My patient died in a cupboard behind a curtain while he was surrounded by drunk and drugs driven. This is what you have to do to prevent it from happening to you: Professor Rob Galloway

Working in A&E, I see the best care, but also as the worst – and that is not necessarily the fault of the NHS.

A few weeks ago I took care of an 89-year-old gentleman who received care who completely failed him and his loved ones, and for us as clinicians. Yet it was completely prevented. It’s a lesson for all of us.

There is only one thing that is 100 percent guaranteed in life – and that is death. But when it arrived at his death, we’re so wrong. He was a proud family man who had given a life of service to the country, in the army then as a policeman.

An avid sportsman, he was fit and good and until a stroke him six months before I saw him, he had had a brilliant quality of life that caused his beloved grandchildren.

But he quickly declined after his stroke, so he moved with his son and needed caregivers three times a day. He was incontinent and had to be hoisted from bed to his chair; He also developed dementia.

His last months of life were not what he had ever wanted.

A few hours before he came to A&E, he became more and more brief – his son called 111, hoping that they would send a district nurse to make him at ease. But it was Friday evening, and instead a blue light ambulance was sent.

Without any pre-planning for what should happen if he became unwell, there was no clear guidance for the paramedics to follow a doctor or gain access, so the only choice was to take him to the hospital.

There he was seen by a relatively junior A&E Arts, who acknowledged that he had caused sepsis caused by a breast infection and gave him intravenous liquids, antibiotics and oxygen.

He then stayed away in the hallway – there were no spare cabinet rooms in A&E or beds in a department.

His son arrived and came to ask our nurse what was happening. When I heard the conversation, I intervened – his son told me that his father had not wanted anything.

He just wanted a comfortable death at home, no extension of his pain.

By that time he had deteriorated and was now semi-conscious but in clear discomfort.

I stopped the antibiotics and canceled his blood tests and X -ray of the breast. None of this was necessary or appropriate – what he needed was palliative care. So I removed the liquids and the oxygen and prescribed morphine to make it comfortable.

The most important thing is that we have organized a cupboard behind curtains to give him some dignity. He was too unwell to transport home. A few hours later he died surrounded by the sounds of drunk and drugs driven patients, heard of his son’s tears by the other patients. A terrible, expensive and unworthy death. It didn’t have to be that way.

My friend’s father recently passed away. He was weak with heart and kidney failure. But he had a plan for when his condition deteriorated.

Six months before he died, he sat down with his doctor and family and talked to what he wanted if it got worse: no hospital, no resuscitation. Just to be home with the dog on his lap, his family by his side, with jazz music in the background and morphine if necessary for pain relief. And that is exactly what happened.

Because they were planned in advance, the doctor prescribed morphine and other important medicines in advance, so they were already in the house – ready if necessary, even in the middle of the night. The district nurses knew the plan and were standing to help.

So when the time came, there was no panic, no hurry to A&E. Just peace and love. That is the power of planning.

Not every general practitioner practice will be so proactive – but this type of planning is possible. Without this you risk being at the mercy of overloaded services that your wishes don’t know – and perhaps the things you and your loved ones never wanted.

We don’t talk about enough dying, let alone how we want to die. But as medicine progresses and people live longer with dementia, cancer and heart disease, for example, it is simply not enough to simply concentrate on how to keep people alive. We have to think about how people can go well.

Too often in the NHS, when a patient suddenly deteriorates, we have been left to make decisions with high bets without knowing what that person had wanted.

Professor Rob Galloway is an A&E Consultant

In 2016, the recommended summary plan for the form of Emergency Care and Treatment (respect) was introduced to prevent precisely this type of crisis decision.

It is designed for people who are the elderly, or have long-term disorders, and it describes in advance from which treatments they would not want to do if things would take a turn for worse.

Ideally, the doctor is done, during a calm, planned conversation with the patient and, if applicable, their families.

The form is not just about tapping boxes. It leads to real, practical decisions – such as whether the person would want resuscitation if his heart would stop, or to be admitted to Intensive Care, with the implications of each well explained.

There is also room to record whether they want antibiotics if they developed sepsis; Artificial food if they could no longer eat; Or liquids through a drop when they were in their last days.

The kind of questions that a general practitioner could ask to help complete the form may be: “If you became very unwell with an infection, would you want us to treat it with strong intravenous antibiotics – whether you only focus on keeping you comfortable?” The CPR question is a key, because resuscitation is misunderstood on a large scale.

People think it is on TV, with someone who holds their breasts, collapses, followed by heroic to be hit and then shocked back to life. Although effective for sudden heart problems, the success rates in the elderly or chronically ill are very low. Most people who receive resuscitation in these circumstances do not survive. If they do that, it is often a life of considerable disability.

Douglas Chamberlain, the cardiologist who introduced defibrillators in the UK, died last month at the age of 94. He always said that many patients and family members falsely believe that a DNR (not resuscitation) order – do not use CPR – means no treatment and left behind to die. That doesn’t mean that at all.

You can still have complete active care, such as oxygen and intravenous infusions and antibiotics. But if the treatments don’t save your life and stops your heart, then a DNR order means that we don’t jump on your chest.

It is important that respect is a plan that has been agreed between the clinical team and the patient, based on what is medically suitable and what is most important for the individual. It balances the clinical judgment with personal priorities and ensures that when decisions are quickly necessary, they are already carefully thought out.

It is crucial that the respect of the patient removes the painful guilt that families often feel when they agree with the doctor not to pursue intensive care or aggressive treatment – because that decision would have already been taken in quieter times.

Yet the shape is not used as often as it should be. Some GPs are not added. Some families do not know that it exists. So when a crisis strikes, we fall back on ambulance calls, hurried decisions and hospital admissions that nobody wanted.

And that is exactly what went wrong for the 89-year-old man I saw that Friday night.

One conversation could have changed everything. If the patient cannot make decisions due to advanced dementia, unconsciousness or confusion due to illness, family members are consulted.

But doctors can understandably more inclined to treat the patient than to offer palliative care. That is where a permanent power of attorney can help for health. This is another legal document that is used if you lose your mental capacity-the decision-making will hand over to someone you trust.

These two written documents are kept by the patient, with copies submitted to the general practitioner, the hospital, the care home and the ambulance service. It comes down to it: if you don’t make a plan, the system makes one for you. So if you have a chronic illness or worries, you can develop dementia, the most important thing you can do is talk. Sit with your doctor. Fill in a respect form – and remember that you can change it. And if they are good, talk to your parents and grandparents about all this.

We spend so much time planning our weddings, our career, our retirement. Yet we rarely plan for the only thing that will be guaranteed to happen.

Filling in a respect form will not stop death. But it can help you to die as you lived – with dignity, with control and with the people you love around you.

I have had countless consultations where someone says: “I don’t want to talk about that yet.” But when is the right time? If you are already unconscious or unwell? The best time is now.

A good death is not lucky. It is about preparation, understanding the limits of modern medicine and the power of good conversations.

@rrobgalloway