Life imitates Christopher Brookmyre novels: a nurse in Britain is on trial for being somewhat overzealous in tackling the bed-blocker problem, to the extent of attempting to hasten several patients’ journey through death’s door. In her efficiency drive, Barbara Salisbury is alleged to have given patients overdoses of diamorphine and withdrawn their oxygen supplies.
Salisbury, who was described by the prosecution as an experienced, capable and efficient nurse, is accused of attempting to murder Frances May Taylor, 88, in March 2002 in that she inappropriately administered diamorphine using the syringe pump, telling a colleague: “Why prolong the inevitable.”
She is accused of attempting, 10 days later, to murder Frank Owen, 92, by instructing another member of nursing staff to lay Mr Owen on his back, allegedly adding: “With any luck his lungs will fill with fluid and he will die.”
I wonder whether (assuming that the charges are true, of course) she was acting out of a personal cruel streak, or whether this is merely the most extreme manifestation of an institutional focus on patient turnover in the Thatcherite/Blairite health system in Britain (as was the plot of Brookmyre’s Quite Ugly One Morning; though, granted, Brookmyre seems to write from a Scottish-socialist point of view).
My thoughts as a physician — I don’t think it is, probably, either of the possibilities he suggests in his last paragraph. Taking the latter first, there are easier ways to free up beds if you buy into the pressure for “efficiency” (which, by the way, most patient-care health professionals, as opposed to management, do not, in my experience). In the US, it is not NHS iof course but the third-party payors and their indentured servants, the hospital administrators, who press us doctors for shorter lengths of stay. The ‘utilization review managers’ come to morning rounds to press us on patients whose continued stay the insurance company is threatening not to pay for — to dump them back on their families sooner, refer them to horrendous but less expensive rehab or nursing facilities, transfer them to public institutions where they will be on the taxpayers’ nickels, or just to street ’em.
What the insurance companies don’t realize is that holding down length-of-stay for a given patient does not save them money in the long run, for at least two reasons — (1) premature discharge before a patient is stabilized leads to inflated costs for her/his care, including potential rehospitalization, in the future; (2) more importantly, an empty hospital bed is like a black hole down which overhead is being poured without generating any revenue, so another patient will just be admitted to fill it in short order. Managed care does not overall affect bed occupancy, especially because decreasing reimbursement has made many hospitals fail and close their doors, increasing the pressure on the remaining facilities. Since bed supply in a region’s hospitals is less elastic than management options for many patients (of cours, not all; every patient presenting to the ER undergoing an acute MI has to be admitted immediately, for instance), my guess is that in most medical specialties, the insurance companies end up paying out largely the same amount overall whether they are paying for many shorter admissions or fewer longer ones.
It is particularly bad in my field, psychiatry, where beds are filled not just from the emergency room downstairs but any emergency room in the region, far and wide, searching for the first vacancy within reach of an ambulance ride. Psychiatric units usually run at >90% occupancy all the time, at least in New England. If the ER team were unable to find an open bed, they would usually scramble harder to find a solution (the one they should have found in the first place??) to allow the patient to be sent home without hospitalization, at least for the moment.
There is a sense, though, in which I am noticing that ‘legitimate’ decisions to withhold medical care and hasten the end of life, i.e. those made via the patient’s wishes not to have extraordinary measures taken to prolong their life, expressed in their advanced directives (also referred to as living wills or DNR orders), are increasingly being made on an economic rather than quality-of-life basis. The influence of a persuasive health care professional over a patient, especially in extremis, or her family to sign opt out of life-extending measures is substantial (just watch the way it is depicted on ER, one of the things the scriptwriters get right on that show, IMHO) , as is their discretion about how scrupulously to adhere to those expressed wishes in the act. Increasingly, it seems to me that health care professionals are buying into the idea that medical care is a limited resource and should be expended where it will do the most good — as if they had the crystal ball that could predict infallibly how much good an intervention will do — and that how costly a life will be to prolong should factor into whether it should be extended. This attitude is anathema to me and contrasts with a — perhaps old-fashioned and outmoded? — notion that life extension decisions and health resource allocation decisions in general should be made on the basis only of the clinical circumstances, quality-of-life, values and principles, and expressed preferences of this patient, in this bed, in front of you now.
With respect to the alternative, that it is an extreme expression of the nurse’s mean streak, these “Angel of Death” health practitioners usually rather have a misguided sense that they are being merciful, IMHO, not expressing any sadistic urges. Control and domination, playing God, presuming to know better, etc. but I don’t think sadistic.
But then again I haven’t read Brookmyre; perhaps I ought to? […do like that Scottish-socialist viewpoint…]
