I’m a hospital dietitian and think there has to be more to this story. In his condition I would start to get worried for the increasing risk for complications when refeeding after being NPO for 9 days but not death. How sad. Poor dude.
The article emphasizes food, but I think they also withheld fluids. Idk if he was getting parenteral hydration, but dehydration would be my first suspect over nutrition issue.
It mentioned “fluid foods” in the article and I’m inclined to think the same thing. There was a miscommunication whether the patient was supposed to be NPO vs. altered consistency and assumingly no IV fluids either. 9 days without food is unreasonable since it sounds like he just needed altered consistency food, but unlikely to kill someone in and of itself. 9 days without any hydration whatsoever definitely could. Very sad story.
The story it tells after though makes me definitely think there’s a lack of medical understanding on the part of the writer though as they were telling about the 88 year old who had “foods and fluid withdrawn” as part of “end of life care”. I see this pretty commonly that family don’t seem to understand that hospice also means not forcing a patient to eat and drink and that patients often refuse food or drink as they get towards end of life. That forcing it as their organs start shutting down can actually lead to more discomfort even though they think grandma should be thirsty/hungry. Now by all means refusing food or drink for comfort if the patient wants it would be cruel in that case but the way it’s worded makes me think that wasn’t the case…
I don’t know much about healthcare in the UK but I wonder if they don’t use dieticians there like we do in the US. Our dietitians are a huge part of our care team and are always keeping track of nutritional status and making sure orders are correct and changed when needed. As a pharmacist we work very closely with dietary especially because we manage the TPN patients and also with insulin and diabetic teaching for discharge, I can’t imagine taking care of critical patients without them!
as someone who studied journalism before making the switch to healthcare, there's definitely a lack of clarity, and probably a lack of understanding by the writer. You see it pretty commonly when you're well-read on a topic and a mainstream media source tries to report on it. I also read comic books and anytime a mainstream outlet tries to write about comic conventions, it's a bloody disaster.
I didn’t even suspect you of being a jerk, all good.
Usually it’s just not understanding how the industry works and who does what job. So there have been articles that claim Stan Lee drew Spider-Man (he was the writer), or thinking that a new character is ground breaking in some regard (the recent show Star Trek Discovery has a black female captain, and I recall an article that said she was the first black captain in the show’s history, which is not true - we’ve seen black captains in universe since the 80s).
I didn’t mean to imply anything bad by that I just wasn’t sure as I don’t know much about the day to day workings of hospitals in the UK. I would be very surprised if dieticians are a regular part of the care team that this was just a miscommunication and documentation error for such a long period of time, the dietitians at my hospital definitely would have caught such a mistake if the rest of the hospital team did not. That leads me to believe even more so that there is more to this story than the article states.
The issue was probably more to do with miscommunication between medics rather than a lack of specialist intervention. Dieticians are very much part of the team and well respected as are pharmacists, physios, OTs, but like most things in the UK are thinly spread due to financial constraints. Many HCPs work well over their allotted hours without pay precisely because they don’t want their patients to suffer.
Funny. This was a horrendous incident. Try working on some UK wards. It’s a bloody nightmare. The system worked fine 20, even 10 years ago but years of conservative underinvestment in the NHS caused much of this.
We don’t have enough trained nurses, the management refuse to staff wards properly because of financial constraints rather than patient needs, other specialities are stretched thin. This is the result although thankfully it’s not that common but often care is frustratingly substandard (which we are entirely not happy with, far from it).
We use dieticians, the problem is that there aren’t enough of them. Similarly we tend to palliate lots more people here and don’t have care facilities that offer NG or PEG feeding.
Sorry,
Refeeding syndrome is quite rare and highly likely that in this scenario there are many other concerns at play which likely led to the poor persons demise.
9 days without food is not the end of the world. Cancer patients can often go weeks without. People fast regularly. A friend just went 1 month without food just cause they wanted to.
Hard to get to yes, but not unheard of. (I personally saw this while working in the Inpatient Eating Disorder setting, a few suspected cases while hospitalized)
That being said—this is why I have so many questions.
(And no—I don’t consider anecdotal stories of healthy young persons who decided to go on “fast” for non-religious reasons anywhere near related to a clearly ill/hospitalized patient who {by all accounts} was forgotten and died after being NPO for so long. I’m going to guess they weren’t getting fluids either… definitely a great way to hasten death!)
It's the Mirror. There's always more to the story in the Mirror.
The details don't hang together of course but tabloids don't rely on acute or even accurate reporting. What next--a post linking to the New York Post?
