I've seen for myself how you are doing. The elderly, at risk, are having house-visits to make sure they are tucked up safe and warm for the winter.  Actually, if you focus on A&E attendances (Read this by the Nuffs) it's not the elderly we should be worrying about.   

The Duchess had a prearranged visit; the nurse turned up 45 minutes late but I suppose the elderly have all the time in the world to sit about waiting.

A chirpy, determined to be cheerful, very pleasant, younger edition of Gracie Fields appeared and ploughed through a form. Every single item (except 2) of information required to fill the form could have been pulled off practice data or social services records. 

Huge duplication? Waste of a visit? Not really. Face-to-face you get a feel for how people respond and live their lives. Trip hazards, personal hygiene... to an experienced eye a visit is worthwhile.

Apparently our-Gracie is The Duchess's 'coordinator of care'. Announced in a slightly raised tone and very s..l..o..w..l..y; I suspect, more to convince Gracie than The Duchess.  The Duchess will be coordinated every three months. I'll have a bet with you; she won't. There are too many duchesses in Surrey.

A named GP was announced. Tra-laa! I have no idea who it is. I've never met her. The Duchess has. Our normal doctor is retiring. The Duchess has been 'allocated'. There is a fast track phone number for her to bypass the switchboard - a very good idea.

Two questions? Oh, yes... here's one:

'Where would you like to die...'  

It came as a bit of a shock. The Duchess thought 'at home'. I said Hawaii.  Can we get the tickets on an FP10?  

Here's cracking question number two:

'... if you ever need cardiopulmonary resuscitation do you agree to Do Not Resuscitate'.  

Bang!  Right between the eyes!  Out of the blue, no warning... do you want to be flat-lined? You can read it for yourself in this document, page 33; the form template.

NHS Employers have written this guidance along with the BMA and the Carbuncle. NHS Employers? Yes, that's what I thought.

Here are a few issues that come to mind: Agreeing with the district nurse and signing (yes the form has to be signed) to a DNR has what legal significance? The form is not witnessed, does it matter? How is the elderly person's competence judged as capable of signing? How are relatives informed? How is this decision transmitted to secondary care and when?

Oh, and has anyone got any idea how an unwitnessed, fire-side chat with a district nurse, who is a complete stranger, might fit into the GMC Guidelines para 132 and the responsibilities of the administering clinician at the time.

Of course DNR discussions can take place as part of an advanced care plan. A chat with our-Gracie is not advanced care planning.  It is a chat with our-Gracie and that's all; going over everything the practice already knows.  

Hospitals have been getting themselves into difficulties over pre-empting DNR decisions. Do they really think this form will help?  No, it is valueless.

What of the vulnerable patient? Some will think 'I don't want to go to hospital they will let me die... they need the beds'. Others might think 'if I don't give the answer they want I won't get taken to hospital'.

And I'll bet the farm, when the District Nurse has gone frail elderly, stick-thin, porcelain-skin, house-bound grannies, who survive at the mercy of whoever is sent on that day to give her 15 minutes of attention, who sees her family only on high-days and holidays; will sit in their chair, look at the four walls and in a desperately lonely moment wont feel the tear splash into their lap; 'I'm going to die... the district nurse knows I am and I am frightened'.

How compassionate can you get...  

So, what do we have?  A complete stranger turns up nearly an hour late and says; 'Hello, how would you like to die?'  If this is your NHS it sure as hell ain't mine.  I am incandescent. 

This is a distortion of guidance, prurient, clumsy, cack-handed, ignorant and cruel.  The idea of the BCF is not to fund sending out strangers to compile a practice death-list. It's about making sure people are happy, well cared for, cherished and live.   

How stupid are the BMA, the Carbuncle and NHS Employers? Who runs the NHS.  Where's No-Man Lamb when you need him?