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So Good evening, everybody. Welcome to the next installment of the Scottish intensive care societies. Evening education updates. Uh, welcome to those who are joining us again and hello to those that are joining us for the first time. Really. The goal of these sessions is to connect the ICU community in Scotland and beyond, and to highlight the really considerable breadth of talent and talents of of subject matter experts from across Scotland. And we've got a brilliant timetable of sessions arranged over the next several months. So please keep your eyes out for upcoming sessions. I know that many of your members of the Scottish Intensive Care Society, but just to really highlight their work. They're an organization who coordinate and represent the specialty of intensive care medicine, largely through education, research and audit. And there's various categories of membership available for all kind of healthcare professionals. And there's a number of benefits that come with membership, including reduced rates at meetings and comprehensive transfer insurance and access to various education and travel bursaries. So our speaker this evening, we're delighted to welcome Doctor Paul McConnell. If you'd like to ask any questions throughout, um, the talk, then there's a chat function on the right hand side of the screen. Um, just to tell you a little bit about Paul. So Paul is a consultant in anaesthesia the Rh in Paisley, and he has a specialist interest in law and ethics. He completed his master of laws degree at the University of Manchester, and he's currently the chair of the scientific ethics subcommittee for the European Society of Anesthesiology and Intensive Care. And in recognition of his work, he was part of the team that were awarded the Humphry Davy Medal from the college for their work in ethics and safeguarding. Outside of work, Paul likes Brazilian jiu jitsu trampoline ing Warhammer forth out for 40,000. I'm going to have to be this Sorry, Paul. I'm collecting comics. And an interesting fact about him is that he once appeared on TV with Chris, Chris Tarrant and the cranky is singing the ugly bug ball. So, uh, now were illuminated. I'm going to hand over to you, Paul. Uh, at the end, we'll come back for some questions. Great. Thank you so much for that. Jilly. Yes. So that was the highlight of my life. Age five. Getting to meet Chris Hunt. Um, So I'm here to talk to you this evening about ethical dilemmas. And I've picked a title that I think a lot of you will have heard someone say something to you or a variation of this, but he would want everything done. So I've got no conflicts of interests when it comes to presenting this. Okay, so this seems an all too common scenario, you know, for full escalation. What does that actually mean? Okay, I want us to imagine a scenario here. Okay. We've got an 82 year old man. He lives alone. He manages its activities of daily living. He's got a devoted daughter who lives two doors down. Well, he only leaves the house with heart, but he enjoys going to the shops. He's got a B m i of 19. He's presented with chest sepsis. He's now in high flow nasal cannula and his BP starting to sag. He's too drowsy to hold a discussion with the ICU team has, of course, been called. And his daughter says he would want everything done. So that's about my heart sink right there. So how should we tackle this? Should We think that this is an ethical dilemma. Should we think that this is a legal dilemma or is this Well, let's think about the first two first. Okay, let's think about the demographic stain of ICU. So around 80% of Critical Care Patient's lack capacity between five and 20% depending where you get information of critical care. Patient's die during their hospital admission. Crinkles care. Survival when associated with prolonged admission greater than 72 hours carries a significant physiological and psychological burden. 24% of survivors are readmitted to hospital within 90 days of discharge. And actually from 2019 pre covid figures, one in five survivors still die within the year. So we had the ethic, a study, and then we had a follow up ethic is to study. Okay, so Ethics one published in 2003. Okay, ethic is to in October 2019 just again ahead of covid. Okay, what did we see when we compare the difference of them? Okay, well, the average patient age had increased in ethic is too. So the average patient age was 70 versus 67. There was significantly more treatment limitations in ethic ast to that was 89.7% versus 68% back in 2003. Okay. Ah, those treatment limitations tend to add a car. Earlier on, in the admission, there was less CPR performed. An ethic is to than ethic is one. Those CPR was still more frequent in southern European and the U. S. A. And there was actually more survival after limitations of treatment. Um, in 25 said 16, but 2019. Okay, that's quite interesting. You know, that makes us think that maybe sometimes less is more. I see you isn't without its harms and burdens. So, you know, I've studied ethics. Okay, so obviously, this is an ethical dilemma. It needs an ethical solution. But how are we going to come up with that solution? Have we got a, uh, sort of, uh, set of ethical standards them that we can use or a school of thought? So we've all been to medical school. Somebody says, Tell me about medical ethics, okay. And people will recite the Georgetown mantra. Okay, so that's autonomy. The right for an individual to make their own choice beneficence. The principle of acting with the best interests in mind. Non Molefe essence. That old one going back, apparently to Hippocrates. First do no harm. And then when people say the other one, the one that we forget about justice, the principle that we should act in a fair and equal way. Well, can we apply this lens to this patient? Well, autonomy is kind of difficult because we can't ask him himself. Beneficence. Well, there might be benefits to being alive being alive. Probably a good thing, probably. What