Friday, 7 October 2016

Metal Nurse: The importance of the flu vaccine

In my second year as a student nurse I decided to write a blog that pretty much transformed my musings from music to health care related stuff. It was about the flu vaccine. I think it was pretty good and so did others, to the point where one of my favourite internet pages, Skeptical Raptor, reblogged it. So here I am, nearly 2 years later having been qualified for over 18 months. Still having to refute myths about this vaccine. If you work in health care there is no good excuse to refuse the vaccine. You do not have an excuse. Lets begin with a few quotes from the NMC Code of Conduct from 2015:

  • "Always practise in line with the best available evidence."
  • "Act without delay if you believe that there is a risk to patient safety or public protection."
  • "Be aware of, and reduce as far as possible, any potential for harm associated with your practice."
  • "Take all reasonable personal precautions necessary to avoid any potential health risks to colleagues, people receiving care and the public."
Those are the points that I feel are the most important. 
And of course according to the GMC Good Medical Practice:

  •  If you know or suspect that you have a serious condition that you could pass on to patients, or if your judgement or performance could be affected by a condition or its treatment, you must consult a suitably qualified colleague. You must follow their advice about any changes to your practice they consider necessary. You must not rely on your own assessment of the risk to patients
  • You should be immunised against common serious communicable diseases (unless otherwise contraindicated).

Swine Flu plush toy.
I would like to introduce the concept "Post hoc, ergo propter hoc.". Translates as "after this, therefore, because of this.". Basically it is when you want to connect one event to another because of reasons to make the world seem like a logical place. You see a butterfly, then a thunderstorm happens. That kind of thing. It's not a very rational thinking process. Okay, why am I talking about it here? One of the many many excuses I hear regarding the flu vaccine has been "My relative had the vaccine, then they ended up with a cold."
One thing does not have to correlate with the other. Especially when the common cold is caused by
coronaviruses and rhinoviruses. The flu is only caused by the influenza virus. And the flu kills. On a regular basis. According to WHO, the flu kills between 250.000 and 500.000, every year. In England in 2013-2014 the Public Health England recieved 904 reports of patients being admitted to ICU, out of those 98 died. That's a whopping 11% mortality rate. According to the European Centre For Disease Prevention and Control, the season between 2014 and 2015:

  • "In 15 European countries that report mortality data to the EuroMOMO project, an excess winter mortality rate of 231.3 per 100 000 above the seasonal baseline was observed. This excess was noted for more than 11 consecutive weeks and was the highest of the last five winter seasons."

No, the flu is not just a bad cold. It's a killer. But not just deaths that we should be concerned about it's the complications that follow having the flu, the complications that arise for those who suffer from chronic illnesses, like COPD or diabetes. For those who have pre-existing lung conditions, the flu is even more deadly. Not just deadly it also exacerbates the disease and they rarely every recovered back to baseline. But it has been found that the vaccine reduces hospitalisations of diabetics by 72%, and up to 52% of those who suffer from chronic lung disease. It reduces mortality and ischaemic episodes in those who are recovering from angioplasty. It also prevents cardiacvascular events. Some of the rarer but also dangerous complications from the flu include:
Influenza associated encephalopathy is a rare complications. But it does have up 30% fatality rate. It is most likely to affect babies from 6 to 18 months old. With one third of those affected will suffer from neurodisabilites. 

Meningitis is a complication that occurs due to a viral infection. The influenza virus being one of the more common virus that can cause it. 

Guillan-Barré syndrome, has long been associated with the flu vaccine. But there is a story behind that. All in all it's the story that sort of defines everything about science, how science develops knowledge and improves on what it knows and continues to define how we as healthcare professionals should follow the evidence. In 1976 there was a case of where it was linked to the flu vaccine, so researchers concluded that there might be a casual link between then the swine flu vaccine and GBS. The most current research fails to find any link between them. If you get infected by the flu you are at an increased risk of developing Guillan-Barré Syndrome, 17 times more likely to develop it in fact.