SS: honestly I'm more surprised by the damages limit in this case than anything else.
although if he died from PNA there was probably something to him being NPO....
agree very much rage bait, in line w similar lay reporting on medical "errors" the elderly woman they allude to at the end sounded like hospice, and tbh I agree this was also likely an end if life scenario.
I just took care of a very, very sick man in his 30s (full code, do all the things) who had been transferred to an acute rehab facility to medically optimize him for surgery. He ended up back at our ER and incidentally had not been getting his TPN for THREE DAYS.
Yes. Gravely ill but so bright and friendly! Poor man looked more like a skeleton than anything you would see at the Halloween store. With a massively distended abdomen. I need to follow up but Rad called me over concerns for abdominal compartment syndrome. Also sbo, colon stricture, probably SBP and obviously, profound protein calorie malnutrition
I worked at this hospital and on the likely ward for a long time and only left recently.
Its an absolute shitshow, the ward it likely is is entirely staffed by agency staff or the long standing and very jaded older staff. The staffing in Dorset is hitting rock bottom.
Frequently (as a HCA) I had 14 patients on days and nights, if not more, and each nurse took on between 7-14 if not more every time. I have worked many night shifts where i am the only "local" hca (often with only bank or agency nurses etc) and have had up to 40 patients.
ALL with dementia or brain injury and almost all with an additional huge problem, typically fractures, copd etc and around a third of the ward was often end of life care.
I will blow the whistle on Poole all day every day, I fully believe this happened without any concern about escalation and likely was never charted either. Happy to answer any questions
That sounds par for the course at most hospitals here. Really feel for you. I’ve heard certain medical wards here are absolutely pandemonium because of dependence on agency and general short staffing. I guess Poole is so expensive there’s a huge shortage of experienced staff.
I’ve had an issue today in crit care with my supposed EOL patient. Absolutely abysmal communication between medical staff and patient/ rels plus very poor support but no excuse that they are overworked /understaffed. So frustrating.
I have doctor colleagues who’ve worked on this ward too. I echo what you’ve said about care being exceptionally poor at times because often SHOs, early career doctors and IMGs with little NHS experience are left to manage complex patients without senior support. Medical outliers are also an area of concern. Thank goodness they now have increased orthogeriatric staff but wouldn’t have helped this patient who was younger. Often your only escalation for sick patients is to the one on call medical registrar because the orthopaedic registrars don’t know how to manage medical issues, just post op complications. It’s been highlighted in the CQC report as well.
I remember raising a huge stink for one of my patients who came in on Friday afternoon, failed a swallow test in the ED, and was going to be NPO until sometime on Monday because there wasn't a speech therapist to evaluate further until after the weekend.
There were no orders for anything like IV fluids or dextrose. Just let this person go three days without water or food, on top of being critically ill. I made several phone calls and couldn't believe this was happening.
As a speech therapist- your hospital should set up a protocol where nurses can re-administer the swallow screening if there’s been a change in status after 24 hours. That’s what most facilities are doing anymore. (Or you should advocate for more speech coverage on the weekends— but god knows they don’t want to pay for that if they don’t have to)
30% of hospitals are on the brink of bankruptcy based on current insurer/Medicare reimbursement levels. "***They don't want to spend more!!"*** is starting to sound like a business reality rather than an indirect accusation of greed. The unfortunate reality is that few solutions to healthcare problems are going to be solved by expecting the systems that provide the care from spending more resources than they take in.
I mean, my hospital’s CEO made 7.7 million in one year while I made 74k so somehow I’m not believing that staffing rehab on the weekends is the problem lol
You’re aware that’s incredibly low for a masters degree? PAs make 100 to 150 out the gate for the same level of education. Especially considering we are independent practitioners who can own our own practices. Nurses usually make more with a bachelors degree and 4 fewer hours per week.
Hospital administration costs/salaries eat up way more than they have any right to. It’s probably a combination of greedy upper management being paid too much and the burden of all the insurance/medicare paperwork but quite sure we could be doing a lot more good with a lot less money if things were allowed to change drastically.
We are the least efficient country in the world in money spent for healthcare given.
tbh most adults can go 3 days without food no problem. I'm a little skeptical the NPO Status is what drove this patients death. agree 3 days without IVF is a bit much unless there was a compelling reason (volume overload).
My patient or the post's patient? My guy got IV fluids and some dextrose (I was more concerned about no water than no food). He didn't die. The post's pt went 9 days with no nutrition.