about non maleficent? It's, we know there's quite a lot of harp and burden associated with I See you and then justice. Is it fair, you know, to use our ICU beds in this way? Is there somebody that needs the ICU bed more than this person or, more accurately, would benefit more than this person. So the Georgetown mantra are four pillars aren't actually that useful. They tell us what the issues might be, but they don't actually give us some answers. Took to the fifth edition of the principles of biomedical ethics before bow shop and shoulders actually acknowledge this because the trouble is you can weigh each of these things differently and different people can do that. They're very useful at telling you that there might be an ethical dilemma. But they're not that useful in telling you what to do about it. So maybe we need something different then. So the Georgetown mantra, these four principles, they're actually very American. Okay, Now, European ethicists know we're grounded in the thoughts coming from Greece, so we might want to take a virtue based approach to this. So what about an appeal to venture? So Marty Heidegger has written an awful lot on this, and he singled out three key virtues that we should consider that of dignity, solidarity and prudence. Okay, so we've got to treat our patient's with dignity. We've got to recognize their inherent humanity, their hopes and their dreams. That sounds really good. But as the picture would suggest, it's all good, clean fun until Leo the 13th, shows up. So we might think about dignity in giving someone a dignified death. Okay, but some people within the sort of Catholic faith or others might think that dignity comes from enduring a degree of suffering. But it isn't within our rights not to treat someone that the ability to treat people has come from God, so dignity seems a really good thing to think about. But again, it's very difficult to actually define him. What about prudence? So prudence are precautionary principle. It's a bit like asking What's the worst that could happen? What is our worst outcome, and can we avoid that? But again, it's not clear what the worst outcome in this case might actually be so an appeal to virtue again, it doesn't really help, so it's kind of useful, and as much as I know what the issues are, but I still don't actually know what I'm gonna do about them. So maybe then this is a legal dilemma, and it's gonna need a legal solution. Well, let's think about this. So one of the landmark cases in medical law was the case of Bark. Now poor Mr Burke suffered from cerebellar ataxia and on the back of the bland decision, bland being the unfortunate gentleman who received severe injuries and head injuries and lip was left in a persistent vegetative state following the hills for a disaster. Um, he had his care or his support withdrawn. Now, Burke was very worried about this because he could envisage a point where he became completely dependent. He might even need ventilation, and he was worried that his artificial nutrition would be withdrawn based on what doctors wanted to do. So he took that to the European Court's, and he argued that withdrawal of his artificial nutrition would be in breach of articles to Articles three and Articles eight. Article, too, Is Your Right to life. Article three is the Prohibition of Torture. Article eight is your right to privacy and private life. So that's your sort of autonomy clause, Okay. He also argued that it would breach Article 14 and that is your right to equal treatment and avoidance of discrimination. He wanted to ensure that if he ended up on a ventilator, he would always receive artificial nutrition and hydration. It went to the European Court of Human Rights, and ultimately his application was refused. It was seen that there would be no breach in his human rights, for while he retained capacity, he could decide the burden of any treatment. However, if he reached the point where he lost capacity, then he would be treated in his best interests, and no doctor could be compelled to provide a treatment they did not consider to be appropriate. Okay, and there's a we reference for that. They're re be consent to treatment from 2002. So as a doctor, you can't be compelled to do something that you think is inappropriate. So if something is inappropriate, that then brings us to this idea of futility, or did I call it the F word? And if we're going to talk about futility, we have to ask the question, Can we define futility? Well, that's simple, yes, but like her dignity, like her justice, like her beneficence and non Molefi, since we can do it in more than one way, and that's when it's not really helpful. So futility is a controversial term. It has become unpopular with ethicists. It's a repeat its use in the 19 nineties, and if you study the literature is use is now declining, actually still features in a lot, of course, documentation. Now we've known about the concept of futility for millennia. Hippocrates himself talked about being over mastered by disease. But the trouble is, futility is ultimately subjective, and it will be based in the values of the doctor or the individual or society or the court's. The preferred term that we can be more comfortable talking about is medically inappropriate because as well see, we are the experts in medical best interests, but not necessarily overall best interests. So both jump and Children seem to like to do things in force. Okay, so four pillars. But they also described four possible states of futility, one that the procedure could not be performed due to the patient's biological state. Okay, if somebody comes in with a decapitation, there's not much you can actually do about that. To that, the procedure cannot produce the intended physiological effect. Okay, well, maybe they've got that decapitation. I can actually put a tube down in direct vision, but that's not going to make any difference. Okay, three. That the procedure cannot produce the benefit that is sought well, actually, the benefit that saw