. Local variations could cause misunderstandings and lead to distressing incidents for patients, families and staff.
Vivienne Nathanson, director of professional activities at the BMA and a fellow of the Royal College of Physicians, said it would be helpful for there to be a national policy in England, "because it means patients, families and healthcare teams know what the rules are".
She said: "Clinicians do not want to do things that are futile. They know when [CPR] can’t make a difference. All it may do is reinstitute sensation. You don’t want to do something that gets a little way but will not succeed.
"For a lot of doctors, this is instituting a lack of dignity, doing something because you can rather than because it will make a difference. Ethically, you should not do anything to a patient that will not benefit them."
Nathanson said decisions not to resuscitate had to be made case by case. "There is no way of saying ’the following types of patient will not be resuscitated’."
Communication was vital and all hospitals should have leaflets to help discussions with relatives. "There is very good research that when you tell people bad news, they don’t remember all of it."
In addition, doctors needed "to help people understand that for most people the process of dying is quite a simple slipping away. It is not violent or traumatic." Fear, said Nathanson, "leads to people wanting resuscitation seeing, say, cardiac arrest as a sudden and violent event, but sometimes the heart simply stops when you get to that stage of a terminal illness."
Families of mentally competent adult patients had "no right to anything in law but in practice, we always try to talk to the family ... but with the patient’s permission. You won’t talk to a family because you don’t like what a patient said. You talk to the family where the patient can’t give their views or you talk to the family to explain to the family."
More Western towns adopt ’toilet to tap’ strategy to water conservation
www.csmonitor.com
This summer, Texas’ drought of the century is an uncomfortable reminder that often there just isn’t enough water to go around. But the 40 consecutive days of triple-digit temperatures and minuscule rainfall may also be boosting the case for a new freshwater source being developed in Big Spring, Texas, and surrounding cities.
With a waste-water-to-drinking-water treatment plant now under construction, Big Spring will soon join the growing list of cities that use recycled sewage water for drinking water – a practice that the squeamish call "toilet to tap."
The trend is expanding as climbing temperatures and dry weather across the West force environmentalists, politicians, and citizens to find newer, better solutions to freshwater resources.
Heat wave: Four things that will rise with the temperatures
"It’s really a natural and cost-effective [solution] when you don’t have another resource available," says David Sedlak, professor of civil and environmental engineering and codirector of the Berkeley Water Center at the University of California, Berkeley. "We have to recognize that as the population of the country continues to move out into the West and as climate change continually reduces the water supply, these issues are going to become more and more important."
The $13 million Big Spring Water Reclamation Plant, due to open early next year, will pump 2 million gallons of water each day to Big Spring and three nearby cities – Stanton, Midland, and Odessa – using the waste water produced by area residents.
"The neat thing about it is that we’ll be able to use 100 percent of the water, 100 percent of the time," says John Grant, general manager of Colorado River Municipal Water District, which serves Big Spring.
Mr. Grant, who began looking into alternative water supplies nearly 12 years ago, says public feedback runs the gamut from "There’s no way I’m going to drink this" to "Why haven’t y’all done this sooner?"
Water reuse plants are not new, and municipalities in states from California to Florida have them.
How it works
In southern California, the largest water purification plant in the world produces 70 million gallons of water every day using recycled sewage water. The $480 million Groundwater Replenishment System (GRS) in Orange County takes already-treated waste water from the sanitation district next door and sends it through a rigorous three-step cleaning process to produce high-quality water that tastes like bottled water, says Michael Markus, general manager of the Orange County Water District.
The water first undergoes microfiltration to eradicate suspended solids, protozoa, bacteria, and some viruses. Second, it undergoes reverse osmosis – a process commonly used for improving water for drinking by forcing it through a filter. Finally, high-intensity ultraviolet light combined with hydrogen peroxide destroys any remaining organic compounds.
"We need to find ways to find more reliable sources of water, and recycling is, in our mind, the best way to do that," Mr. Markus says. "This is a source we can count on, because we can control it."
The GRS is classified as an indirect potable reuse plant, which means its purified output doesn’t go directly into the drinking water distribution system. Instead, the water is piped to a large ground water basin, where it sits for about six months. The aquifer serves as an environmental buffer between the purification plant and the tap.
"From a public perception standpoint, if you take [the water] back to the environment, the public’s memory of where it’s been is taken away," says UC Berkeley’s Mr. Sedlak.