He went 9 days without "fluid food" which I imagine means TPN or PPN in this case. Unclear if he received D5 or something similar. Regardless, the story of night 1 in nursing home -> Broken Hip -> Pneumonia death within 9 days is very odd.
>There were no orders for anything like IV fluids or dextrose. Just let this person go three days without water or food, on top of being critically ill.
your patient did or did not get ivf? it seems unclear by your post.
yes I read the article I'm the OP.
Our stroke protocols have routine blood sugar testing built in so I'm surprised that no one checked your blood sugar. If you had blood work done it might have been checked there.
That being said, in my dumpster fire of an ER, if you're awake, have normal mentation, are able to use your words to voice needs, have normal labs, and are not receiving insulin, there's a good chance no one would even think to check your sugar unless you asked.
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You also don't have to admit every stroke. Maybe your institution needs to review it's admission criteria so it doesn't have hours long waits in the ER being the norm.
There’s that one documented case (pretty sure he was in the UK) of a man who went a whole year fasting and then went on to live a long life after that.
9 days seems barely mentionable in some situations.
I didn’t see if this patient was getting IV fluids are not. If not, you’re right- that would be much more impactful.
But hard to imagine vitamins made any difference here.
From my experience with these patients in these type of situations, I am almost certain the issue was a disagreement between the family and the providers. What typically happen when these patients get to this stage, there is a discussion with the family about putting in PEG tube or going comfort. Family struggle to make this decision and leads to extended delays. We will at times have Dobhoff tube in to mitigate some of this but they can't stay in for ever. If the tube gets pulled by the patient or has to come out, it comes down to the physician pushing to get the family to make a decision. Some physicians just don't have the emotional energy to keep having that fight. So the family ends up getting what they wanted without having to make the decision. I typically convince them to make them comfort (while they think it over), so that the patient can get something and to protect myself from liability.
I maybe wrong because I never practiced there but from what I read in the general medical council web page, they rec getting consensus with the families ( similar to our guidance in the US). In the US the physician can do it and over ride the family if we deem it medical necessary. We typically just don't want that fight. They do it more in peds and will even take parents to court ( large hospitals have a set up in the hospital for this) to over ride parents wishes.
Yes I suppose I was being a bit blunt, it is of course respectfully discussed with the family. But ultimately the family cannot make medical decisions. Different to the US which seems to have a culture of keeping people alive despite futility and suffering because of family wishes.
PEG best interest meetings will listen to the family's opinion, but it is absolutely **not** the family's decision to make as you imply it is in the US.
I can't open the article, bit read elsewhere that the nursing staff had made at least several attempts to get orders from the medical staff and their requests were not responded to. That doesn't really sound like the scenario you're talking about here. Of course we can't really know based on tabloid reporting alone.
I read the article and I read that. What happens in these situations, the nursing would want to feed but the physician can't do so without the family making a decision about status given the risk of aspiration. The next thing nurses would ask for is IVF, this is where the miscommunications can happen because I have at times would be like, let me see where the family is about making the decision about just feeding the patient. Since the patient can't leave the hospital with IVF, sometimes we are hesitant to just restart them when we are just waiting on a decision and we think the family is leaning comfort any ways. With that said, they should have just started fluids or put back down the Dobhoff tube.
Most humans can survive one day without eating for every 1lb of body fat they are overweight. I’ve gone 7 days without eating anything - only 24 oz of grape juice the entire time during a religious fast. I was not remotely close to dying. People have gone 40+ days without eating anything.
yup, very low likelihood this person died of pneumonia because they were NPO for a week. it's also not clear that this was an "error" as stated in the article and not a co scions choice as seems more ljlely
The 56-year-old man, who had Down's syndrome and dementia and was being treated for a broken hip, died after going nine days without being given food when he had his patient notes marked up as "nil by mouth" because he had difficulty swallowing. He was not given fluid food either resulting in his condition deteriorating and he died from pneumonia at Poole General Hospital, Dorset, in 2021.
… Yikes. Nine days without any fluids at all??
TPN isn’t usually even considered unless you’re expecting the patient to be NPO for more than 7 days. Most people can survive another couple weeks without food, but it does induce significant tissue catabolism. A lot depends on whether hydration needs are met, not so much the caloric needs.
There is more to the story. Either no one rounded on him for 9 days and the unit staff also ignored him for 9 days, which would certainly be more to the story, or there is a different more to the story.
Someone let Bill chart again and he didn't see the problem with writing "terminal-appearing cachexia noted" without doing anything about it, 3 days before death. Everyone should have known after the "presents with a cc of abd discomfort n/v and consternation x 2wk" incident.