But why do I rail against health care staff who refuse to be vaccinated. Simple. We take care of acutely ill patients. We are around them all the time. We take care of people who are infected with some nasty nasty illnesses. One in three people who get infected by this virus are asymptomatic carriers. So the danger of infecting those who are vulnerable increases. Because you can pass on the virus without ever showing symptoms yourself. It is infectious for at least 24 hours prior to any symptoms developing and is infectious 5-7 days during the infection. Which is why herd immunity is so important, or community immunity for those who like concepts that rhyme. In a nutshell herd immunity is where there is enough people vaccinated against a contagious diseases to protect those who cannot be vaccinated and/or are vulnerable to disease that are easily spreadable. And (I will be repeating this point) healthcare professionals are a big part of that herd (or community) in hospitals. This is important to remember, there are people who rely on this. And all of them will be in our care. The list includes:

The list is of course not exhaustive.

Most healthcare workers seem to have no objections to vaccinating against other illnesses, like measles or hepatitis B. But somehow they seemed to have this blind spot when it comes to the flu vaccine.

The "I've never had the flu, so I don't need the vaccine" excuse doesn't work. For the same reason as "I never got pregnant, so I don't need contraceptives." Or  "I've never been in a car crash, so I don't need a seat belt." Don't work. I've never had hepatitis B, you can be sure that I'd have that vaccine again. Same goes for all of them. I've never had Tetanus, but you can bet your bloody arse that I'd get the Tdap if I've had a serious cut when walking around mother nature. I've never had Yellow Fever, Typhoid, Cholera, Japanese Encephalitis or Hepatitis A but yes I'd have that vaccine if I was travelling to those countries where they are prevalent.

And honestly I struggle to understand why, most of the time I think it is purely out of sheer bloody mindedness rather than actual facts. Some people see it as a form or rebellion against a higher authority. It's one small needle. Once a year. And it's there to protect us, our loved ones and those who we are taking care of. There is not beating around the bush about this. At worst we will get a sore arm, 24 hours sniffles and an immune system that will know how to battle the flu. It's a myth that you get a cold after a vaccine and it's a myth that healthy people don't need a vaccine.

I have come across people who just flat our state "I don't agree with it." What is there not to agree with? It's a low risk thing to do. Even young health people have died from the flu. In fact if you look at the greatest epidemic in human history, the Spanish flu, majority of those who died were aged between 20-50. The more I listen to people who object to it, the more I get convinced that it should be mandated as a requirement to work in healthcare, like they do in America. Require those who don't vaccinate to wear masks if necessary. We are there to take care of the patient. Not our ego. Our egos will heal, some of our patients might not because of ill-thought out refusals.

"What about my right to refuse?" Well, what about it. Yeah, sure you do have the right to refuse it. But what about the right of the patient  to be taken care of by someone who works within evidence based practice? What about the right of the patient to be taken care of by someone who takes every step to make sure that THEIR health and well-being is the centre of their care?

Is the vaccine perfect? No, sadly it isn't. But it still offers the best protection available. Currently it offers between 50% and 60% protection, which is damn sight better than 0%. Though currently there are some great developments in terms of developing a universal flu vaccine. The issue is that there is more money for pharmaceutical companies in people getting ill with the flu, rather than the vaccine. But as an organisation like the NHS, we save money on people getting the vaccine. There is a reason why every medical organisation in the world recommends that their staff have the annual flu vaccine. And it's all about protection.

Are there complications with the vaccine? Certainly, but they are rare. Redness, soreness and localised swelling are most common. 1-2% of those who get the vaccine might get a fever. Rarer side effects include hives, urticaria, racing heart and high fever. Anaphylaxis might occur in 1 case per million doses given. But 
compared to the chances of getting the flu, I'd rather have the vaccine.

