Talking about ceilings of treatment when clerking older trauma patients

by Antony Johansen
Consultant Orthogeriatrician, Trauma Unit, University Hospital of Wales, Cardiff
Clinical Lead, National Hip Fracture Database, Royal College of Physicians, London

Corresponding author e-mail: antony.johansen@wales.nhs.uk

Published 06 April 2020

Editors note: Communication with patients and relatives is something we all do. When planning elective surgery in normal times, this is often a straightforward, uncontroversial conversation. However, during the current COVID-19 pandemic, communication with frail patients at high risk and their worried relatives is more difficult. As a consultant (in the older age bracket!) about to become resident on-call without ‘junior’ cover, I will be admitting elderly patients and being the clinician that has to have these conversations and I admit to being nervous about it. The following article therefore gives a practical, no nonsense approach, which starts to give us the language we need for this task.

 

Hip fracture outcome has improved enormously in recent years, and cardiopulmonary resuscitation (CPR) is usually appropriate in the peri-operative period, when the focus of care is on prompt initial anaesthesia/surgery with a view to discharge.

However, this injury typically affects older people with one or more significant comorbidities, and such patients will be hugely vulnerable to coronavirus. CPR and ventilation of a frail inpatient who has also developed coronavirus respiratory failure is futile, and poses a risk to those attempting it.

Patients should each be assessed as an individual and we are required to explore their preferences on admission to hospital. The opportunity to do this during initial clerking should not be missed, especially given the current ban on subsequent family hospital visits.

Staff often find these conversations difficult and they may be deferred or missed out altogether. The following ‘prompt card’ text is intended to help clinical staff open a dialogue with patients and their loved ones when they first present, so appropriate ceilings of care can be discussed before an emergency arises.

 

External BMA Resource:

COVID-19 – ethical issues. A guidance note.