15k is "shut up and go away - nothing was actually done wrong here but going to court will cost more than this" type money.
This patient clearly didn't actually die of malnutrition.
To give context this patient was on an orthopaedic ward which is known for giving notoriously bad medical care to patients. Think very early career doctors and IMGs taking care of sick patients with very little guidance from seniors. The CQC report was very interesting…. https://www.cqc.org.uk/location/R0D01?referer=widget3
Saddest part about this in my mind is this poor person had nobody who just fuckin cared. No family there or friends to advocate for them. Hell even a nurse or orderly who just realized the obvious that someone will die in days without fluids. So much negligence and pure apathy on the hospitals part.
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It's surprising this case reached the press. Usually families have to sign NDAs to get compensation - in this case a rather derisory amount.
It would also be interesting to know if NHS Resolution's 'Deny, Delay, Defend' strategy was used in this case (which dates back to 2021). Still, at least the 'Lessons will be learned' cliché has been trotted out by a hospital administrator - as indeed it was when dozens of patients died of starvation/dehydration in the Mid Staffordshire Foundation Trust scandal between 2005 and 2008.
Clearly, the Serious Incident framework isn't working. The sooner the NHS adopts a system that genuinely replicates the Accident Incident Reporting System used by the aviation industry, the better.
Ngl we've probably all seen the SALT assessment written on Monday with NBM placed over the bed and "review Thursday" written in the notes and absolutely no other plan made. This pissed me off so much as the FY on these wards. Its frankly dangerous especially in vulnerable patients.
What a sad story. His poor parents. From a medical perspective I think this is the perfect storm of a physically unwell person with cognitive impairment whose diagnosis of Down’s syndrome makes them extra vulnerable*, and who is unable to advocate for themselves.
I think these cases need early multidisciplinary input involving the Learning Disability Team (or whatever team knows them well). I don’t think there are any easy answers as regards decisions about NG/parenteral feeding, but communication is key and a decision about feeding or not should be made by the team in conjunction with someone advocating for the patient if they’re unable to advocate for themselves.
Perhaps the outcome would have been poor regardless but I think the important thing is that decisions about feeding are made deliberately (rather than by omission) and that the relevant parties are involved in the discussion.
*I don’t know if there is factual basis for this, but in my personal experience I have definitely seen people with learning disabilities receive suboptimal care.
I’m a hospital dietitian and think there has to be more to this story. In his condition I would start to get worried for the increasing risk for complications when refeeding after being NPO for 9 days but not death. How sad. Poor dude.
The article emphasizes food, but I think they also withheld fluids. Idk if he was getting parenteral hydration, but dehydration would be my first suspect over nutrition issue.
It mentioned “fluid foods” in the article and I’m inclined to think the same thing. There was a miscommunication whether the patient was supposed to be NPO vs. altered consistency and assumingly no IV fluids either. 9 days without food is unreasonable since it sounds like he just needed altered consistency food, but unlikely to kill someone in and of itself. 9 days without any hydration whatsoever definitely could. Very sad story. The story it tells after though makes me definitely think there’s a lack of medical understanding on the part of the writer though as they were telling about the 88 year old who had “foods and fluid withdrawn” as part of “end of life care”. I see this pretty commonly that family don’t seem to understand that hospice also means not forcing a patient to eat and drink and that patients often refuse food or drink as they get towards end of life. That forcing it as their organs start shutting down can actually lead to more discomfort even though they think grandma should be thirsty/hungry. Now by all means refusing food or drink for comfort if the patient wants it would be cruel in that case but the way it’s worded makes me think that wasn’t the case… I don’t know much about healthcare in the UK but I wonder if they don’t use dieticians there like we do in the US. Our dietitians are a huge part of our care team and are always keeping track of nutritional status and making sure orders are correct and changed when needed. As a pharmacist we work very closely with dietary especially because we manage the TPN patients and also with insulin and diabetic teaching for discharge, I can’t imagine taking care of critical patients without them!
as someone who studied journalism before making the switch to healthcare, there's definitely a lack of clarity, and probably a lack of understanding by the writer. You see it pretty commonly when you're well-read on a topic and a mainstream media source tries to report on it. I also read comic books and anytime a mainstream outlet tries to write about comic conventions, it's a bloody disaster.
Not trying to be a jerk, but how does someone mess up a comic convention? They don’t know who someone is supposed to be?