We are there to  take care of and protect our patients from harm. We barrier nurse them. We gown up and use face masks when needed. We use gloves, we wash our hands. We give intravenous antibiotics and anti-virals. But a small needle that will protect you from a dangerous disease is somehow a step too far? Really? 

Thursday, 29 September 2016

Metal Nurse: Sexual Health Care for the Older Generation

Everybody likes sex. Everybody likes to read up on sex. Everyone should have sex. On some level we should be more open about talking about sex. In recent years we also have been able to open up about one ageing taboo: Old people having sex. Now, it's is something that needs to be tackled but no one really wants to talk about it. Why? Well, who wants to imagine their parents having sex? I don't. I am pretty sure that my kids don't either. But it is quite frankly beautiful to know of, that people in their twilight years are still enjoying themselves. More and more people seem to be enjoying their retirement age having lots and lots of sex. And who can blame them? Now that it's all out in the open the next thing we have to discuss is the rise of STD's in the 50+ population.

During my university years I volunteered  in the Chlamydia Screening project which was part of Best2Know. So I got to know about how common STD's are in the university student population. There's a big focus in getting the 18-24 to get tested for chlamydia and give free condoms in order to stave infections. It was interesting and fun to assist with, but since most of the people I take care of are a lot older, I started wondering how common STD's are in that age group. Turns out it is quite a lot. I had read that currently the over 55's are second highest group in terms of increase in new STD's diagnoses.

Middle Aged Spread
So now that we've managed to open the discussion about older adults having sex. Maybe we should start talking about contraception with the elderly. Some survey's done show that a lot of those who are still sexually active do want to find out more about STD's, but often don't feel like that can. In recent years cases of STD's has rise in the population aged 50 and over. According to the CDC, HIV alone as increased by 15% from 2000 to 2010 in that particular age group. Syphilis has been on the rise again, even though you would have thought that that one was gone the way of the smallpox. Gonorrhea and chlamydia have both seen big increases in the older generation.  Now the issue we have with these numbers is because it is based on people who seek treatment, so there is a big danger that the number of infected individuals is much higher.

But why is this an issue? People of that generation tend to not want to talk about it. Unless it's about bragging rights, they like to talk about being in a new relationship. But don't want to talk about the potential consequences of being in a new relationship. With a partner they might not know the past sexual history off. Women in particular after menopause think that they won't need contraceptives like the condom because they won't get pregnant. But condoms are not just there to prevent pregnancy, they are the ONLY contraceptive on the market that prevents STD's. And you are never too old to use a condom. Maybe the conversation needs to be about how to use them correctly. Because it is a myth that sex is less pleasurable with a condom, but this myth persists. Besides this generation is the one that grew up with the contraceptive pill, so the talk for condoms most likely didn't happen, and research has shown that those over 40 are less likely to use condoms. Mostly I'd imagine it is because they are just so damn embarrassed about it, they shouldn't be. They've been given a new lease of life. You can get Viagra pretty easily (just don't buy them online) to help with erections, lubricants to help with vaginal dryness and meeting new people has never been easier thanks to the internet.

What would help, as we open up and talk more often course, is if doctors and nurses started incorporating sex education into our health promotion. Or maybe GP's could include sexual health checks with their annual physical assessments. Especially if we suspect that some individuals are practising unsafe sex. Maybe it's time to introduce sex education for over 50's, there is plenty of focus on sex education with teenagers. But in reality how much do adults know about safe sex? Should we really presume that as people get older the stop enjoying sex altogether? The urge to have sex might decrease but that is not the same as stopping altogether. It isn't just infectious diseases that they could discuss, this could be incorporated with talking about erectile dysfunction and vaginal dryness. What medication they could take to alleviate those symptoms and/or what medication they are taking could cause those symptoms. Because I don't don't know how often those side effects are discussed or even contemplated when new medication is being prescribed to patients. Us health professionals also have to do our bit and confront our fears and prejudice regarding sexual health, especially with people who are old enough to be our parents.