it's not getting the tube down. It's oxygenation and actually recovering from things, and then four, that the procedure has a lot of burdens, harms and costs the outweigh. It's anticipated benefits, and what we've done is gone from a very absolute state of futility, with one and two into a relative state of futility, a qualitative futility by the time we get to four. And if things are quality for that point in time, we've got to ask ourselves, Well, who can make that decision? Who applies the values in this scenario? So what about a quality versus a quantitative approach? Okay, so Schneiderman advanced this. Okay, He said a treatment is useless if it has failed in the last 100 patient's. So that's good job done. We can go home now because we've got a definition of futility. But now we've got to define uselessness. This is the trouble with philosophy, Okay? We just keep kicking the ball down the road slightly. There's no definition of useless here. What do we mean? Do we mean it's useless because the patient isn't alive at five years? Is it useless because the patient is on aliva? What year is it? Useless because it doesn't actually make any difference to the survival, but they feel more comfortable as a result of it. And actually, the case that we're going to talk about now I am coming up. Baroness Hale made actually a point about things like aromatherapy is not going to make any difference to the patient's outcome that it might make them feel a wee bit better. Therefore, is it useless? Okay, so how can we measure this? Okay, we have to ask, Is the treatment a burden to the patient? Well, that's easy if the patient has capacity, because the patient themselves can answer that. But who could define that burden if the patient cannot The patient in advance? Well, yeah, we've got advanced directives, but when it comes to end of life care, they've got to be pretty specific and thoroughly witnessed. Is it the family that makes us feel quite uncomfortable? That is it the medical team? Well, we'd probably feel more comfortable with that. Or is it the course Spoilers. The ultimate arbitral will always become the course, but we don't really want to get there. So this brings us now when we're thinking of burdens to some of these best interests and where they lie. So I said this already. Doctors might be expert in some of these medical best interests, but they're not. They're the experts in their overall best interests. Okay? They must address welfare in their widest sense. Okay. They should consider previous wishes of the patient's beliefs and values. Dame Butler Sloth talked about best interests encompassing not just their medical needs but their psychological, social spiritual beliefs as well. Now the weight given to these, though, is variable, particularly when it comes to questions of underlying capacity. And actually, if this all goes to the court's, quite often, the court's will use a scoring sheet in a tally sheet to actually compare things. I think that comes from one of the original cases. Re A. At the end of the day, people have a right to dignity, however, they choose to define it and self determination. And we talk about a strong presumption of life when thinking about these cases and court's. But as Socrates himself recognized death, maybe the greatest of all human blessings, so treatment, limiting decisions and withdrawal. So one of the biggest cases, as I had a profound effect over the last few years is James be entry. Okay, so, following a prolonged I see admission of greater than 12 months, the hospital sought permission not to further escalate Mr James care, Um, as he was in a minimally conscious state. Okay, so they're not even talking about withdrawing support here. What they're saying is, should he deteriorate again? We don't want to recommence renal support, and we don't want to restart Visa pressors now. His family opposed this, and this went through all the sort of levels of the court's in England. So in the first instance, the court protection okay, it was refused. Okay, so this court's sided with the family. They said recovery does not mean a return to full health, but a quality of life that James would regard as worthwhile. Now the Court of Appeal looked and went. This person has been in ICU now for nearly 18 months. He's in a minimally conscious state. No reasonable person would want this existence. However, in the final, summing up with Baroness Hale at the Supreme Court's, they said the reasonable patient does not exist insofar as it is possible. To ascertain the patient's wishes is those which should be taken into account because they are a component in making the choice which is right for them. So what does that actually mean? Okay, well, if you pick the judgment apart, bark still stood. A doctor could not be forced to provide treatment that was not clinically indicated. But how we define clinically indicated particularly end of life care is slightly more difficult because they said a treatment is not futile. If it brings some benefit to the patient, even if it has no effect on the underlying disease or disability. And recovery does not mean a return to full health. It means the resumption of a quality of life that the patient would regard as worthwhile. And again if we are going to talk about best interests or in Scotland under the WI benefits a patient's best interest in corporate not only their medical interests but also the patient's welfare in its widest sense. This had pretty big implications, though, because what it did, particularly the way that the appeal was thrown out was it moved from the objective patient. Okay, this sort of mythical being that we can ascribe certain values to to the subjective patient, the patient in front of us. But if every case went the way of James, you would be looking at 16 petitions to the core of protection per day in England, so that's not really sustainable as well. Okay, and it is interesting that the court's recognize that, but kind of backed off a bit. There's another quote from