Choice in a demographic timebomb?

demographic timebomb

There’s lot of talk about the demographic timebomb — with increases in life expectancy, and the trend (in the West) for smaller family sizes.

Globally the percentage of the population that is 65 or older will double from 10% to 20% by 2050. In the UK, forecasts suggest there will be only 3.3 working age adults earning money to support the pensions and care of each elderly person.

This is better than in Japan, where there are only 2.1, but much less secure than the 11.3 in Bangladesh.

This demographic timebomb is not only an economic problem. Where are all the carers going to come from as these older people get sicker and frailer, and need support?

Read more…

The best videos on palliative care?

When I spoke at St Josephs hospice on home deaths, the lovely audience wanted specific links to what I think are the best videos on palliative care. Here they are below.

Before that though, I wanted to share some more local data. I spoke about the shocking effects on deprivation in Scotland, and said it would be similar elsewhere. I’m not happy to be proved right.

This week’s BMA News Review says that, in Tower Hamlets, “adults can expect to have the disease profile of a 75 year old at the age of just 55”.

So, it’s even more important to look at Martin Wilson on ‘realistic palliative care for an ageing population’. This includes shocking data, and shocking conclusions, on how living and dying if you’re in a deprived area is like being on another planet. As well as how death is a feminist issue:

Then, here’s Kieran Sweeney talking about how, amongst other things “… clinicians inadvertently heap small humiliations on patients”. This is, sadly, true. Please talk a moment to think if you have ever done this. Not on purpose, of course! And how you might never do it again.

 

 

Compassionate Neighbours gets a makeover

After the Compassionate Neighbours makeover: the new advert card

What a great Compassionate Neighbours makeover! The St Josephs hospice initiative is now offering “friendship and a listening ear” to anyone who asks for this — rather than focusing only on people at the end of life. This will surely increase the referrals.

It may even mean that people who doctors might label as at the ‘end of life’ get help earlier.

Those who contact the new improved Compassionate Neighbours will be given information about a wide range of local services. Anyone who is nearing the end of life can be offered the ongoing excellent Compassionate Neighbours end-of-life service.

I already commented on the first ever randomised trial of effectiveness of volunteers at the end of life. This had problems getting enough referrals. I think the Compassionate Neighbours makeover will help with this sort of problem.

Individuals and families — especially people with long term conditions — don’t like being told they are close to, or at, the ‘end of life’.

They are, after all, spending more time time living than dying.

Maybe other end-of-life services need to learn from the Compassionate Neighbours makeover? 

Volunteers may help in the last year of life

This first ever randomised trial of effectiveness has shown that volunteers may help at the end of life. But its methodological problems may say even more about the challenges facing volunteer services.

The results showed a trend in favour of the intervention and it was concluded that:

“Doctors and other clinicians can confidently refer people in their last year of life to volunteer services for support. They can expect that these services may slow a person’s decline in quality of life.

It was also recommended that Policymakers should continue to promote the involvement of volunteers in end-of-life care.

The study limitations were said to include “study power, blinding, missing data, attrition and intervention fidelity”.

But I think the limitations of the study actually give important clues about volunteer support services for people nearing the end of life.

Read more…

Bystanders in Victoria do more and better CPR than Londoners

St Johns doing refresher training in CPR for bystanders in Victoria Australia

Bystanders in Victoria, Australia are twice as likely to do CPR if they see an out of hospital cardiac arrest than they were 10 years ago. This means that local people are increasingly likely to survive cardiac arrest, maintain their independence and have a good quality of life.

  • More than half (61%) of people who were witnessed to collapse by bystanders in Victoria received CPR, compared to 36% 10 years ago.
  • Patients who received CPR from bystanders in Victoria were approximately 11 times more likely to be found in a shockable rhythm, the cardiac rhythm most favourable to survival.
  • More patients first shocked by bystanders in Victoria were discharged alive from hospital (55%) than those who had to wait for first shock by ambulance paramedics (28%).
  • Patients who received CPR from bystanders in Victoria were twice as likely to be discharged alive from hospital as those who did not receive bystander CPR (12% vs 6%).

Professor Karen Smith has described how quick intervention is the key to survival.

Bystanders in Victoria take a number of steps to improve survival:

“The first step is bystanders being able to recognise that someone is in a cardiac arrest and calling [their equivalent of 999] to ask for help from the emergency medical services. Secondly, a bystander can initiate resuscitation, by performing CPR or, if available, using a public automated external defibrillator to shock (defibrillate) the patient so as to return them to a normal heart rhythm.”

Ambulance Victoria does well when compared to other international agencies.

More than one-third (35%) of Victorian patients who were seen to collapse, who had a shockable heart rhythm on arrival of help, and subsequently received resuscitation by emergency medical services survived. This increases to 38% for patients in metropolitan Melbourne.

Most Victorian survivors were discharged home (83%). Of patients with a cardiac arrest in 2014-2015, who were followed up for 12 months, 74 per cent of those working prior to their arrest had returned to work 12 months after their arrest.