The focus on safe sex campaigns and use of contraception has been always on the younger age group, if only because they remain the group that contract most STD's on the most frequent basis. They tend to also be the most likely to seek out help if/when they are aware that there is a problem with their genitalia. They get free chlamydia screening kits and they get free condoms given on a regular basis. The other reason of course why the focus has been on this group is because they will hopefully be paying taxes for a long time, well up until they reach retirement age, and have children. But they won't be able to do any of that if they don't get their various STD's sorted and treated quickly. Because the economical factor of neglected cases is immense. The other reason why the focus is on the younger age group is because some STD's like the Human Papillomavirus, if left untreated, can lead to people developing assorted cancers. Up to 70% of cervical cancers have been attributed to an chronic and untreated HPV infection. Up to 25% of oropharyngeal cancers have been linked to HPV.  But of course the problem doesn't just lie with cancer. Then there is also the cases of infertility, because fertility treatments are extremely expensive and time consuming.

Then there is the issues of differential diagnosis. With all this in mind various STD's should be considered as such. Gonorrhoea, Chlamydia and Syphilis, all have various signs and symptoms that go with other diagnoses.

But why neglect those over 50's? Because as the populace get older they will need more treatment for long-term illnesses, and adding something that can be both treated and prevented so easily into the mix is just going to cost the society more. As The Kings Fund has pointed out, patients with long term conditions could cost the UK an additional £5 billion by 2018. So why add untreated STD's into the mix?

Tuesday, 27 September 2016

Metal Nurse: Self Harm and Suicide Attempts

This isn't a topic that I read an awful lot about until relatively recently. Maybe it's because I've got two daughters and I worry about their well-being especially seeing as one of them is approaching the age where self harming is most common. Maybe it's because as I get older I meet more people who have self harmed one way or another. Whilst this article will mostly focus on self-harm, I will also touch base on suicide attempt since they often overlap. And because of having a personal history of it.

 According to a report by Health Behaviour in School-Aged Children up to 1 in 5 children aged 15 self harm and a large proportion of those are girls. That's not to say that boys don't self harm, they do. But either they are less willing to admit to do doing do or they do in a way that most people don't consider to be self harming. We still don't expect boys to be as emotional mature as girls, so there might be a case of easy dismissal when they feel the need to offload their burdens but can't because they are boys. And boys don't talk about feelings instead they commit suicide.

My interest in writing this particular article was not so much the self harming itself, but the attitude I have come across. The attitude that self-harming is somehow all about attention, that people who attempt suicides are just time wasters, essentially that people who suffer from various mental health issues do not deserve medical treatment. The problem with that attitude is that it invalidates how these patients feel. They need help, we might not always be able to provide that help, but what we should be able to provide them with is environment that feels safe. Where they feel not so much like a burden, somewhere where they don't feel judged by their actions and decisions. As healthcare professionals we are not only responsible for our patients physical well-being but also their emotional well-being.

Quote from Mind

So maybe if we start with the basics.

What is self harm?

It's a fairly self-descriptive phrase. But for those who need it said, it is the act of harming oneself. Self-harm can come in form of intentional overdose, harming yourself by cutting, burning and punching yourself. There are of course other more subtle ways of harming yourself, for example by starving yourself, over eating, practising unsafe sex, binge drinking, etc.

Self harm cycle
We also have to remember is that people who do self-harm are not doing so in order to commit suicide. In most cases this is to assist them with coping with their heightened emotional states. It is a form of distraction. It is a way of coping. It can also be looked as an act of self-preservation, as some people do it as an emotional release.

Bear in mind is that self-harming is usually an indication of a problem rather then the problem. It is mostly a manifestation of that persons personal circumstances, whether they are under unusual amount of stress, depression, past abuse, some form of past trauma, neglect, loss, etc, the list is pretty endless. It is essentially a cycle of self torture. Some people use it as self punishment for when they feel they have done something wrong to someone else. Some patients also plan on their self harm, whilst others do it more spontaneously.