Baroness Hale, which says that is not to say that his wishes must prevail any more than those of a fully capable patient must prevail. We cannot always have what we want, nor will it always be possible to ascertain when Incapable patient's wishes are. Still. This case has then highlighted several problems when to seek best interests is actually fairly well defined. Who to seek them from? Well, we kind of know that, but the weight to be given to them has less defined. But if you look through your a wi your mental capacity at your mental health act, what best interests are specifically is barely defined at all. And that's really difficult because everyone comes from a place of compassion and everybody is sure that they are working in the patient's best interests. That's a really interesting the paper that have put their from Donley best interests, patient participation in the Mental Capacity act okay, really changes the way that you think about these sort of things. So we've explored things ethically. We know what the issues are. We're no further forward. We've explored things legally now, so you know roughly what you're allowed to do. But we might still not be assured what we should do in this case. So I didn't used to have that much truck with philosophy, okay? And I never got this idea of the linguistic turn. I always thought it was people talking about the inherent table nous of a table and things. But that's Ludvik victim Stein there. And he is possibly one of the greatest philosophers of all time. He thought about language. He actually argued that there was no philosophy. There was no such thing as a philosophy philosophical problem. It was all a byproduct of the misunderstanding of language. The problem is in how we communicate with each other, and that's where our difficulties lie. So maybe this is a communication dilemma. Unfortunately, that means that we're gonna have to talk. So I don't need to tell any of you guys this conflicts common okay. Within certain studies and intensive care, and in general medicine, up to 48% are supported between clinicians and family. Okay. The triggers seem to be the timing and the communication. Okay, I will do everything I can for your dad. But is my everything the same as your everything? Are we talking about the same things here? Well, we're both coming from a place of compassion and from beneficence. But we need to be clear with each other what our expectations are. So let's think about why conflict arises, okay? And it is because of potentially a difference in priorities. So we're professionals were scientists. Okay, we've got science background. Okay. We view good care as coming predominantly based on a biomedical model. We've got things that we can measure. We've got targets that we can reach. That's what's important that shows that our care has been good. The family's views on good care were mainly inspired by a sort of holistic life world approach to things. Okay. Giving good care from the healthcare professionals point of view included great attention to structure, communication and centralized decision making. But good care from families. Point of view. We'll that includes seeking exhaustive information. And if we think about some of the high profile cases beyond Daintree, some that are very emotive. If we think about Charlie Gard and Archie Evans, uh, the recent batters be keys. Okay, it's about seeking exhaustive information and participating in the end of life. Decision making are the triggers for conflict. Well, of course, there are okay. Whenever we institute our limit or withdraw life sustaining treatment, that's a potential area for conflict. Okay, whenever we think about discharging patients from the ICU, that's a potential area of, uh, conflict. How do we deal with uncertainty? Does our anxiety uncertainty translate through into anxiety and into moral dilemmas? Have the families or they're faring team, or sometimes even us got unrealistic expectations? Is there a problem in explaining the patient's diagnosis or prognosis? Is there a reluctance to address end of life care issues such as general poor communication skills? Do doctors own uncertainty about their clinical judgment? Does that cut them through? Our family's been told, one thing by the ICU team and a different thing by one of the referring teams. Other ethno cultural misunderstandings as well. So we think actually back to when we were talking about are four principles. It's really interesting. Now we have got a very Western concept of autonomy. But if you actually read literature that comes from Southeast Asia, um, and more sort of Chinese backgrounds. The approached autonomy is slightly different. There might be a more communitarian slant on to it. The family may be seen as its own entity, of which the individual patient is a part of. Do these things lead to conflict? How can we then deal with conflict? Well, we've got five things that we can think about doing. Okay, if the level of we can think of in terms of the level of cooperation and the level of competitive this. Okay, so if there's a high level of, um, cooperation, okay, but a low level of a common competitiveness, then, actually, maybe we want to accommodate the family in these cases. Okay, in the middle ground between the two is a compromise that might be seen as a good thing that I win. Or it might be seen as nobody really getting what they want. We always want to strive for collaboration with the family. And what we want to do is avoid these local operation states of avoidance or worship competition. If we think about this competition is a win lose scenario. Accommodation is a lose win scenario. Avoidance is lose. Lose compromise might be lose. Lose but it might be acceptable. We want to work in collaboration with the family and that is giving them their place to discuss their loved ones beliefs to discuss their own fears. Now that's not easy. In a short period of time, cooperation towards a common resolution for a mutual satisfactory outcome is what we want to work