I spent the day shadowing the doctor at the hospice which I volunteer it. I really enjoyed this experience and it was amazing to be given the opportunity to see a more clinical aspect to the hospice. It was very different from my usual role during the volunteering.
When I first joined the doctor in the morning, he was filling out a form to order a controlled drug from the pharmacy for one of the patients. A controlled drug are drugs that can be very harmful if not used within safe limits. I was really intrigued to learn about the procedure and all precautions that are taken with these types of drugs. The doctor told me that it’s important that his handwriting remains the same on all the prescriptions as when the order reaches the hospital pharmacy they will check it against the previous orders as one measure of precaution to ensure that it is a genuine prescription. He also mentioned the significance of the dosage being correct as if a patient receives the wrong dosage it can cause a lot of harm. This is double checked by writing the value for the dosage in both numbers and letters. The pharmacist who receives the prescription will also be experienced in giving out controlled drugs and will have to double check the dosage is safe.
The drug that was going to be given to the patient was going to be inserted using a syringe driver. I was not familiar with what this type of equipment was so I used a book at the hospice to read up further on it. I learnt that it is used to administer drugs into a patient and is particularly useful for patients who require drugs over a long period of time or regular doses. I began to wonder why syringe drivers were being used as opposed to a drip so I spoke to the doctor about it who told me that it was because syringe drivers were much easier to use as there was no need to fiddle about trying to insert it into a vein, they can be placed anywhere on the skin. I found it very interesting reflect on the considerations doctors would have to make when deciding on the contents of the syringe driver to ensure that if multiple drugs were being given using one syringe driver they will be compatible. By compatible, they won’t form a precipitate or perhaps cancel each other out to make the drugs ineffective.
I also accompanied the doctor on an informal MDT (multidisciplinary) meeting with a nurse where the handover was given and she was able to exchange information about each of the patients with the doctor so he was able to create a picture of the position each of the patients were in before visiting them during the day. After the handover, we discussed formal MTD meetings which take place in the hospice weekly. The doctor mentioned that the meeting is attended by the hospice doctors, district nurses, Macmillan nurses, physiotherapists, managers from another hospice, healthcare staff managing the ‘hospice at home department’ to mention a few. In this meeting each patient is discussed on how their car e and treatment could be improved and whether any of the different disciplines have any better ideas for them. Referrals are also made so all the healthcare staff can discuss together and assess the need of potential patients who may be admitted to the hospice. After having this conversation with the doctor and observing the handover I was truly able to value the multidisciplinary based teams within healthcare. Everyone has their own specialities and can bring their own level of expertise to the table and together it will ensure that the patient is at the centre and is receiving the best possible treatment from the perspective of social care, physiotherapy, a dietary perspective, rather than just from the point of view of a doctor.
One of the patients whom I visited with the doctor truly allowed me to reflect on the four principles of medical ethics. This particular patient was unconscious and had been so for a while so did not have Autonomy and could not consent to a checkup, so it was up to the doctor to act on his best interests and a usual checkup was what the doctor needed to ensure he could update himself on the patient’s condition today. Despite the patient not being able to consent to this checkup, nor have the capacity to consent to it, when the doctor entered the room he still introduced himself and at every stage spoke to him and told him what he was going to do. Later he told me that this was because of the importance that consent and capacity of a patient are only thought to be true for a specific moment in time. Despite the patient having previously not displayed himself as having capacity, this morning his condition might have changed and he might have actually been able to respond to what was being said.
The doctor only conducted a basic check up of this patient and reason why he did not carry out a full body examination was based on beneficence and non-maleficene. As this patient is unconscious he is just lying down on one side for the whole day, so every so often the nurses come and move him to prevent him from getting bed sores. The nurses noticed that when they would move him, despite being unconscious he would still grunt out of pain. This was fed back to the doctor and to make the patient more comfortable they decided to place this particular patient on a painkiller which he would be given half an hour before the nurses would be due to move him. Reflecting on this, it was an act of non-maleficence that the doctor chose not to put him through a rigorous examination as that could have caused him unnecessary pain. This could also mirror the principles of justice as a full body examination was actually unnecessary at this stage and by conducting one it would not be considerate of the other patients who the doctor had to also share his time with.
After that we went to see a patient who the nurse mentioned during the handover as refusing to take painkillers despite being in pain. The patient was aware that he was taking very strong pain killers such as morphine and was worried in case he was become addicted to them to the point that he thought he was psychologically feeling as though he was in pain so he could take the painkillers. From the patients history it was known that he had previously suffered from a drug addiction so it was understand let why his experiences would cause him to worry about such matters. This patient did have Autonomy so when we went in we ensured that he was happy for me to observe which he was. The doctor reassured him about taking painkillers and explained to him that he would only become addicted if he was requiring more painkillers to fulfill an adrenaline rush that he would be receiving from taking them. This chat seemed to reassure the patient a little and he admitted that he was starting to come to accept that he could take the painkillers without becoming addicted. The doctor listened to the patient’s chest and I was also able to listen to it even though at this stage I was understandably not able to distinguish or recognise any sounds.
This particular patient was suffering from a throat tumour which restricted his ability to swallow. If he attempted eat anything, it would pass through his trachea rather than his gullet and land in his lungs where it could cause serious problems. This was why he had a food pipe through which he would be able to receive his daily nutrition and I was able to have a look at it. The food pipe was inserted directly through his abdomen into the stomach cavity. I was rather surprised that this was how food was given as I had expected it to be a nasogastric tube like my brother had been given when he was first born and unable to swallow. I decided to ask the doctor about the distinction between the two and I was interested to learn that the nasogastric tube is more likely to be given as a temporary option compared to the food tube that directly accesses the stomach. I am also able to reflect on reasons such as the fact that the nasogastric tube is very visible compared to the direct tube which is very discreet as being a reason for why it may be chosen for some people who may not feel comfortable wearing a pipe on their face.
Before and after visiting each patient both the doctor and I used the hand gel provided to act as an infection control precaution. I spoke to the doctor about ‘superbugs’ such as MRSA and the importance of using alcohol gel to kill off any bacteria so it’s not passed between patients. I was really intrigued by his mention of C. difficile as I had heard of this bacterium but not quite been aware of its capacity. C. difficile creates spores which it stays within and is able to break out when it had entered a person. This means that it’s not affected by the alcohol gel so if a patient was carrying C. Difficile we would have had to wash our hands with water before then going to visit another patient.