Why do people self harm?

Now then, this is were it gets a little trickier. And for some a little harder to understand. As I mentioned previously, it is essentially a way to cope with external circumstances and internal turmoil. For some it is a form of release. Like opening up a valve full of pent up rage, stress, self-doubt and so on. Others have said that it makes them feel more alive after feeling numb for so long. That the negative emotions they were experiencing before a self harming incident was reduced. For others it feels like the only aspect that they can control in their lives, when there are issues occurring that they feel is out of their control. For some it feels like the closest they can do to suicide without dying, a form of prevention so to speak. These individuals might be feeling low, and do not know how else to cope with pressures that are surrounding them. Whether it's due to social pressure, family, education, etc. There will always be outside stress factors that will contribute to a person self-harming.

How common is self harm?

Well. That is something that is pretty hard to put a finger on. It is in the top five of reasons for acute medical admissions, with over 150,000 attendances per year. The exact figure of how many people self harm is hard to find out, most studies have been done in form of survey's and questionnaires after an admission to hospital due to self harming and/or attempted suicide. But the Royal College of Psychiatrists put the figure somewhere around 400 in 100,000. According to the RCPsych people of all social groups and all ages engage in self-harm and/or suicidal behaviour, but teenagers, veterans and prisoners are at particular risk.

In America for example the suicide rate amongst 15-19 year old has doubled since the 1960's, in the UK self-harm is largest cause of death amongst 20-24 year olds. As I stated earlier, girls are more likely to self-harm and contemplate about suicide. But boys are more likely to commit suicide. Sadly some research from Australia has shown that the younger the patient who presents with self harm and/or suicide ideation, the lower priority they are given compared to those who are aged between 35-44, this is broken down even more in terms of method. Patients who self harmed with blades are deemed as less of an emergency compared to those who expressed the idea of self harming, with a greater preference also being given to male patients.

What can be done?

There is plenty of improvement that needs to be done regarding the care of patients who present with self-harm. Generally the lack of documentation is pretty shocking to start with. In 2009 a small retrospective study pulled 25 patient records from various A&E. These patients had presented into Emergency Departments with self harm. None of those records had documented mental state examinations. Suicide risk and risk factors had either been poorly documented or not at all. So obviously documentation needs to be improved upon, but mostly what is probably more important in my opinion is to raise the staffs awareness of the importance of those details. Yes, some of these patients will be calling for help and that is something that should not be ignored. Why are they crying for help? What is their story? What has lead to them presenting with self harm and/or suicide attempt? NICE provide excellent guidelines on initial management of patients who present in A&E with self harm. Which includes assessment of physical and mental health well-being, as well as safeguarding status. To be taken to a place of safety, or at least taken care of in a place of safety.

The biggest difference we can make is not to take self harm lightly. Which is what majority of these patients express their disappoint about. We need to stop, look and listen. But it is getting harder and harder to give these patients the treatment they need and deserve. Funding for Mental health services continue to be cut down. Waiting time for counselling is sadly going up. According to this report by MIND, 1 in 5 have been waiting for over a year to receive some sort of treatment and 1 in 10 have waited for over 2 years. This is not acceptable.  As general nurses who work in A&E and Medical Assessment Units, we do not get enough time to help. Generally we end up taking care of up to eight patients, each who have varying degrees of acuity. Most of the time we end up neglecting those with mental health problems because they appear physically healthy.

If in our care what we can do, or at least should make an attempt to is to talk. I know I keep on repeating myself. But this is important. If they don't want to talk, but want to continue self harm instead, with blades for example. Then at the very least we should be able to make sure that they use clean blades and have equipment ready to clean their wounds and put on clean dressings on. Teach them how to dress the wounds properly. Teach them how to perform first aid. Provide them with a safe space. And then be available to talk, or make sure there is someone there that they can talk to and/or want to talk to. We can provide paper and pens if that helps, so that they can write out their thoughts and frustrations. We can provide a marker pen for them to use on their skin instead of a blade. We can give them ice cubes, elastic bands, etc etc. If we can't prevent the damage, we should limit it.