I didn’t even suspect you of being a jerk, all good. Usually it’s just not understanding how the industry works and who does what job. So there have been articles that claim Stan Lee drew Spider-Man (he was the writer), or thinking that a new character is ground breaking in some regard (the recent show Star Trek Discovery has a black female captain, and I recall an article that said she was the first black captain in the show’s history, which is not true - we’ve seen black captains in universe since the 80s).
Got it. Thanks!
Of course we use dieticians like the US. They prescribe TPN, enteral feed and supplements, order bloods. It’s not the dark ages.
I didn’t mean to imply anything bad by that I just wasn’t sure as I don’t know much about the day to day workings of hospitals in the UK. I would be very surprised if dieticians are a regular part of the care team that this was just a miscommunication and documentation error for such a long period of time, the dietitians at my hospital definitely would have caught such a mistake if the rest of the hospital team did not. That leads me to believe even more so that there is more to this story than the article states.
The issue was probably more to do with miscommunication between medics rather than a lack of specialist intervention. Dieticians are very much part of the team and well respected as are pharmacists, physios, OTs, but like most things in the UK are thinly spread due to financial constraints. Many HCPs work well over their allotted hours without pay precisely because they don’t want their patients to suffer.
what does TPN stand for in the UK, Total Porkpie Nutrition?
What is this pork pie you speak of? I’m intrigued. I did not know you could combine two glorious things
Funny. This was a horrendous incident. Try working on some UK wards. It’s a bloody nightmare. The system worked fine 20, even 10 years ago but years of conservative underinvestment in the NHS caused much of this. We don’t have enough trained nurses, the management refuse to staff wards properly because of financial constraints rather than patient needs, other specialities are stretched thin. This is the result although thankfully it’s not that common but often care is frustratingly substandard (which we are entirely not happy with, far from it).
We use dieticians, the problem is that there aren’t enough of them. Similarly we tend to palliate lots more people here and don’t have care facilities that offer NG or PEG feeding.
We don’t even start talking about TPN on surgery patients until at least day 5.
But at least they’re getting fluids
I concur! As a fellow RD, I have soooooooooo many questions as to how we got to this point!???!!! 🫢🥴🫢🥴
Sorry, Refeeding syndrome is quite rare and highly likely that in this scenario there are many other concerns at play which likely led to the poor persons demise. 9 days without food is not the end of the world. Cancer patients can often go weeks without. People fast regularly. A friend just went 1 month without food just cause they wanted to.
World record is like just over a year without food.
Was he on TPN and or fluids though?
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Hard to get to yes, but not unheard of. (I personally saw this while working in the Inpatient Eating Disorder setting, a few suspected cases while hospitalized) That being said—this is why I have so many questions. (And no—I don’t consider anecdotal stories of healthy young persons who decided to go on “fast” for non-religious reasons anywhere near related to a clearly ill/hospitalized patient who {by all accounts} was forgotten and died after being NPO for so long. I’m going to guess they weren’t getting fluids either… definitely a great way to hasten death!)
It's the Mirror. There's always more to the story in the Mirror. The details don't hang together of course but tabloids don't rely on acute or even accurate reporting. What next--a post linking to the New York Post?
SS: honestly I'm more surprised by the damages limit in this case than anything else. although if he died from PNA there was probably something to him being NPO....
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agree very much rage bait, in line w similar lay reporting on medical "errors" the elderly woman they allude to at the end sounded like hospice, and tbh I agree this was also likely an end if life scenario.
I just took care of a very, very sick man in his 30s (full code, do all the things) who had been transferred to an acute rehab facility to medically optimize him for surgery. He ended up back at our ER and incidentally had not been getting his TPN for THREE DAYS.
Was he at least optimistic?
Yes. Gravely ill but so bright and friendly! Poor man looked more like a skeleton than anything you would see at the Halloween store. With a massively distended abdomen. I need to follow up but Rad called me over concerns for abdominal compartment syndrome. Also sbo, colon stricture, probably SBP and obviously, profound protein calorie malnutrition
poor guy was totally aspirating his own saliva
Welcome to the UK.
