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At the age
of 93, my mother went through the ‘living will’ procedure with her GP,
and registered her wish not to be resuscitated. Sadly, when she had a
cardiac arrest while in a care home for a short period of respite care,
this information was not available to those treating her. She was
resuscitated in the ambulance and her final three weeks were not as any
of us would have wished. So when you have issued instructions, how do
you make sure they are carried out?
Celia Rose, Plymouth.
Your GP should be able to provide a living will, or there are versions on the internet
The sad and traumatic outcome after the careful arrangements your mother made for herself is a travesty.
A
living will, or an Advanced Decision to give it its proper name, is a
form patients can use to indicate whether they’re willing to have
various medical treatments – such as resuscitation, artificial feeding
or mechanical ventilation – should they become incapacitated and unable
to express their wishes.
Your GP should be able to provide one, or there are versions on the internet that you can print off and sign.
When your mother signed the document, it should have made her wishes legally binding. So, what went wrong?
It
failed when she entered the nursing home for respite care: the
registration paperwork should have recorded the fact of her Advance
Decision – but clearly it didn’t.
When
my patients sign such a document after discussion with me, I ask them
not only to leave me a copy for their file at my practice but also to
make sure there are copies with their will and their next of kin.
Of
course, even this would not have necessarily helped your mother. Part
of the problem lies with a general breakdown in communication.
Another problem is that political correctness and fear of litigation
Before
the European Working Time Directive put a block on the maximum number
of hours doctors – and nurses – could work, they were ever present; this
aided communication with patients and their relatives, and meant wishes
were passed on and acted on. This is no longer the case.
Another
problem is that political correctness and fear of litigation mean that
people who are clearly dying, as your mother was, are being resuscitated
to try to keep them alive.
It
saddens and alarms me that resuscitation is too often tried on patients
who have suffered a cardiac arrest at the end of an illness from which
there is no prospect of recovery.
Resuscitation,
especially on the frail and elderly, is a brutal, physical process –
the last thing you might want your loved one to have to experience.
It
also rarely works on these occasions. When it does, the patient will
need treatment in intensive care – traumatic and unpleasant at the best
of times. And then they’ll continue to battle with the terminal illness
with which they’d suffered prior to the cardiac arrest.
Medical
staff must adhere to every wish and expressed need of patients under
their care. But the bottom line rests with ourselves.
As
relatives, we must monitor not just the frontline staff, but also the
managers – and whenever there is any concern or worry about the way our
loved one is being treated, phone the hospital or nursing home and
demand to speak to the duty administrator and report our concerns head
on.
And
if you or a family member is in a situation where their Advanced
Decision may be relevant, tell every health professional involved in
their care that the patient has one of these signed, legally binding
documents – never wait to be asked.
My
GP has told me that I have a high cholesterol count (over eight) and,
therefore, may be at risk of a heart attack. I am 65. I’ve been advised
to alter my diet to reduce the risk, but have to wait for three months
before I have another test. Surely this is too long to wait? Anything
could happen in that time.
Mrs Sandra Ephgrave, Torquay.
Hopefully,
I can put your mind at rest. The recommendation is that for good
health, your cholesterol level should be below five – what you need to
bear in mind is that it will not have suddenly jumped up to eight: it
may have been high for a long while, maybe many years.
Though your level is significantly elevated on this recent test, you can’t conclude you’re in immediate danger.
There
is no doubt that coronary heart disease – where cholesterol is
deposited in the arteries that supply the heart muscle – is a potential
worry for anyone with high cholesterol levels.
Control
of coronary heart disease depends upon changing the known risk factors,
and high cholesterol is one of these – the others being high blood
pressure, smoking, diabetes, obesity and lack of exercise.
Diet
is the mainstay of treatment. For some patients this alone is
effective. The principles of a cholesterol-lowering diet include
reducing fat intake – especially saturated fat.
Some
experts take the view that the link between saturated fat and heart
attacks remains unproven. However, most of us eat too much saturated fat
– 20???per cent more than the recommended daily maximum of 20g for
women and 30g for men, according to the British Dietetic Association.
Changing
to a cholesterol- lowering diet with discipline can reduce cholesterol
by up to 20 per cent within months. It does take time – adapting to the
diet is a major process. Most of my patients do best with help from a
dietitian rather than just being handed a diet sheet.
However,
in severe cases – when the total cholesterol level is more than 50 per
cent over the recommended top reading of five, a cholesterol-lowering
drug, such as a statin, may be necessary.
A three-month wait before
your next test is reasonable if your health is otherwise good and all
 the other risk factors have been considered.
But
for that test, ensure it’s carried out on a ‘fasting sample’ – this
means that after your evening meal the night before, you have nothing
except water (which you can drink freely).
This
shows your cholesterol at its lowest – ie, best – level, when it hasn’t
been skewed upwards by food you’ve just eaten. Not all doctors agree
this is the best measure, though my teacher and influence, Professor
Barry Lewis, a guru of coronary heart disease prevention, insists upon
it.
Please update me on your result in three months.
WRITE TO DR SCURR
To contact Dr Scurr with a health query, write to him at Good Health Daily
Mail, 2 Derry Street, London W8 5TT or email [email protected] –
including contact details.
r Scurr cannot enter into personal
correspondence. His replies cannot apply to individual cases and should
be taken in a general context. Always consult your own GP with any
health worries.
By the way…?Should YOU take aspirin to prevent cancer?
Only
last week, or so it seems, we were debating the pros and cons of
statins. Now we are faced with an even more complex discussion: should
people be taking a low-dose aspirin each day to not only ward off heart
attacks, but to reduce the risk of developing and dying from cancer?
Research
published last week shows that daily aspirin reduces the risk of death
from colon cancer after eight to ten years of taking it – and lowers
mortality for many other cancers after five to 15 years.
Aspirin is
already given to people with heart disease to prevent a heart attack –
the benefit being that it makes the blood less likely to stick together
and form a clot. For this reason, it is also given to those at risk of a
stroke.
However, aspirin has the potential complication of unwanted
bleeding. So, while the benefit for those in at-risk groups outweighs
the danger, is this the same for healthy people? Given the pressures on
GPs, the last thing they need is legions of patients arriving to discuss
the use of aspirin. Yet what each of us does need is an understandable
summary of the risks and benefits, which takes into account our own
personal circumstances.
So, here is my summary. In those aged 50 or
over, with no known heart problems and no history of excess bleeding,
the benefits of taking a single daily 75mg dose of aspirin (a quarter of
a standard aspirin tablet) for the prevention of cancer and heart
disease may outweigh the risks.
The aspirin will result in a 20 per
cent lowered risk of having a non-fatal heart attack, no reduction in
the risk of a non-fatal stroke, and a 12 per cent risk reduction in
cancer incidence – after taking the aspirin for about eight to ten
years. In other words, for 1,000 such people, by the time they reach 60 –
with an average risk of heart disease or cancer – there will be six
fewer deaths, 17 fewer non-fatal heart attacks and six fewer cancers:
all at the expense of 16 more major bleeding events.
This is enough to enable most of us to make a decision.
The
complicating news is there’s been another recent report that some
people carry a gene that increases their risk of heart attack if they
take aspirin. But gene testing is not yet routine, and despite this new
and even more confusing research, the statistics above still stand.
Yet
it is worth remembering that there is much to do before worrying about
aspirin. Those who enjoy the best health will still be those who are not
overweight, do not smoke, have normal blood pressure and take daily
exercise. Aspirin will not rescue those who abuse the simple rules for
good health.
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