In recent years we have become very good at bereavement and know who to contact for those type of situations. We have become very good at comforting relatives when we know that that their loved ones are getting closer to leaving the realm of the living. But we haven't become so good at referring people to counselling, there doesn't seem to be a way to refer patients straight from ED or Medical Assessment straight to counselling. Or IAPT. We also either deny ourselves the time or just plainly don't have the time to sit down and talk to them. What they do get often is a referral to mental health services, they get to speak to mental health practitioners about their initial problems. But then they get put on a waiting list. And more often than not, they return. And they return again. And in the long term if this cycle isn't stopped will lead to more potentially preventable deaths.

Taken from SANE
The point is that we shouldn't judge people because they self-harm, because we don't know what lead to that decision. We don't know what kind of experiences would lead to someone to put a knife on themselves and slice over and over again, or take XX amount of paracetamol, or stub out cigarettes on themselves. As nurses it is not for us to decide that they are weak, or seeking attention. In fact if they are seeking attention then we should do our best and find out why they are doing so. We are there to assist people at their weakest moment, whether that be physical or mental. We are there to care for those who need it. We are there to support and hopefully heal our patients.

Saturday, 17 September 2016

Life was not always better.

Me and me other half went for a bit of a walk not that long ago. During that walk we decided to have a walk through one of the cemeteries in Lancaster. Don't judge, we just wanted to have some romantic Gothic time.
I find it fascinating walking through some of these cemeteries. The information you can get just glancing at some of the headstones is pretty interesting. Especially when you find headstones like this one. Listing 4 children that died before reaching their second birthday. 
This used to be the reality not that long ago. Couples would have hordes of children. In the hope that at least some of those would reach adulthood. And this is still the reality in certain areas of the world.
Today this isn't the reality. Today the reality is that we have 2 sometimes 3 children and we can be pretty damn certain that they will reach adulthood. Go to university, get married, have children of their own, get divorced and hope for grandchildren of their own. 
And why is this? Well there are few factors. The biggest ones being improved healthcare. Both public and private. We have vaccines for illnesses that used to maim and/or kill children in their droves. We have antibiotics. We have ventilators. We have bronchodilators. We have defibrillators. We have radiotherapy. We have chemotherapy. We have insulin! We have some of the most amazing medicine in history that ever existed. With more on their way. 
We have more food today thanks to modern agriculture and genetic modifications. We can now feed more then we ever could. Thanks to lest pesticide usage. Thanks to being able to use less space that grows more per acre.

Public sanitation is of course miles better than it used to be. Again, thanks to modern technology and science. Drinking water is safer and better than it used it be.

Dentistry is at it's best today. With fluoridation of water and more. 
And yet... And yet we have people who want to demonise today's technology. In some cases they actively campaign against them, and want to make sure that less fortunate countries don't get them. They somehow think that everything was nice and rosy in the old days. That everything was so much better in the days before modern technology.
No, it was not. Life was dirty and short. You died. And you died horribly.
Vaccines save lives. Medicine save lives. GM technology save lives. Hippies and luddites don't.

