What needs to change to ensure better care for people with ME/CFS with feeding difficulties?

Agree about the debate about the non-working stomach. The drs in hospital only considered the NG tube I thought?

Yes, I thought that the NG tube was the only one tried.

I would like to read the Coroner's 27th Sept statement again where I think she summarised the treatments that had been tried. I can't find a link to it- to be followed up tomorrow. Please add if you have it anyone.
 
This really is off topic, we have all of this info on the Maeve inquest thread which is probably where this should be.

I think my point is quite straightforward- the reasons given at inquest by the medics were that the infection risks and risk to the stomach were too great to use any/all other types of feeding. Those risks surely remain whether one is under a section, or not. I don’t think they discussed doing these alternatives under a section because a section wasn’t carried out. A section wasn’t carried out because the medics felt there was capacity.

I feel like I’m on the stand and I’m being questioned. I think we all know what the medics did and said “doesn’t make sense” and feels very wrong.
 
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This really is off topic, we have all of this info on the Maeve inquest thread which is probably where this should be.

My thought is that it would do much better to stay here because the other thread may be accessed by people who do not want to read this.

Those risks surely remain whether one is under a section, or not.

I don't think they necessarily do because the relative risks change. Moreover, the issue is what would actually have been policy and doctors are notoriously bad at explaining how they justify their policy - it shifts with assumptions all the time.

I feel like I’m on the stand and I’m being questioned.

Yes, I am really sorry about that. But I am spending about three hours a day listening and listening and thinking and thinking and arguing and arguing in the hope that I might be able to help. I want to make sure that what I say isn't based on my misunderstandings. Quite often it is. I am still not sure I fully grasp what went on here. There are at least two different possible sequences of events. They relate differently to BSG and RCP policy and if I try to do more it is going to be in terms of criticising those policies.

I am just asking for everyone's help.
 
I don't think they necessarily do because the relative risks change. Moreover, the issue is what would actually have been policy and doctors are notoriously bad at explaining how they justify their policy - it shifts with assumptions all the time.

Would the relative risks outlined by those medics in their evidence (which I’ve outlined as hygiene and stomach not being used) changed if a section was obtained? If so, how so? If not, sectioning is a moot point




Yes, I am really sorry about that. But I am spending about three hours a day listening and listening and thinking and thinking and arguing and arguing in the hope that I might be able to help. I want to make sure that what I say isn't based on my misunderstandings. Quite often it is. I am still not sure I fully grasp what went on here. There are at least two different possible sequences of events. They relate differently to BSG and RCP policy and if I try to do more it is going to be in terms of criticising those policies.

I am just asking for everyone's help.

what I do is a flow chart. Start with “feeding” and draw lines down for each type (NG, NJ PEG PEJ TPN) at the end of the line give the reason “given at inquest” why it wasn’t done OR that is wasn’t even mentioned at inquest, and “assumed” reason. From there you do another line with your argument why that reason is BS.

It might help you as I feel like you’re having a few different conversations at once, and I can’t answer them all nor should I be expected to on a thread about George Monbiot’s article.
Apologies don’t work when followed by “but”. I didn’t agree to help you do this, So just assume my messages on this thread can be disregarded, no need to quote respond, the info is on t(e other thread should you wish to look.
 
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Hmm. I don't think the information or understanding have to be complete, it's more of a spectrum with ME at the "shocking paucity of information and understanding" end. But we can't say that anyone who has to make a decision in the face of incomplete information and uncertainty would lack mental capacity. Donald Rumsfeld made decisions in the face of unknown unknowns, which is apparently a common concept in project management and strategic planning circles. Nasim Taleb had the capacity to make a fortune betting on black swan events without knowing what they would be or when they would happen. Making decisions in the face of uncertainty where even the laws of probability don't apply is very much a thing.

My understanding of the situation regarding ME is that it is a horrendous (I'm practising not using the "f" word) mess, and most of the treatment options available are unhelpful or harmful. I still have to make the best decisions I can under those circumstances, and would modestly posit the notion that I have the mental capacity to do so. As a mild patient with family support, my decision has been to reject all unproven treatments, avoid the health service, and hunker down until the landscape is a little more friendly, hoping that pacing allows me the best QoL in the meantime.