towards. Okay, and that sometimes means we need to think you know creatively about where we can find benefits for both parties. Okay, it requires a mutually trusting relationship, and that's we're talking and regular updates come in. And it's not easy. This is why there's a lot of work now being done on the role of mediation. We don't want to end up in court's okay if we look at the outcome of the James case in, um, entry, there was a 70% turnover in staff after that case. We want them to involve mediation. If we think that there are going to be an issue, how do we build collaborative skills there? Okay, so we actually we need to talk with families we need talk with patient's where we can we need to share each other's needs and objectives okay. We need to be honest about what those objectives are. Families have got to feel that there is a free and full shading of information. Okay, You've got to signal to them that you intend to explore alternatives. You might know what the outcome of those alternatives are, but you need to show that you're at least exploring them. Okay? Insisting joint problem solving before moving towards a solution. Okay. And if emotions get high, that's not the time to interact. Okay. What? The key skills for avoiding conflict update regularly. Listen, actively. Be honest, seek clarification and explore options jointly. I think the most important thing, though, is to be calm. Show respect and empathy. Okay, This may be all become routine for us. But for the families that you meet, this is life changing for them. We've got to point out as well. Ok, that withdrawal of therapy does not mean withdrawal of care. Okay? We talk about refocusing our care towards making sure that people are comfortable. Okay? We don't want to talk about withdrawing. That sounds as if we no longer care. It sounds as if we're taking away things. It sounds as if loved ones might suffer. Okay, so we've got to emphasize that just because we are no longer pursuing a therapy that does not mean that we're stopping to care and do what is best for their loved ones. So the thick, um, pre covid published their end of life care guidance. Okay, was published in September 19. There's an executive study summary. There's a full document at 70 pages, and there's also a lay version available as well for the public. What the key recommendations well for patient's have no realistic chance of surviving critical illness and returning to life they can value the physical and psychological burdens of invasive and distressing treatments may outweigh the potential benefits. We all agree with that, and outcomes from critical illness are not only measured in terms of survival, but also in terms of patient preferences surrounding their quality of life. Okay, this is this taking in this idea of the subjective patient, what should we do? We should avoid firm prediction's both positive or negative. Okay, um, and that can minimize conflict. Honesty and empathy and communication are essential, and lots of studies have shown that if they actually feel that the staff care for their family, they will accept bad outcomes. Okay, clear and contemporaneous documentation can aid Future discussion's okay. And that's not just from the point of view of going to court's, which we all worry about, but in mediation that can be really important as well. Okay, the use of key phrases can assist in conveying uncertainty and building understanding between critical care teams, patient's and families. Learning from previous case examples can help staff deal with new cases and dilemmas. And actually, we need to talk about discussion's that we've had with families We need to talk about when they went well or when they went badly as much as we would talk about other clinical incidents. Okay, what the recommended core elements to facilitate involvement Will. They include a family presence in ICU family support, which is access to leaflets, education psychologists, the use of patient's diaries using a structured communication tool Okay, such as value or spikes and regular family conferences and then specific consultation with ICU teams. So having a chaplaincy and social workers and psychologists and even ethicists and family navigators think some of that is coming from the literature that's been done in the States, though. But in an ideal world, we should be involving these other people to support families and to support ourselves. That's just really a summary chart there from the end of the fiction book. Okay, but you can see here that the point is to adjust and think about multidisciplinary approach is And are you reaching a consensus? And the end of life care has to ultimately be individualized. Okay, if you can't reach a consensus, then you still might end up in courtroom. You can see there at the bottom. Things might go as far as the European court. So let's get back to our scenario, then. Okay? Are 82 year old male lives alone? We're speaking to his daughter. His daughter says he would want everything done. How can we approach that? Well, we have to explore what doing everything means. So we got some take homes from this before we, um, have any questions? Well, unfortunately, we've got to accept. Okay, Conflict is common, So maybe we need to anticipate it. Okay. Futility is poorly defined. It can be quite a trigger word and best interests, though we want to use that phrase all the time are actually quite elusive. The key will always be communication. And an ethical and legal dilemma can only be solved by talking. Okay, These are emotional times. Okay? Try and have a standard wise framework that works within your department allows for flexibility. Okay. Nobody finds this easy. You have to take care of families, but you have to take care of yourselves as well. So is there a way forward? Well, there we go. There is a nice end of life care overview there. Okay, There's an uncertain prognosis. Be honest and clear about your uncertainty. Avoid firm prediction's. Okay. Ask if there are any advanced statements