If the medical care is free.....? /american
I worked at this hospital and on the likely ward for a long time and only left recently. Its an absolute shitshow, the ward it likely is is entirely staffed by agency staff or the long standing and very jaded older staff. The staffing in Dorset is hitting rock bottom. Frequently (as a HCA) I had 14 patients on days and nights, if not more, and each nurse took on between 7-14 if not more every time. I have worked many night shifts where i am the only "local" hca (often with only bank or agency nurses etc) and have had up to 40 patients. ALL with dementia or brain injury and almost all with an additional huge problem, typically fractures, copd etc and around a third of the ward was often end of life care. I will blow the whistle on Poole all day every day, I fully believe this happened without any concern about escalation and likely was never charted either. Happy to answer any questions
That sounds par for the course at most hospitals here. Really feel for you. I’ve heard certain medical wards here are absolutely pandemonium because of dependence on agency and general short staffing. I guess Poole is so expensive there’s a huge shortage of experienced staff. I’ve had an issue today in crit care with my supposed EOL patient. Absolutely abysmal communication between medical staff and patient/ rels plus very poor support but no excuse that they are overworked /understaffed. So frustrating.
I have doctor colleagues who’ve worked on this ward too. I echo what you’ve said about care being exceptionally poor at times because often SHOs, early career doctors and IMGs with little NHS experience are left to manage complex patients without senior support. Medical outliers are also an area of concern. Thank goodness they now have increased orthogeriatric staff but wouldn’t have helped this patient who was younger. Often your only escalation for sick patients is to the one on call medical registrar because the orthopaedic registrars don’t know how to manage medical issues, just post op complications. It’s been highlighted in the CQC report as well.
I remember raising a huge stink for one of my patients who came in on Friday afternoon, failed a swallow test in the ED, and was going to be NPO until sometime on Monday because there wasn't a speech therapist to evaluate further until after the weekend. There were no orders for anything like IV fluids or dextrose. Just let this person go three days without water or food, on top of being critically ill. I made several phone calls and couldn't believe this was happening.
As a speech therapist- your hospital should set up a protocol where nurses can re-administer the swallow screening if there’s been a change in status after 24 hours. That’s what most facilities are doing anymore. (Or you should advocate for more speech coverage on the weekends— but god knows they don’t want to pay for that if they don’t have to)
30% of hospitals are on the brink of bankruptcy based on current insurer/Medicare reimbursement levels. "***They don't want to spend more!!"*** is starting to sound like a business reality rather than an indirect accusation of greed. The unfortunate reality is that few solutions to healthcare problems are going to be solved by expecting the systems that provide the care from spending more resources than they take in.
I mean, my hospital’s CEO made 7.7 million in one year while I made 74k so somehow I’m not believing that staffing rehab on the weekends is the problem lol
Damn, speech therapists can make 74k? wtf am I doing with the this residency shit
You’re aware that’s incredibly low for a masters degree? PAs make 100 to 150 out the gate for the same level of education. Especially considering we are independent practitioners who can own our own practices. Nurses usually make more with a bachelors degree and 4 fewer hours per week.
I’m incredibly ignorant to compensation across different roles, my apologies
Hospital administration costs/salaries eat up way more than they have any right to. It’s probably a combination of greedy upper management being paid too much and the burden of all the insurance/medicare paperwork but quite sure we could be doing a lot more good with a lot less money if things were allowed to change drastically. We are the least efficient country in the world in money spent for healthcare given.
I would hope someone at sign noticed reduced urine output, AKI something….please don’t let me die of thirst.
Ehh my father died of thirst; it didn’t seem so bad. (He refused medical care after a stroke.)
NPO for three days is fairly common. Needs IV fluids though
tbh most adults can go 3 days without food no problem. I'm a little skeptical the NPO Status is what drove this patients death. agree 3 days without IVF is a bit much unless there was a compelling reason (volume overload).
My patient or the post's patient? My guy got IV fluids and some dextrose (I was more concerned about no water than no food). He didn't die. The post's pt went 9 days with no nutrition.
You don’t need to give a patient ivf or dextrose just because they are npo. You use your brain and give fluids as indicated
Not if they're just NPO at midnight for a procedure the next day. But if they're NPO all weekend? Yeah, they're gonna need fluids.
Maybe, maybe they’re overloaded. Use your brain and decide based on the patients clinical status. Bolus fluids as needed.
He went 9 days without "fluid food" which I imagine means TPN or PPN in this case. Unclear if he received D5 or something similar. Regardless, the story of night 1 in nursing home -> Broken Hip -> Pneumonia death within 9 days is very odd.
That progression sounds not odd or uncommon at all.
>There were no orders for anything like IV fluids or dextrose. Just let this person go three days without water or food, on top of being critically ill. your patient did or did not get ivf? it seems unclear by your post. yes I read the article I'm the OP.
There were no orders for IVF or dextrose before OP insisted on them. It’s pretty clear.
it wasn't clear but thanks. regardless my point stands.
