Please note that Dr Stuttaford isn’t familiar with all the circumstances in individual cases and can only deal with the points raised in general terms. Patients should always discuss any specific problems they have with their own doctors.
Readers’ questions are answered as examples of general problems commonly met in practice. It is a good rule in medicine that only their own doctors know the patient well enough to pontificate on the case as there are often other factors unknown to strangers.
My father has been in and out of hospital in recent months with emphysema. I have no knowledge of whether or not the treatment is correct but I worry about the lack of attention to his diet - if he eats, he eats, if he chooses not to, no one seems to pay any attention. I find that he needs a lot of encouragement to eat, as one might give a child, but of course I am often not there to offer this wheedling. I don’t want to just weigh in and criticise the hospital staff. I feel ignorant about what is “good care” and would like to inform myself. How do you suggest I go about this? Kristine Stone, York
No patient, whatever their age, is likely to thrive and to have a well maintained immune system if they are malnourished, undernourished or, if elderly, too often starved. It is unthinkable that babies, or young children, would be allowed to feed themselves. It should be, as it always was, the first principle of good nursing to make certain that a patient is kept clean, comfortable and that his, or her, nutrition are carefully monitored so that they have every opportunity of overcoming whatever ill they are suffering.
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One of the characteristics of chronic bronchitis and emphysema is that in its more advanced stages chemicals are produced in the body that produce wasting. This makes it even more essential than the elderly chronic bronchitic should be helped to eat and be persuaded to take the necessary nourishment. This requires time, an understanding of the patient’s needs and their disabilities. Too often unsuitable food is left by patients, who may be so weak that they are unable to feed themselves, or may even have such poor sight that they are unable to see the food. I have been to see patients in hospital, and watched meal times and have seen them progressively starved unless relatives were able to help with the feeding.
So far as it is possible to judge from your letter your father would not be reckoned to be receiving good care. You should certainly discuss it with the hospital staff and should have made a note of specific incidents that underline your point. Hospital administrators do an immense disservice to medicine by being so defensive about the care the nurses (and sometimes doctors of course) provide that the patients’ relatives feel there is no justice and that the hospital’s pride is standing between them and the care of their loved ones.
I have seen two elderly relatives die in hospital in recent times. In both cases they were given morphine to ease their pain. At the time I thought this was normal treatment but recently I have read stories in newspapers about how morphine can hasten death. Can you explain how morphine can hasten death, and can you advise on how a relative can be sure the dosage is enough to ease pain without hastening death. Adam Forster, Leamington Spa
The intention of all well planned and good terminal care is that the patient should suffer as little pain as is possible, and be kept as comfortable as is compatible with their disease, and any treatment that they are having for it. Morphia, or other opioid drugs, are still the mainstay of severe pain relief. It can now be given in long acting forms, or by using a pump in a continuous delivery, rather than by intermittent injections. Morphia has the disadvantage that it depresses the respiratory centre in the brain. Because of this adverse effect very high doses of morphia, or smaller doses in the frail, may in some cases shorten life. If this side effect is never utilised to shorten life deliberately it is both good medicine and theologically acceptable (approved by the Catholic church). In some instances the relief of pain so improves a patient’s condition that morphia may not hasten death but lengthen life. We have all seen too high doses of morphia used without regard to its side effects, but the dosage required to relieve pain will vary from person to person and obviously from condition to condition. Experience teaches a good doctor what is needed but I don’t think there is any hard and fast rule that can govern this. Pain control, and the concepts of the Macmillan nurses and the hospice movement, have done much to help us all to learn how to relieve pain without inducing unnecessary side effects. If you have worries, and your relatives are in a good unit, discuss them with the staff.
At the age of 85, my mother is due to go into hospital for tests. She has had good health until recently and has never had to stay in hospital before - even to have her children - and is both distressed and fearful at the prospect. What do you suggest we do to help her through this traumatic time? P. Coombs, Glasgow
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This is not an uncommon problem. A fear of hospitals and of doctors is, I suspect, partly a fear of loss of the ability to control someone’s own life. The minor daily problems are taken out of the patient’s hands. Someone else decides when and what they eat, when they are washed, when they clean their teeth and, especially for older people, the distaste and feelings of loss of dignity engendered by having to be helped to go to the lavatory or horror of horrors use a bed pan. All you can do now is to explain just why it is important to go to hospital, for if the necessary tests are neglected this may produce greater troubles in the future. Make certain your elderly mother is fully conversant with the visiting arrangements and, if she is used to the telephone, how she can have one to use from the hospital. Let her know that you will be there to see her daily but remember that very often short visits are less tiring for patients than longer ones. They don’t want to be forgotten but nor do they have to want to suddenly become great conversationalists.
Q&A on financing long-term care