outlining the patient's values and wishes. Okay? Asked. Do the proposed treatments offer a minimum quality of life acceptable to the patient's, um or can they achieve their goals for a good life? Okay, Preservation of life as a physiological entity is not necessarily paramount. Okay? Preservations of a patient's preferences and values can also enable a good death. So that's a relatively quick run through this idea of futility, best interests and what we mean by he would want everything done. Um, I had a wee bit of help from Claire McLaughlin, who works in the south of England with some of the work on conflict resolution and a big thanks as well to Ken McKinley and want to seek me. We did an essay, End of Life webinar together, and a lot of this came up in that as well. So there are some useful links, and I'm now happy to take questions or open the floor to shorter speeches disguised as questions. Thank you very much, Doctor McConnell. Um, that was a great talk. We've got a few questions in the chat here for you, so I'll just go through, uh, one by one. So, um, Julie is written. We've talked about the role of mediators when communication between clinical teams and families breaks down. How does that work? In practical terms, who are they? What point do you engage? Engage them? And how do you go about engaging one? So mediation is still relatively within its embassy? Um, at the moment, there is the Medical Mediation Foundation, which is based in England but do have representatives up in Scotland as well. I think, um, when you engage one, well, that's actually a really difficult question that will be down to the individual scenario, you know, what will you be looking for? Will you be looking for signs that there is a breakdown in communication combined with the clinical scenario where you think that conflict might arise, you know from it. How is your family behaving, you know? Are they aggressive? Are they completely trying to avoid, um, updates? Are they taking lots of notes? Do you feel as if you're being constantly watched as any explanation you're given? Not quite good enough. You know, these might be triggering things. You think actually, there might be a problem in here? Um, it's useful. And some of the big centers in America talk about this about actually having communication rounds in the afternoon. So you've got your morning ward round and then a communication round with families in the afternoon. And that way, an experienced doctor can actually spend time with each of the family and try and bring the family along with them, and you'll get a feel for how well things are going there. If you don't think things are going well, that's probably the time that you want to start thinking about help. Now, whether that is help with in your own unit help from another unit in the forms of second opinions or starting to engage mediation services. Um, at that stage and as I say, the Medical Mediation Foundation is now up and running in England. And Chris Danbury, who was the expert witness in the entry case, um, as well also now runs Medical Mediation Service. He was actually so shocked by the way the entry went and saw, Um, not just the difficulty of the family, but actually the difficulties of all the staff in the unit. Because when that case went to court's, you had people in court's being aggressively cross examined during the day and then going back at night to care for Mr James. Not a huge psychological toll. So that's why he sat that up. So this will come from experience. Um, by the resources are out there, they're not wonderfully well known at the moment, but it's probably something that we need to start accessing. Okay? And it's not about admitting defeat by getting a mediator in okay, It's actually about trying to do the best for everyone. Your patient, your family and actually yourself and your team. Thank you very much. That that makes a lot of sense. I think communication rounds be, um, a really good way of kind of heading off issues at the start. Um, we've got a few questions. Um, but we've got a bit of time, which is good. So I will carry on. Um, So Helen Jordan has asked why the different levels of court's is the next level up looking at the same aspect of the case. And does it only move up to the next court's if there is a disagreement? So, um, this actually comes down to sort of legal structure more so what you have in England, you, the court, the court protection, okay. And then beyond that, that can then go to the court of appeal. And then that can go to the high court's. And then you can appeal in theory again. Go to the Supreme Court's and then you might. If all bets are off, go to the European Court's when a decision is made. Okay. They've got the appeal. Must show that the judge didn't consider something if it so you must have legal grounds for your appeal. Okay, So you could say that. You know the judge, you feel that the judge made, um, this decision, but they didn't actually take into account something else. Okay, so there must be new grounds. You can't just go and say I'm not happy with this decision in this court's. We're just going to take our decision next one up. You must then present something to the next level of court's that shows there was legal Ms thinking or more information. There must be something new, too. Either the case or you're pointing out some sort of flaw in the reasoning that was reached at the Bottom Corp. But you can't just go. I'm not happy with this. I'm not presenting more information. I'm just going to go to the next level up. I see. Thank you very much. Um, next question from Sean Keating. Um, so this is something that I had got about actually, when you were talking as well. Um, where a more distant member of the family, um, turns up or maybe has conflict with the rest of the family? Um, he's written, starts to dominate or attempt to dictate care when they're not mentioned as next of kin. in addition, how do you manage this? So it's all a bit crap, really? When that happens, and it happens all the