Mind you I would agree that most of those offering treatments lack capacity due to their woeful understanding of ME, perhaps that's what you meant.

EDIT: I see we have cross posted. We are probably saying the same thing.
It’s bad enough. What do those facing all this but have no support and find those around them sort of have these it can’t be that bad try this for a year attitude not prepared for the responsibility of how huge a set back and deterioration that causes

it’s terrifying having everyone around you insist on enforcing ‘hope’ ie they hope the illness we talk of is BS and we are wrong cos they are going to not give us what we need and force us to risk going from can just about look after ourselves to disaster because it’s getting frustrating’ then when what happens is as predicted abandon and repeat again

that’s the story of ME

it’s terrifying because you find out no one holds to account those who enforce decisions onto you to be responsible for the entire implications you wear and are then blamed for. And because that is then even more ‘too much’ expectation of help, even tho it should be a ‘you break it you buy it’ you instead get the same done again because people renege and aren't up to standing by their own decisions and the full consequences whilst happy to do so for you.

it’s a horrific life .. well it isn’t a life BECAUSE you never even get those choices. Things get undermined in some way because people can't honour things, they eventually give someone what they needed months before as if the situation is the same now and it 'not working' proves it wouldn't have when that person was more well before being messed around.

I think those who live at the brunt need a voice in this.

when life as people would deserve has never been an option on the table and you will not just be left holding the baby alone for others choices but also you’ve had little others have had or taken for granted then it’s a completely different ball game of what’s important

just tiny joys you want to have once ticked off becomes vital and limiting pain and control over your body but also honesty in this sort of thing so you stop being in the position you are forced to perform one day and stop being a disappointment to all by your mere presence. It’s just looking for moments of peace

and those who have options and protections can’t speak for or see that world nevermind anyone relate to the real decisions people there are really facing.
 
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“given at inquest” why it wasn’t done OR

The problem is that this was post hoc rationalisation in the full knowledge that this was a patient assumed to have capacity. The reasons are all BS but I want to get as close as I can to the sequence of reasonings that went on in 2021. That doesn't come out of any data we have as far as I can see.

If a decision was made that PEG could not be offered whatever then as far as I can see the conclusion has to be just that those making the decision were incompetent. If on the other hand things would have been different had there not been mental capacity and that distinction derived from the writings of members of BSG then we have a policy issue that needs addressing. The second is for me a more important possibility to chase because it has implications for others.
 
Another way of looking at it might be that you cannot diagnose (in BPS terms) a functional disorder and at the same time claim the person has mental capacity because a functional disorder entails a failure to understand what is going on. Even for those who happily accept that they have seizures due to 'FND' if they go on having seizures then their minds must be getting things wrong to produce the seizures.

So there cannot be this third category that should not be given support. There are only two options, both of which merit support.
The way things have been twisted to be set up removes all the faith in that person and voice over themselves

no matter how many times they allowed themselves to be damaged by the lie of a compromise of ‘we’ll just try my way first and if you don’t improve we’ll support you in yours’ the support in your way never happens and no one ever takes responsibility for the harm they caused but denies that

and so the functional = inferences is a terror. It’s beyond ‘just’ health destroying it’s a removal of accountability and responsibility of others whilst placing all choices with them

I find it hard to get people to understand the life I’ve lived under because well it’s asking people to imagine removing so much you’d assume you don’t even see it. It’s a tyranny where as your body is broken you are punished for it and more control over yourself is removed by those who made those bad decisions in the first place. And your voice counts for nothing. Speaking or showing your body is proof of madness for it not fitting with their expectations and you know that so you are always having to deal with keeping yourself safe from this human nature thing no one else sees nevermind is on the rough end of.

we have strange dilemmas vs others if if you’ve never had a kind year in your life are you better of stopping thinking of your future that doesn’t add up and taking the little security you have to buy seeing what one quiet year without hassle and bullying feels like so that you’ve experienced it. Once. And maybe that would help your health more.

