In fact, I saw two examples of good practice – one was probably better than the other, but both had a positive outcome of patients; I’ll explain.
We have been working for the past couple of years on a ‘pathway’ to guide doctors and nurses in the hospital on how to treat those patients who have distressing symptoms relating to dementia or delirium; this is sometimes called challenging behaviour or, behaviour that challenges, by those who are more informed.
(The former suggesting that there is something wrong with the person who is terrified, confused, or, disorientated that needs treatment, the latter, that it is us – the doctors, nurses and carers who are challenged by the unusual behaviour)
We are on the brink of publishing some guidance (thanks Beth, Steph & Jo) – it has taken so long because, of our over-analysis of what ‘challenging’ means and other aspects of care and treatment that are complicated by us wanting to follow guidelines, yet still ensure that what we are doing is person-centred;
There has been a move over the past few years, thanks to the very hard work by colleagues in the hospital to increase our understanding of what it means to have either delirium or dementia. Reframing the condition – moving from suffering to living, doing to, to doing with and encouraging independence and wellbeing rather than care and dependency.
All this is great and I should probably celebrate more all that has happened.
Anyway, to the two acts of good practice –
They are from entries in the clinical notes; the first, was:
‘Patient spat our lorazepam, but now settled with some company from medical staff. Nursing staff unable to administer salbutamol as patient gets too agitated to sit at bedside, and is currently settled in the dayroom’
I liked this as it showed a doctor (likely in the early hours of the morning) being pragmatic – approaching the patient professionally, not personalising the behaviour ‘aggressive old man’ and accepting that what is important is that the person (the patient) is OK – they are settled in the dayroom. The treatment (Salbutamol) is less important than the patient’s condition. (assuming they are not critically ill, which doesn’t fit with the descriptor, ‘settled in the dayroom’)
The second entry made me very happy –
‘Asked to prescribe sedation for patient as shouting and agitated.
When I approached Brian* he was calling ‘help me’ – he asked me to readjust his pillows and was subsequently settled.
I don’t feel I can prescribe sedation for him, as his is not posing a risk to himself and is settled with reassurance’
*Not his real name
Looking more deeply, you can see in the second entry, not only did the doctor talk with the patient, they have described him by his name – they have moved from patient to person; they haven’t even issued a prescription to be spat-out; they have seen what is usually before us – frightened, vulnerable people – our mothers, fathers and grandparents.
This was again in the middle of the night, and reading these words makes me feel that all the work we have been doing has helped a shift in perceptions.
I know this is still not the universal experience for all patients, whether in my hospital or any care setting in the country, but surely this is a positive move; surely when people see that medicalisation, medicating, diagnosing, and treating is sometimes less important than connecting with a person, we are winning.