time, you know, it seems to be more and more, you know, nephews from California. Um, come over. Um, yeah, it's difficult. So, first of all this whole notion of next of kin, uh, that doesn't really have much in the way of legal standing. Okay, At the end of the day, the person that's important is the person that's in the ICU bed, okay? And you're going to act within their best interests Now. You want to do that in a way that minimizes conflict. So you're actually going to go through the same steps here, But you have to emphasize, you know, that you are acting in this person's best interests. You have to try and communicate with them to say, Look, you know what are your object objections here? What are your objectives? You know, what are you basing this on? If you can't reach a resolution again, you're going to go through mediation and you're going to go, um, to the court's. Now, the court's will probably are are much more likely to side with the medical team in that case, because you are saying that you are acting in their best interest. This is their medical best interests. You have spoken to other family members who think that this is within their best interests, and actually, this person has come over and doesn't really know that much about the person. Okay, your focus has always got to be on the patient. There's no easy way, you know, you know, to deal with this. Um, if people come over and ultimately are malicious and want to cause trouble, they will cause trouble for you. You can only do your best to try and diffuse that. But ultimately your doctors, you can't be asked to do anything that's inappropriate. You can seek guidance. You can seek second opinions you can bring mediation in. It's all ultimately the same, of course, that you're going to go through, but it does. I think it tends to. It tends to stick in you a wee bit more when it's somebody who's not otherwise been involved in this person's life. You know that's doing that so no easy ways. The court's, if it gets that far, are far more likely, you know, to find, um, in favor of I was going to the hospital team, but find in favor of the patient, because ultimately, that's what it's all about. Is that okay? Is that cop out? So I think, um uh, just as a kind of a tendon, too, that if they if there's a conflict between the family members Well, how much do you think we have to, you know, get involved and manage that? And what? It's not a role to get involved in disputes within the family members. Okay, um, I think you know what you want to do is you want to find them, uh, family members who do know the patient best you know, who have been involved in their lives. Okay, you can say to them, you know that. Explain that you know that this more distant member of the family is causing issues, you know, that is something that ultimately they will have to sort out themselves. Okay, if the fact distant family members, you know, the at the end of the the trouble is you know, everyone is allowed their day in court's. Okay, um, and if the distant family member really wants to push and push and push and push it. You might end up there, but they'll find that they they don't really have any sort of legal basis, you know, on this Thank you very much. Um, so now I've got a question from target. Seem, how are we going to manage the conversations with parents of adult nonverbal patient's E g cerebral palsy who have had numerous difficult conversations in the past and don't believe the end of life is a possibility? I mean, this is going to sound really flippant, but with a lot of difficulty. Okay, It is difficult because these people have been there before, you know, they've had lots of these, um, conversations. At the end of the day, you have to approach them, you know, with honesty, openness. Okay, you have to emphasize that Whereas they may have survived things in the past, you know, when they were younger and when they have not had the same amount of physiological hits. Uh, that things are different now. You know, you do your best. You have to talk to them with compassion. These would be ones that you would probably want a low threshold of having second opinions, um, and bringing in mediation. So all these things can be done and a very sort of low conflict manner. Okay, um, but there's no way around That entry, you know, has in some ways, as we pointed out, opened the floodgates a bit. Okay? We want to avoid going to court. We want to use things like mediation, but we might end up there. Okay. And people's expectations can be very difficult to manage, particularly in this case. Okay, um, the adult nonverbal stuff, particularly people who have, you know, um, who are under sort of adult guardianships and things is really difficult to deal with. But even when that comes to court in the end, a guardianship, you know, a power of attorney, they still have to act in that person's best interests. Thank you very much. Um, I can't see any questions in the chat at the moment. Um, so I just had a quick question, Um, and we'll see if anybody has any more. Um, just wanted to know about kind of when you did your a slightly different topic of the master of law and kind of what you kind of how you got into doing that and how you kind of fitted that around, uh, your work. So my wife would say that I fitted around my work and family life badly. Um, but it was hugely enjoyable, okay? And it was very interesting. It's a master of laws and ethics, so there are doctors that do it, but they're also lawyers do as well. And it's interesting talking to the lawyers because the lawyers get very frightened by what we actually would consider standard day to day practice. It's very different to the way that they think about things. Has it changed my practice? Yeah, um, particularly a lot of stuff around capacity, Um, and mental health law. Um, the idea of how we're actually probably pretty bad at using substituted decision making. Okay, um, we tend to put our values onto these patient's. The relatives use substituted decision making as