But to others who won’t , refuse to delve into the truth you are faced with they see it as madness. Writing off your future security. Not realising there is no future or security whilst your health is being made worse. So your choices are really invidious and different when you step back and think what do you have wanted out of your whole life

Not onky do you have no support or even someone who will be by your side in those little things you choose to have it actually gets undermined so you never even get those little bits of peace. That year of feeling what it was like in life to just not be a massive hassle to the extent someone has to let you know and make you miserable ‘as a nudge’ fir.

all these pseudo psychologists love to talk about expectations- of others and yourself - as if they’ve ’got it’ on that and it’s all perceptions. But the massive difference with me/cfs is it’s the opposite it’s leading your entire existence under imposition of others slap dash expectations or doing them to yourself self-bigot ing in an attempt that if you just please them then maybe removing that bullying will be less exertion than pushing your body so far beyond to meet them. Those are the choices we’ve lived under. Nudge - the profession of giving someone no good choices that work. An ends meeting existence is never on the table and you know it even in a lull because we’ve been there and know quiet just means someone hasn’t got fed up yet to the point they impose 'that frustration' on you (as if the inconvenience to them is worse than you experience daily).

it’s important we include those who have no support because fir me/cfs the hostile environment has made that to be a much much bigger proportion of the cohort and for a more extended time. I don’t know if it’s most of us or a niche but it can't fail to be more than other conditions. We know those with support who don't experience this need to be heard, and can offer a blueprint to what is better, and there are many who I massively appreciate get it and see it and are great supporters. But sometimes some of those people also inadvertently undermine us, don't want to hear it as it will scare them, and don't believe how vulnerable you are/what happens without a safety net (or someone who will disapprove of that sly dig someone who 'seems nice normally' will say to you on the street for no reason other than they can get away with it etc), or were in the think of the wrong timing to get it and unlucky with the demographic you are surrounded with (certain sectors seemed to be 'trained' more in certain simplistic ideas).

Because the social etiquette medal is given to those who say 'it's not always that bad' etc. And many of those who have it that bad are too ill to look convincing even if they can speak. So it's a sensitive topic. But for the opposite reasons people think - things can be so bad they aren't heard, or we assume there is some misunderstanding etc.

but when we do try and speak on ‘living’ in it and what that means we know the choices really are and the reality of what people do despite promises or hope very few believe us , so we feel we can’t even if we have the energy because that world seems so obscure and sad to others they assume it mustn’t be true and is somehow a product of a state of mind. Which takes more autonomy away as a risk.

Which reminds me of that thread by the Australian ME organisation (ME tip of tongue memory) which had 3 words in it: one of which was autonomy

which I think was a topic so fundamental, but so little-done yet that I mentally bookmarked it for a 'how do we even start but this is absolutely key to be bringing into discussions about pwme'

then it’s a mammoth task to describe in words that make sense to others. This is the right thread for this particular post because a lot of eg the RCP/LM and strange ideas of us just needing re-education - well it's all about having a right to who we are, as people, as well as safety and living etc. I just haven't got the elquency to nail that one right now.
 
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If a decision was made that PEG could not be offered whatever then as far as I can see the conclusion has to be just that those making the decision were incompetent. If on the other hand things would have been different had there not been mental capacity and that distinction derived from the writings of members of BSG then we have a policy issue that needs addressing. The second is for me a more important possibility to chase because it has implications for others.
That's a useful summary.

To some extent, we don't have to know for sure what went on in Maeve's case. If there is clinical guidance that is likely to be interpreted as making various forms of assisted nutrition off limits for people assessed by the treating clinicians as having 'functional (behavioural) disorders', even when they are heading towards starving to death, then that is a policy issue that needs addressing.

Of course knowing for sure that this is what happened to Maeve would make efforts to address the policy more compelling, but, regardless, if the guidance is there supporting actions that would allow people to starve to death, then the guidance needs to be invalidated.
 
The problem is that this was post hoc rationalisation in the full knowledge that this was a patient assumed to have capacity. The reasons are all BS but I want to get as close as I can to the sequence of reasonings that went on in 2021. That doesn't come out of any data we have as far as I can see.