Wednesday, 14 September 2016

A cult is a cult is Soka Gakkai

Before moving to the UK I used to be affiliated with a Buddhist organization called Soka Gakkai. I used to practice my Buddhism religiously. But since moving to the UK, I haven't practised it with any degree for 10-11 years now. I still got the books. I still got the beads. I’ve still got most of the paraphernalia that came with it. But now they are all collecting dust. Sitting there and reminding me of the good times I had with them and the bad times that lead me to them.
I still identify myself as a Buddhist, but now I prefer to use the term Fairweather Buddhist as coined by my former boss and current friend. Sometimes I identify myself as Angry Buddhist as my other half sometimes does.
Since de facto leaving the whole group, it’s been interesting to watch and reflect on my days with them. The reason I joined them in the first place was that I was quite keen on the idea that I and everyone around me had the potential of reaching Buddhahood. Basically I could be better than I am and so can everyone else. This intrigued me on the most basic level and also on a more philanthropical level. Helping others has always been something that I’ve wanted to do. And besides at the time I was in a bad bad place mentally and being a group of like minded people helped. And the chanting as well.
What didn’t help was being told that it was the only true Buddhism. That always grated for the same reason as hearing people that their religion is the one true religion. It doesn’t work like that. You find something that will help YOU. Not to help someone else’s ego.
When I asked what the words meant that I was chanting I was told that there was no need to understand them. Just that I chanted them. Studying was encouraged. But only as far as the SGI curriculum was concerned.
You could only have the Gohonzon, every thing else were false idols. Including my little Buddha statues (That I still own).
Then there were the pilgrimages. And make no mistake that’s what they were. People HAD to make trips to XYZ to attend a conference. That also grated.
It is the cult of personality that Soka Gakkai is. Currently Soka Gakkai seems to be the podium for a gentleman called Daisaku Ikeda. Who writes books, delivers sermons and travels the world and provides words of (contrived platitudes) inspiration. But no one is allowed to dispute his words. He is the messiah. He is the modern day Buddha and no one else is.
And that is just not on. I don't hold with those "qualities" in other religions, why should I tolerate it in mine?
I still got friends involved in the group. And they all do strive for peace and harmony. And that is good. But it all still reeks a little bit of the exchange that Brian (Not the Messiah) had with his followers regarding individuality.

Thursday, 4 August 2016

Metal Nurse Spaketh: Dying Matters

"But on the most basic levels a Nurse has 2 roles
They impact people in positive ways not limited to and as far as  saving someone's life in the very literal sense
And comforting someone as their candle light flickers out."
I've worked in healthcare for a long time. Nearly 16 years now. And I have seen a lot of people dying. I've been there when the last light flickers out. I have been present when patients families are surrounding there loved one, saying goodbye one by one. I have performed more last offices than I've been able to keep count off. And here's the kicker. It never gets any easier. My experiences as a nurse aren't unique. We all go through this. Every time it happens when I'm on shift, my mind invariably turns to mortality. Mine, my children's, my loved ones, my family, my parents. We all know that life is finite, that it will end at some  point. But it never feels right, it never feels like it should happen. But it does and it will.

Thinking about how I would like to end my life. I am sure I would not want it to end in a hospital or a nursing home.

Currently we have a document called "Do Not Resuscitate". This is often done by the elderly since their chances of surviving a heart attack is so very very slim and resuscitation is brutal on the human body. There is this misconception that DNR also means that no treatment will be given for various illnesses, this is not true. DNR is only in case the patient has a cardiac and/or respiratory arrest from which they are unlikely to survive.

But what a lot of older people are also taking out alongside it is something called "Advanced Directive" or "Living Will". These can be about where they'd like to be cared for at the end of life. Or it could be about not wanting to go to hospital for treatment. Not because they think they will get bad care. But more because they feel like that they've seen enough of life and their end is coming then it should be spent in familiar surroundings.

But far too often those Living Wills are not adhered to. Family members beg for their relatives to be saved. To be cured. They put the doctors and nurses into position they shouldn't be pushed into. Because they cannot bear to be without their relatives, which is understandable. But if your relative has made their wishes known, then you should go by those wishes. I cannot think of a worse death than dying where you don't want to be. Surrounded by people in uniforms. They might be caring, but they are also prolonging the inevitable. 

I would rather die at my preferred place than at a hospital. I like most of the people I work with, but not enough to spend my dying moments with them. Far too many people die in hospital rather then their  preferred place of care. Those dying moments should, realistically, be shared by those who you love and care for. Those last moments are important, because those are the moments that stay with those who have been left behind.