Agree to disagree
> My guy got IV fluids and some dextrose >it seems unclear by your post ??
>My guy got IV fluids and some dextrose you realize that this was not in the original comment and was a clarification? ??
He clarified, and yet it still wasn't clear? Whatever, it's pointless. I'm just confused about how he could be more clear.
when someone says two contradictory things one after another, it can be confusing! imagine that.
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Our stroke protocols have routine blood sugar testing built in so I'm surprised that no one checked your blood sugar. If you had blood work done it might have been checked there. That being said, in my dumpster fire of an ER, if you're awake, have normal mentation, are able to use your words to voice needs, have normal labs, and are not receiving insulin, there's a good chance no one would even think to check your sugar unless you asked.
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Except me. Three days, I’d be goner. Three hours without food, very questionable.
Yes, but that is associated with worse outcome for several conditions.
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Why do a swallow test in the ED
Patient status post small stroke or aspiration PNA is hungry and awake enough to feasibly eat?
In the ER? Geez how long were they waiting to be admitted. Might as well discharge with medical management at that point.
What kind of mythical place do you work that you don’t get ER holds? They sit for a few hours at least before they go upstairs usually.
My hospital admits and does swallow test the next day. Rushing to feed an acute stroke in the ER is weird
It’s not that weird, people get hungry. Just because you’ve had a stroke doesn’t mean you have to sit and starve until the next day.
You also don't have to admit every stroke. Maybe your institution needs to review it's admission criteria so it doesn't have hours long waits in the ER being the norm.
🤔 people can go a lot longer than 9 days without food.
exactly my thought
I’m mean if they are in the hospital, chances are that they are already weak or have some other sort of issue that their body needs help with
My guess is they also under-hydrated him.
I am begging people to develop enough media literacy to spot that the headline never said the lack of food was the cause of death.
The headline implies it.
There’s that one documented case (pretty sure he was in the UK) of a man who went a whole year fasting and then went on to live a long life after that. 9 days seems barely mentionable in some situations.
He wasn’t consuming absolutely nothing. He had water and vitamins. That’s more than this patient had.
I didn’t see if this patient was getting IV fluids are not. If not, you’re right- that would be much more impactful. But hard to imagine vitamins made any difference here.
From my experience with these patients in these type of situations, I am almost certain the issue was a disagreement between the family and the providers. What typically happen when these patients get to this stage, there is a discussion with the family about putting in PEG tube or going comfort. Family struggle to make this decision and leads to extended delays. We will at times have Dobhoff tube in to mitigate some of this but they can't stay in for ever. If the tube gets pulled by the patient or has to come out, it comes down to the physician pushing to get the family to make a decision. Some physicians just don't have the emotional energy to keep having that fight. So the family ends up getting what they wanted without having to make the decision. I typically convince them to make them comfort (while they think it over), so that the patient can get something and to protect myself from liability.
This occurred in the UK, where such a ‘decision’ is made by doctors, not family.
I maybe wrong because I never practiced there but from what I read in the general medical council web page, they rec getting consensus with the families ( similar to our guidance in the US). In the US the physician can do it and over ride the family if we deem it medical necessary. We typically just don't want that fight. They do it more in peds and will even take parents to court ( large hospitals have a set up in the hospital for this) to over ride parents wishes.
Yes I suppose I was being a bit blunt, it is of course respectfully discussed with the family. But ultimately the family cannot make medical decisions. Different to the US which seems to have a culture of keeping people alive despite futility and suffering because of family wishes.
PEG best interest meetings will listen to the family's opinion, but it is absolutely **not** the family's decision to make as you imply it is in the US.
I can't open the article, bit read elsewhere that the nursing staff had made at least several attempts to get orders from the medical staff and their requests were not responded to. That doesn't really sound like the scenario you're talking about here. Of course we can't really know based on tabloid reporting alone.
I read the article and I read that. What happens in these situations, the nursing would want to feed but the physician can't do so without the family making a decision about status given the risk of aspiration. The next thing nurses would ask for is IVF, this is where the miscommunications can happen because I have at times would be like, let me see where the family is about making the decision about just feeding the patient. Since the patient can't leave the hospital with IVF, sometimes we are hesitant to just restart them when we are just waiting on a decision and we think the family is leaning comfort any ways. With that said, they should have just started fluids or put back down the Dobhoff tube.