If a decision was made that PEG could not be offered whatever then as far as I can see the conclusion has to be just that those making the decision were incompetent. If on the other hand things would have been different had there not been mental capacity and that distinction derived from the writings of members of BSG then we have a policy issue that needs addressing. The second is for me a more important possibility to chase because it has implications for others.
have we gotten to the bottom of why this no PEG thing came in, and I mean really - was there some funding thing or was it sold on a waste of money in these types. Which could be about 'commissioning' (primarily commissioned for IF, not x, y, z which take more time or whatnot?) stuff I guess that I wouldn't be aware of?

Or as I saw notices from I think one of the colleages or somewhere official about concerns of reports of PEG reducing during lockdown was there reasons to do with that which either began or accelerated this? What actually started it all and then gave the thing traction?

I have a feeling that the two things you've listed are feeding off each other to bridge cognitive dissonance, because of that need for post-hoc rationalisation/justification that a decision was correct etc. The recent video from Merryn Croft's mum and sister has detail that is distressing but makes me think that even where something ended up having to be done as per someone giving clear instruction it would help there is potentially reluctance from those who end up with said instructions. I can't be sure whether that is an 'on principle' or some of the things might seem that way but were due to risk with anaesthesia or what not.
 
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I’m not in this discussion, I was on the Monbiot thread. If you’re looking at the Maeve case, you can re-read her thread as to what was said at the inquest, and the extensive discussions (which some here took part in) don’t tag me in here, I’m absolutely beyond my limit with being tagged, especially where a few words of a sentence I wrote are taken out of context as a start point for some other discussion.

from page 8 of the thread about Maeve a selection of quotes. Not my words, words reported as being what was said at the inquest.
View attachment 22518 View attachment 22515 It seems Dr Strain is giving evidence this morning. He is a Consultant and also a Snr lecturer at Exeter Uni Medical School and advisor to Action for ME.

In June 2021 Maeve had been put on an eating disorder ward.

NG tube was considered, but she couldn’t tolerate sitting at 45degrees so it wasn’t given. Risk of sepsis if she were to have TPN so not given.

TPN would only be offered if she was sectioned
View attachment 22519

Dan Wyke on twitter “Dr Roy’s argument seems peculiar - we couldn’t give a dying person TPN because it’s dangerous” (Dan’s paraphrasing)
Sarah Boothby is questioning Dr Roy about contingency if the NG failed

Dr Warren discussing the insertion of NG tube, caused Maeve to deteriorate and she requested removal (date not specified)
View attachment 22551

22 July was before NG tube was removed
There was an MDT
DrWarren now going over PEG feeding- why not
View attachment 22552
 
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Good report on today’s proceedings in the Evening Standard, including lots of quotes from exchanges with Dr Roy: https://www.standard.co.uk/news/crime/doctors-exeter-the-times-b1172944.html

It confirms the following exchange that was tweeted and referenced above:

(Dr Roy's testimony, part 2. Not going to express my opinions of this in these posts; just reporting.)

The coroner mentions that the family had concerns that many consultants at the RD&E did not believe that ME is a physical illness, and asks his views on ME. He replies that, while he is not an expert on ME he did not think there was any question in this case that her ME was not recognised as a real condition. He also states that they were lucky to have the services of Dr Strain who while not an ME specialist did have expertise in managing ME, and that he had discussed ME with Strain for around an hour. He states that based on this conversation there was nothing that would have influenced the nutrition decisions going forward.

Discusses an initial email from Maeve's GP, who was concerned about Maeve's deterioration over the period of around six months, that she was on a limited liquid diet and had clearly been losing weight, & that there was "Harley Street" (presumably Dr W) advice to initiate NJ feeding in anticipation of swallowing difficulties. He stated that he replied to this email indicating his surprise at the suggestion that NJ feeding should be initiated in the absence of a swallowing assessment and stated that there were multiple assessment steps before non-oral nutrition could be initiated. He further suggested an urgent review of ME and a SALT assessment before further considering non-oral nutrition and further suggested the need for "robust psychological support". He added that the GP was in the best place to determine the necessity of an admission but suggested that as the gastro department had no expertise with severe ME she should not be admitted to a gastro ward as her main problem was clearly the severe ME.