Public’s resistance
The biggest hurdle in water reuse is public acceptance – or the "yuck factor," say experts. "Toilet to tap" is unappealing to many people even though the water is high-quality and pure.
"That’s a stigma that people need to get over," says Davis Ford, adjunct professor at the University of Texas at Austin and an expert in environmental and water resources engineering. "[Water reuse] is not new science. It’s absolutely safe with the disinfection we have ... it’s good-quality water."
A better balance: More feast, less famine
http://www.economist.com/
WORK TODAY IS about far more than economics. More even than when Theodore Roosevelt extolled its virtues, people over the world over want work not just to put food on the table and money in the bank, but as a means of gaining personal satisfaction. The changes now under way stand to make the world as a whole significantly better off and allow many more people to win the prize of being able to work hard at something worth doing. Yet, as this report has explained, there are many people who are not winning the prize and for whom the outlook is grim, even in rich countries where getting a decent job had been taken for granted.
Globalisation and other pro-market reforms were sold as a package deal. Opening up a country’s markets, the argument went, would increase overall wealth in every country, and policies for internal redistribution would help the inevitable losers—or else their personal misery could have serious social consequences for everyone else. That is why jobs are rightly at the top of the political agenda the world over.
Where unemployment is currently higher than usual, there is enormous pressure on politicians to spend money they have not got on quick fixes that almost certainly would not work. But almost everywhere, what is needed from government are the sort of fundamental reforms that can make a big difference in the long run, beyond the next electoral cycle.
The mismatch between the skills demanded by employers and those available in the market is a reflection both of bad choices by students, who have not thought hard enough about what will help them find a good job, and of education systems that are too often indifferent to the needs of the labour market and too slow to change even if they try. It is not just Egypt where the universities provide training for public-sector jobs that are no longer abundant yet fail to equip students with what they need to thrive in a market economy. Out of necessity, India is emerging as a model for tackling these problems, both because its companies have become expert in turning useless graduates into useful ones and because it has allowed industry to take the lead in creating a huge new programme to tackle skills shortages.
A second challenge is for governments to create the right conditions for businesses to create more jobs. That means running sustainable macroeconomic policies, so that firms need not fear that their investments will be undermined by another economic crisis; sensible regulation; and a tax system that is both competitive, with low marginal rates, and does not distort business decisions in arbitrary ways. Given the importance of job creation, it would make sense to shift some of the burden of taxation permanently away from employment towards consumption or carbon emissions. And since entrepreneurship plays a big part in creating jobs, especially in the phase when young businesses expand rapidly, government should do all it can to encourage more of it—though in view of its poor track record in this area, that should be mainly a matter of supporting (rather than obstructing) private-sector-led initiatives.
The goal of creating flexible labour markets should not be abandoned, but in future the ways in which inflexible labour markets are loosened up should be given more thought. The countries with the biggest youth-unemployment problems tend to be those where either there is no flexibility (as in much of the Middle East) or where flexibility applies only to newcomers to the jobs market, whereas older incumbents have continued to enjoy the protection that made the labour market inflexible in the first place (as in Spain). The political attractions of leaving the incumbents’ privileges untouched are obvious, but so, by now, are the social consequences of making the young bear most of the costs of flexibility.
Long-term unemployment often turns into permanent unemployment, so governments should aim to keep people in work, even if that sometimes means continuing to pay them benefits as they work. Health care and pension systems should be (re-)designed to allow workers as much flexibility as possible, not least in deciding when to retire. In the rich world these welfare systems were built on the assumption that men with lifetime nine-to-five jobs were the main breadwinners. In emerging markets that are introducing social protection for those unable to earn a living, the systems should be designed in ways that do not discourage work.
There is no excuse for delay in starting to put in place these long-term solutions. Jeff Immelt of GE may well be right to think that in America “ultimately we will get it sorted,” but he is also right that political dysfunction in Washington, DC, has “an opportunity cost. It is not like the rest of the world has stopped while we are going through this.” The same is true in many other countries where reform. has stalled or is not even on the agenda yet.
And while individuals wait for their governments to get their acts together, there is plenty that they can do to give themselves the best chance of surviving and thriving in the new world of work. They need to clean up their image on the internet, get in touch with their entrepreneurial DNA and brush up on their serial mastery. And form. their very own posse.