well. And we're not very good at supported decision making, not even shared decision making, supported decision making am as well. If you think about the mental capacity act and your other capacity, we're supposed to maximize what capacity people have, and we're still not very good at that. Okay, um, so it's affected my practice that way. It's really affected my practice when it comes to things about consent and consent for procedures as well, and has made me ask some difficult questions myself about things on euthanasia, how we define, um, autonomy and how we actually define life itself. But that's probably that's probably another lecture in itself. Have you got any questions? We've got more questions. Um, so from Joanna Morrissey, Wales. Any advice on introducing communication rounds? Make time for it. Okay, um, if you think about it, you know, if we're looking at holistic care, what do we say? We've got our biomedical model down. We're really good at that. You know, our ward round is all about that. OK, make time for communication rounds. You know, make time in the afternoon to have a designated person that can actually be available to speak to the relatives. Don't necessarily weight. No, just for one of the nurses say they want to speak to you. See if you can actually go around and speak to folk. Um, in the afternoon. Okay. Now, when we were phoning, it was strange because covid was was awful, you know? And it really took away, you know, as seeing families. But a lot of the units made efforts to have a phone communication round in the afternoon, you know? So it's possible to find the time to do that? Yes. I was thinking about the phone calls and covid in in the afternoon. How? That was kind of a model for communication rounds. Um, I've got a question here from Joe Hawkins. Um, do you think some of our problems our self inflicted I think that often we aren't honest enough with ourselves about very likely and predictable negative outcomes, Critical care. So we offer in effective treatments, just in case we are wrong, even though we aren't. Yeah, I think that's that's I think that is a pretty fair thing to say. Okay. I mean, it's difficult. We all got into this because we thought we could be heroes. We could make a difference. You know, um, you know, we're going to save lives, and we've got to have a bit of, you know, belief in our ability. Um, to do that. Okay. But we're not always right, you know. Um, I think it was 2015 paper in the Journal of Intensive Care. So they looked at and they actually came up for English. I see us a number needed to treat for I see you and it's seven. So that's pretty good. You know, if you had, you know, some sort of drug that had a number needed to treat of seven, you'd be great. That's great. OK, but there's an awful lot of burden that comes with that seven. Okay, because, you know, we're admitting people that might get better by themselves, but we're also admitting a cohort of people that aren't going to get better regardless of what we do. Okay. And everyone is always looking for hope, you know, And that's part of the cruelty of intensive care, because we're the bit where the hope definitely stops at that point in time. You know, um, it's a bit like we talked about going for those, you know, one course and a higher court and a higher court's. And if you think you're coming through the hospital, you know, and you've seen any and you've seen the acute medics and you've been in HD you and you've been in ICU and it's got, you know, less hope each time. But each time you move to a different. But there's always that bit of hope you know has been dangled. Okay, so some of that is a self inflicted, you know, a problem. Okay, but it's very difficult to know what to do about that. Um And I think you know, what would you worry most more about? Would you worry more about you admitted somebody to intensive care And you treated them for 40 hours and you saw that they weren't getting any better or that you didn't admit them. And then you had that worry that you might have been able to do something else. So I think as we become more holistic, as things move on, we are sort of victims of both our own success in our own feelings. That makes a lot of sense. Um, I have a question from Sanja an an kuma. Can we involve local palliative care teams in initiating withdrawal of treatment? Discussion's in ICU. That's very useful, you know, and I think it's probably it's very difficult because different hospitals have different levels of palliative care resource. You know, um, we have on several occasions have palliative care in at the Rh in ICU. Um, and it's always been uniformly excellent. You know, when it happens, these people are specialists in this. So I think it is something that you should approach your local palliative care teams. Um, with it's probably a resource that we don't make enough use of. But we also know that palliative care teams are hugely stretched, um, as well. But I would welcome anyone that that wanted to persist with that. So thanks. Thanks, everyone, for for the questions. That was brilliant. And And thank you so much. Doctor McConnell for the talk. Um, Julie just popped a couple of slides up here as well if we don't have any more questions. Um, so I got to mention our ASM in March 2nd and third of March in ST Andrews. Um, got a really packed program for you there. Um, so all the details are on that poster there. And for the next month, Um, next month's talks going to on the 16th of February. Um, so we've got, um, Doctor Rada. Same Darren talking to us about the exam, and I'm going to get a candidate as well to come and speak. Um, so that will be for trainers and trainees to help prepare for the thick. Um um So if we've got no more questions, Um, well, thank Doctor McConnell again. And the feedback form we've just popped in the chat. There would be really grateful if you could fill that out, please. So thanks everyone for coming and see you all next month. Thank you very much. Thank you very much. Bye, everyone.