There was a discussion between the coroner and Roy about the various concerns with her being supine, the intolerances to feeding, vomiting, etc. The witness agreed that those were concerns and also stated that Maeve was intelligent, had full capacity and had declined NG feeding at that time. Also a discussion of aspiration risk, and Weir's view expressed yesterday that although the "Royal College guidelines" recommended feeding while elevated Weir thought - and this is the coroner's expression of what she thought Weir said - that those guidelines were generally only applicable in stroke patients without an intact cough or swallow reflex which did not apply to Maeve.

The witness replied that in his view this was incorrect and that the risk of aspiration is not related to this but rather is related to "gravity", and that if one's stomach is not emptying and the patient is supine the feed can "roll backwards". He mentions various factors that can affect motility. He also states that a "basic principle of nutrition" is that if a patient has a functioning gut that it should be used and atrophy will occur if it is not, and that in a patient without ME it is possible to rebuild those muscles although there is no evidence about recovery from gut atrophy in pwME.

(to be continued)

I have never heard of that in the context of people being fed IV on ITU for whatever reason. It sounds like hot air to me.

Edit: Dr Roy seems to have made quite a bit of this idea of needing to keep the stomach used. As far as I know there is no evidence for that at all.

(Part 3/Roy. There is a lot of highly simplified anatomical discussion & explanations which I did not try to jot down. Again, I won't offer commentary.)

Weir's recommendation of an NJ was discussed. Roy gives his views as to potential progression of interventions that can be used, from NG to NJ to PEG/PEJs to PN, but indicates that the decision-making when proceeding from one intervention to the next is very nuanced and individualised. Asked by the C he acknowledges that just because someone declines an NG tube an NJ wouldn't be given and acknowledged that in some cases it may be appropriate to go directly to an NJ. States that NG feeding generally better tolerated as stomach designed to take larger volumes & boluses of food whereas small bowel designed to have liquidised food at the rate your stomach gives to it - taking away the "biofeedback mechanisms". Explains satiety from "neurobiofeedback in the stomach" which you don't have when feeding into the small bowel.

He returns, again and again, to Maeve's "fully intact capacity".

C asks about NG vs NJ risks. R explains NJ is more securely anchored in the small bowel. He states that NGs can be inserted bedside by anyone trained to do so whereas NJs are placed endoscopically or with interventional radiology and usually with sedation or occasionally with a GA. Displacement risk lower for NJ, but in the context of someone lying flat & vomiting can still dislodge. Easier to tell at the bedside if an NG is correctly placed by aspirating (acidic) gastric contents whereas checking an NJ more difficult (documented at what length it is secured & written on the tube and the length is checked; if there is concern X-ray is required). Emphasises NJ temporary; tubes last 6wks-3mo depending on manufacturer.

C asks if Maeve would need to sit up for NJ feeding. R replies that while aspiration risk is lower with NJ it still a risk & would want to feed at an angle. States there is nutritional value in feeding into the stomach. With vomiting an NJ may displace; they are designed to be temporary. Main risk with any form of enteral feeding aspiration; if NJ falls backwards into the stomach it is effectively an NG tube. A discussion of bolus vs. pump feeding. Says greater aspiration risk with pump feeding as seconds to minutes to stop feed. Equipment essentially identical for NG/NJ.

Moving on to PN. R says PN is used fairly commonly in IF units but it is dangerous, very high risk and life limiting because of the side effects that can come with the long-term use of PN and in the short term the most significant risk is that of line sepsis. More anatomical descriptions & descriptions of techniques. States that essential that sterile conditions are maintained - gives a simplified description of a central line; states that in someone with "good baseline physiology" that can be fatal and that in someone with "poor baseline physiology" it will definitely be fatal.