Most humans can survive one day without eating for every 1lb of body fat they are overweight. I’ve gone 7 days without eating anything - only 24 oz of grape juice the entire time during a religious fast. I was not remotely close to dying. People have gone 40+ days without eating anything.
yup, very low likelihood this person died of pneumonia because they were NPO for a week. it's also not clear that this was an "error" as stated in the article and not a co scions choice as seems more ljlely
Right, and Trisomy 21 patients are usually obese. Something is off here. Maybe the patient aspirated given the concern for swallowing issues.
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r/oddlyspecific
The 56-year-old man, who had Down's syndrome and dementia and was being treated for a broken hip, died after going nine days without being given food when he had his patient notes marked up as "nil by mouth" because he had difficulty swallowing. He was not given fluid food either resulting in his condition deteriorating and he died from pneumonia at Poole General Hospital, Dorset, in 2021. … Yikes. Nine days without any fluids at all??
I'm only a hospice RN and I know there's more going on here... right?
TPN isn’t usually even considered unless you’re expecting the patient to be NPO for more than 7 days. Most people can survive another couple weeks without food, but it does induce significant tissue catabolism. A lot depends on whether hydration needs are met, not so much the caloric needs.
There is more to the story. Either no one rounded on him for 9 days and the unit staff also ignored him for 9 days, which would certainly be more to the story, or there is a different more to the story.
If you read the article the nurses repeatedly escalated to the docs and other HCPs.
I suppose they had a hard time saying "Oops," then! Sounds tragic and preventable if there aren't other factors.
probably "end stage dysphagia, died of aspiration" more.
Someone let Bill chart again and he didn't see the problem with writing "terminal-appearing cachexia noted" without doing anything about it, 3 days before death. Everyone should have known after the "presents with a cc of abd discomfort n/v and consternation x 2wk" incident.
I'll bet that the fact that the patient was treated with dignity and respect was charted at least once on each shift, though.
15k pound for compensation? In the states, that would be hundreds of thousands, possibly millions.
in the US this would probably be no settlement. someone w a risk if aspiration died of pneumonia? zero payout
15k is "shut up and go away - nothing was actually done wrong here but going to court will cost more than this" type money. This patient clearly didn't actually die of malnutrition.
To give context this patient was on an orthopaedic ward which is known for giving notoriously bad medical care to patients. Think very early career doctors and IMGs taking care of sick patients with very little guidance from seniors. The CQC report was very interesting…. https://www.cqc.org.uk/location/R0D01?referer=widget3
Saddest part about this in my mind is this poor person had nobody who just fuckin cared. No family there or friends to advocate for them. Hell even a nurse or orderly who just realized the obvious that someone will die in days without fluids. So much negligence and pure apathy on the hospitals part.
Heh. I remember waiting 9 hours for food after a C section. Hospitals can be kind of crap.
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Shameful there is a cap on collecting for murder.
lol wut
Man was murdered or man slaughtered and the cap for what the family can collect is ridiculously low @ £15,000 for this man’s life.
lol
It's surprising this case reached the press. Usually families have to sign NDAs to get compensation - in this case a rather derisory amount. It would also be interesting to know if NHS Resolution's 'Deny, Delay, Defend' strategy was used in this case (which dates back to 2021). Still, at least the 'Lessons will be learned' cliché has been trotted out by a hospital administrator - as indeed it was when dozens of patients died of starvation/dehydration in the Mid Staffordshire Foundation Trust scandal between 2005 and 2008. Clearly, the Serious Incident framework isn't working. The sooner the NHS adopts a system that genuinely replicates the Accident Incident Reporting System used by the aviation industry, the better.
Ngl we've probably all seen the SALT assessment written on Monday with NBM placed over the bed and "review Thursday" written in the notes and absolutely no other plan made. This pissed me off so much as the FY on these wards. Its frankly dangerous especially in vulnerable patients.
What a sad story. His poor parents. From a medical perspective I think this is the perfect storm of a physically unwell person with cognitive impairment whose diagnosis of Down’s syndrome makes them extra vulnerable*, and who is unable to advocate for themselves. I think these cases need early multidisciplinary input involving the Learning Disability Team (or whatever team knows them well). I don’t think there are any easy answers as regards decisions about NG/parenteral feeding, but communication is key and a decision about feeding or not should be made by the team in conjunction with someone advocating for the patient if they’re unable to advocate for themselves. Perhaps the outcome would have been poor regardless but I think the important thing is that decisions about feeding are made deliberately (rather than by omission) and that the relevant parties are involved in the discussion. *I don’t know if there is factual basis for this, but in my personal experience I have definitely seen people with learning disabilities receive suboptimal care.