This still means 26% of people previously working have not returned to work. And, unfortunately, substantial numbers of people die or do not return home after their cardiac arrest.

But, if you’re going to have an out-of-hospital cardiac arrest, Victoria in Australia is a better place to do this than the UK! Bystanders in Victoria are much more likely to help you.

Surely, this is a challenge we Londoners need to rise to!?

Read more at:

http://ambulance.vic.gov.au/about-us/research/research-publications/

https://www.ambulance.vic.gov.au/more-victorians-surviving-cardiac-arrest/

Bystanders or lifesavers?

Bystanders can make a difference. Image: Urban lifesavers

If bystanders do CPR after a cardiac arrest, they can save lives.

If you’re a bystander, and you do CPR, you can double or even treble survival rates.

In the UK, there are more than 30,000 out of hospital cardiac arrests (OOHCAs) every year. But only 7-9% of people survive. In other countries, survival after an OOHCA is much higher : it’s 21% in North Holland, 20% in Seattle and 25% in Norway.

The low survival rates in England are partly because less than half of bystanders here perform life saving CPR.  This compares with almost three quarters of Norwegians intervening. Survival rates there are up to three times higher.

Every minute without CPR or defibrillation can reduce the chances of survival by around ten per cent. After ten minutes with no CPR or defibrillation, only two out of 100 victims (or less) have a chance of surviving.

Read more…

The Heart Age Test: investing in your arteries

Heart Age Tool: Image from PHE blog

The Heart Age Test works out how many years you can expect to live without a heart attack or stroke. Take 3 minutes out of your day and take the Heart Age Test. Then you can make simple changes, like doing more activity or quitting smoking, to reduce your risk — before it is too late. 

No doctor’s appointment is needed. The test is an online assessment for anyone over 30. You input some basic physical and lifestyle-related information, and get an immediate estimation of your ‘heart age’.

We should all aim for our heart age to be the same as (or lower than) our real age.

Read more…

Cardiac arrest and natural dying

Dan Beckett_talking about natural dying on BBC Radio Scotland. Cradle to Grave

Natural dying and cardiac arrests are quite different things. Dr Dan Beckett has explained how cardiac arrests may (may!) have a reversible cause, while natural dying doesn’t.

In a cardiac arrest, the heart stops first. Quite often this follows a heart attack and problems with electricity in the heart. Defibrillation may sometimes be able to restart the heart.

In a natural death, the heart tends to stop last, as part of the natural process of dying. CPR is likely to be futile because the body is dying. It may even be harmful since it leads to an undignified death, and may prolong the dying process.

Read more…

Can scenario planning help with discussions about CPR?

scenario planning and CPR

This post is about scenario planning and CPR. The new RESPECT resource purposely, and quite rightly, considers CPR in the context of other advance care planning decisions.  But even with RESPECT, I dont think worries and discussions about CPR and DNACPR orders are going away anytime soon. I’ve already suggested that scenario planning  could help here.

I want to start by making it clear that CPR can be a very good thing.

It’s definitely a very bad thing that, in the UK, only 8% of people who collapse not-in-a-hospital survive CPR.

Better ‘bystander’ CPR could and would improve this overall figure.  My posting on ‘Learn CPR from YouTube’ is for the pupils of a supplementary school in East London, and in August I will be speaking about CPR on a satellite channel aimed at the Bengali community.

Sadly, though, some people are never going to benefit from even the best CPR.

The Resuscitation Council is clear that, when “a person is dying—for example, from organ failure, frailty, or advanced cancer—and his or her heart stops as a final part of a dying process, CPR will not prevent death and may do harm.”

To be more specific, “Cardiopulmonary resuscitation is futile for in-hospital cancer patients with widespread incurable disease and poor performance status.” 

However, there are lots of people for whom the situation around CPR is less clear cut. These individuals might benefit from a discussion of the worst, usual and best possible scenarios.

Let’s start with the best case. We’re concerned here with people who have organ failure, frailty or cancer. So the very best case scenario, in medical terms, is that they get back to how they were before the CPR. Usually the CPR only happens because something has got much worse – so the ‘best case’ may well not be very good.

International meta-analyses have found that that survival after CPR is even lower for older patients, and for those who need help with activities of daily living.

For example, two large meta-analyses, found that survival to hospital discharge decreased especially when the patients were aged over 70., Of course, age can be a ‘marker’ for overall health or functional status, so van de Glind’s 2013 meta-analysis concluded that “older age alone does not seem to be a good criterion for denying patients CPR”.

What about the less good outcomes? There are some very bad scenarios after CPR for people with chronic diseases.

I’ve already shared one of these, with Debbie’s story.  Michael Stone has described another — when paramedics make decisions about individuals they have never previously even spoke to. These stories are not actually the worst case scenario, in my view. I think surviving with one’s heart beating and significant hypoxic brain damage would be even worse.

Other people may, of course, think differently — but I think that everyone making a choice for themselves should surely know of these potential scenarios.

I also think that patients and their families might want to consider another sort of scenario altogether…

When my own father died (of cancer), no-one attempted CPR. Instead, I kissed him, told him I loved him and laid down beside him.