C asks if PN can be performed in the community. Yes, R replies, that is a big role of I/F units. In Exeter was overseeing a number of patients on home PN, although reliant on either having a patient who is sufficiently independent to perform it themselves & relies on their ability to maintain sterile conditions; for less independent patients there will be intensive nursing need. Mentions some of what is required - e.g. blood sugar monitoring & that initiating PN requires inpatient stay; community nursing needs to be available & patient/family need to be trained.

(to be continued)

Guardian: ME patient’s consultant tells inquest staff’s unfamiliarity with condition was ‘unfortunate’:
https://www.theguardian.com/society...-unfamiliarity-with-condition-was-unfortunate

“Sean O’Neill, told the inquest he thought the ‘belief question’ was a central one. He said: ‘The reason I keep coming back to this belief question is because I think it pervades not just the treatment of Maeve but of many patients.’”​

I'm going to have to draw this to a conclusion as I'm struggling, so I'll just give the most salient points from my scribbled notes, which I'll keep in case anyone has questions, but this will be my last post on the subject otherwise. I've concentrated more on the technical details that I think journalists will be less likely to report on, but there were many poignant and heartfelt moments.

Roy:

* In emails he discussed the priority requirement as being for the ME to be reviewed by a specialist even while it was reported that they were struggling with maintaining more than 700 kcal. He had spent about an hour with Strain discussing ME but information didn't influence his nutrition decisions whereas there are other conditions where general principles of nutrition aren't appropriate & different approach required.

* Met Maeve twice. PEM very severe & required a long time to recover from any exertion; even discussions in the same room too tiring. Many very personal details here. In July he had a discussion with Dr Warren (under whose care Maeve had been placed) re NG feeding. Ward team performing "practice runs" of sitting her up. Roy had concerns about NG feeding but based on Strain's advice it was tried.

* In September Roy emailed Strain to raise the question of whether an "urgent psychiatric review in order to consider sectioning" was required in order to implement artificial nutrition "in best interest" but Strain and his colleagues dealing with Maeve more directly were happy that Maeve had capacity. He then claimed, bizarrely, that having intact mental capacity was "somewhat atypical with ME" as he understood that ME can cause brain fog and cognitive impairment.

(Personally, I don't remotely believe that he suggested an "urgent psychiatric review" because of the potential for brain fog.)

* He wrote an email for an MDT meeting in which he was clear why in this case he did not believe PN should be used: firstly, that it was not indicated because there was no IF; secondly, that if there is a functioning gut then not using it leads to the gut muscle wasting and that it may no longer work and we do not know if this could happen irreversibly in ME so it was important to maintain enteral feeding; and thirdly that because of hygiene an aseptic technique could not be maintained and that it would have likely led to line sepsis and death.

* He said that even if they were able to address the hygiene issues there were two conditions where he might have considered PN in someone with a functioning gut: firstly, if it was felt there was a reactive or primary psychiatric condition then PN could be a "bridge" to a psychiatric intervention; the second possibility was as a "bridge" to a possibility that Strain was investigating, one of an "experimental" approach in Germany.

(Again, this consideration of PN as a "bridge" to a psychiatric intervention is... notable.)

* In a discussion of palliative care Roy states that PN is used in specific palliative care settings but is too problematic to use in the last phase of life due to food overload etc.

* Says that the (2007, I think) NICE g/l only advises on hydration & dietetic input but does not discuss NG/NJ/etc feeding.

* On the Baxter/Weir/Speight paper he had not been aware of it but has read it since. Points out that it was a case report but not a trial; says it emphasises the problem of not recognising ME as a diagnosis which was not the issue here & said that some of the cases were of patients with IF which would be an indication for PN. Says nothing in the paper that would have changed things in this case.

* A very poignant family question: he was asked whether he believes "the RD&E did everything it possibly could" to save her life? He replies that he does (!!) and goes into a long explanation about how everything that could have been tried was tried.


And a few points from Warren's (diabetes & endo & gen int med) testimony:

* C asked his view of ME, physical or psychological. He replies that he does not know & does not find it a productive question to dwell on as in the guidelines it's described as complex and of "unclear aetiology"; that it's not defined by a specific test, which does not imply that it is not a physical disorder but that he does not know what causes it and so reserves a position. Says that although he doesn't know the cause it can still be taken seriously, that there are needs that clearly need to be met, and not knowing should not imply that it is malingered or imaginary.

(This is curiously similar to the views of other witnesses.)

* Only dealt with Maeve during a short period in July. C asked if he had experience working with patients with severe ME or similar to Maeve; he did not. Asked if he had completed training on ME; said he was unaware of any such training on the NHS. Strain had tried treating her with vitamins, colchicine, aspirin and fludrocortisone.

* NG feeding trial required at least a 30 degree angle but preferably 45 & they insisted that the team had to have witnessed this. Could not be weighed so proxies were used like arm circumference & also serum albumin checked. Did not discuss progression to NJ etc but rather attempt to resume oral feeding. Maeve had found the experience of having an NG tube upsetting, difficult and tiring and Warren felt it had been a failure & possibly counterproductive and that it would be better to remove it.

* He was asked to read from what appeared to be the minutes of a meeting wherein his objection to the possibility of PEG feeding was notable; saying that her situation was difficult as it was not a "solvable problem", that PEG feeding carries risks and that inserting a PEG "would medicalise Maeve to a degree". He tries to backtrack on some of this, stating that there was nuance that was not adequately captured.

(The concern over medicalisation is notable here.)

* Questions from the family: he was asked whether he had any thoughts on the biological underpinnings of ME - "no, not any useful thoughts". He had read Weir, the NICE g/l, some of the literature which he generally finds "unclear". Another Q was about the appropriateness of situating her on the eating-disorder ward rather than the neurology ward. Suggested the "bed management team" thought that anyone needing feeding could be treated the same way but doesn't think that Lowman (sp?) was inferior to Bowlam (sp?) ward. Another interesting question SB posed was that she had kept her own records and there was a disparity between her and the ward's records of Maeve's nutritional intake; he suggests her kidney function was adequate at that stage and also suggests nutritional intake not always recorded well on the wards.

A fantastic job by @Nightsong.

It is all becoming clear that the problem was very much as suspected - not a fault with guidelines but with people putting groundless theories before what was needed.

I have had some suggestions about things to add to my Qeios piece, which I can do whenever I wish. I will wait until the dust has settled but there are some things I think could well go in.

People here were of great help in getting my piece into a reasonable shape. I am reassured that maybe the two key sentences in the conclusions were on target:

The simplest, and I think robust, analysis is that management of patients with stimulus challenge, often in the context of unsubstantiated diagnoses, and outside established guidelines, has caused a huge amount of avoidable distress and needs to be abandoned.

and

The least one can say is that if psychosocial factors are involved, nobody has shown useful understanding of them, or of how to manage them.

How is intensive psychological support or indeed 'attention to the ME' supposed to help when nobody knows what they are doing?
 
Of course knowing for sure that this is what happened to Maeve would make efforts to address the policy more compelling, but, regardless, if the guidance is there supporting actions that would allow people to starve to death, then the guidance needs to be invalidated.

The problem is that there is no formal guidance. It is all a matter of interpretation, even if the implication is there.

I may have got this quite wrong. The real reasons for things going wrong may be something else, which is why I am keen to try to check and re-check. We probably need a formal enquiry into all these cases but I don't see that happening.

Unfortunately my attention span is not great these days and I tend to rely on others to pick up things I forget,

I would be happier if this discussion was on a thread that did not carry an individual name.
 
I haven't been following the thread, but I couldn't see this mentioned: If there was a reason for not providing a PEG/PEJ, why did Maeve not get parenteral nutrition? If she at some point was able to get ~700kcal orally, the rest could have been provided parentally if a NG/NJ or PEG/PEJ tube did not work.

So for the future, it's not just "what reasons was there for not giving PEG" but also "if a pwME can't tolerate tube feeding, why didn't the patient get parenteral nutrition?"

JE has already mentioned risk of infection and thrombosis as risks with parenteral nutrition, I'll add that it's also in no way comparable to getting nutrients through the gut - the compounds found in the feed is only what we know 100% are required, there are many compounds in foods we know little about (and some nutrients previously thought to be non-essential, have been found to be essential based on people on artificial feeding suddenly developing deficiencies)
 
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I haven't been following the thread, but I couldn't see this mentioned: If there was a reason for not providing a PEG/PEJ, why did Maeve not get parenteral nutrition? If she at some point was able to get ~700kcal orally, the rest could have been provided parentally if a NG/NJ or PEG/PEJ tube did not work.

Thanks, yes.

I think with the revisiting of the original information from X it is clear that the diagnosis pf ME/CFS has effectively been used to deny options that otherwise might have been provided. Other things would have been done if the diagnosis was not 'functional'.

Clearly other factors like home context and time frame are relevant but that is taken into account in general guidelines anyway.
 
Thanks, yes.

I think with the revisiting of the original information from X it is clear that the diagnosis pf ME/CFS has effectively been used to deny options that otherwise might have been provided. Other things would have been done if the diagnosis was not 'functional'.

Clearly other factors like home context and time frame are relevant but that is taken into account in general guidelines anyway.

Is ME/CFS officially classified as ‘functional’ by, I don’t know how to put this, central NHS hospital guidance or those instructions that they send around?

Or is it that BPS pump out webpages and papers including chronic fatigue or chronic fatigue symptoms or CFS/ME in their abbreviated list of conditions that they consider to be functional and this makes everyone concerned confident it’s close enough to official hospital policy to go ahead with out fear of looking like you’re needlessly starving people to death when they tell you they’re hungry and thirsty and you say that there’s nothing you can do?

Or it is it local level hospital guidance, for only some or maybe for most individual hospitals?

Also is that the guidance to not treat those functionals, who are a waste of resources and don’t need help anyway, is obscured from public view as far as possible or is it an explicit secret guideline somewhere, like the hospital policy no one was able to see recently.

In which case hard to say where the instructions came from with any precision or whether they exist at all in any specific context?

Or is it that all these medics don’t have official guidelines at all they just know that they know what to do and what not to do, because they are so very on to us all with our ‘non specific symptoms’ wink?
 
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Is ME/CFS officially classified as ‘functional’ by, I don’t know how to put this, central NHS hospital guidance or those instructions that they send around?

The problematic guidance is not hospital policy, no does it come from BPS psychiatrists. It comes specifically from gastroenterologists who are physicians (RCP members) and also members of the British Society for Gastroenterology. They have written articles and guidance protocols that propose that feeding support should be discouraged for people with 'functional' illness.

Whether or not they specify including ME/CFS or CFS/ME in this group I forget but physicians with this sort of view (which seems to be the majority these days) tend to do so. What they have focused on is the idea that Ehlers Danlos Syndrome patients have this sort of functional problem. I have discussed this in my updated Qeios article ( https://www.qeios.com/read/T9SXEU ). As far as I know this is complete nonsense and simply reflects the 'unhelpful beliefs' of physicians passed on to patients as inappropriate diagnoses. There is this strange irony that the people who believe in 'functional' are the often same people who elaborate stories about non-existent 'biological' problems. (BPS likes to have its bio bit too but a nonsense bio bit.)

So these writings are out there (and cited). Feeding support is supervised by gastroenterologists so the writings are known to the controlling feeding support. 'Gut-brain axis' seems to be their favourite term.

What I think is needed is for a dialogue to be set up with the College of Physicians to challenge the content and use of these writings and to try to get the College spokespeople to commit to saying that they are inappropriate. Approaching the College rather than BSG may have the advantage of being able to enlist support from branches of medicine that can see things more clearly from a distance.
 
In which case hard to say where the instructions came from with any precision or whether they exist at all in any specific context?

Part of the problem seems to be the use of shadowy categories that are both explicit and not. Some people are put into them, explicitly or not, when guidelines don't provide answers.

The danger is that this allows healthcare to do nothing. If a system's based on guidelines and there's no guideline, there's no responsibility.

That's palpably indefensible, but it'll happen by default if no one stops to think about what's going on in front of them, or if no one is in charge, or if people don't know what they can do in guideline-free zones and common sense has been regulated out of the system.
 
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