Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Are we engaged?
- Stephen Workman (14 September 2001)
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Decision making: a two way process?
- Alberto Febles (16 September 2001)
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Promote "pro-choice" advance statements
- Michael H K Irwin (16 September 2001)
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Engaging patients in medical decision making
- Syed Shahid Mahmood (20 September 2001)
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Patient's Preferences
- Stuart Weatherby, Simon Ellis (25 October 2001)
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Stephen Workman, Assistant professor Dalhousie University
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In order to engage patients in medical decision making it is necessary to engage the patient. |
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Alberto Febles, GP Registrar Crown Dale Medical Centre
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EDITOR- Professor Kravitz and his colleague Joy Melnikow discuss the difficulty in the process of medical decison making. The apparent mismatch between patients as 'health consumers' and doctors as 'health providers' is often a reality. They also discuss the variability of decisions in relation with patients' attitudes to risk. True. However, the pathways guiding the doctor-patient relationship are in fact far more complex. Consumers -in the broadest sense- can be misled, necessities can "artificially" be created, opinions can be skewed and preferences can be influenced. At least this is what publicists believe. I am unsure whether such beliefs can also apply to the "health consumer". When we acknowledge the fact that patients' expectations are high and that doctors, in the most crude way, are publicly accountable for their actions (and decisions), delegating the hard and risky task of decision making to patients can even appear attractive. Yet, the interaction between patients and doctors is filled with contradictions, misunderstandings and, perhaps, defiance. It is not difficult to assume that this is even more complicated in an average 8-10 minute consultation. The sometimes obscure reason for someone to seek medical attention, at a particular time in someone's life, is often the force under which most decisions are made. The term "health" implies different things for different people, the priorities remain sometimes unrecognised, the longer term goals are often irreconciliable. Non-compliance, defaulting appointments, second or third "opinions" requests, complaints, are all examples of unmet needs, that is, failure (not the doctor's, not the patient's but a failure of the two-way process) to acknowledge each other. In the end, couldn't we even question the fundaments of our western health system?, that is, to improve the health of the community we serve, meaning perhaps living longer, delaying the onset of disease, reducing time of improductivity and, importantly, raising the perceived wellbeing. But this is the point. Being well could mean anything, it changes over a life time, can even be an undesiderable outcome. And sometimes, not even comprehensive, tailored information can overcome the intriguing dynamics of the doctor- patient interaction. I wonder whether by consciously intelectualising the cencept of engaging (allowing) patients in the medical decision process, we doctors think in fact (may be at an unrecognised level) that we are 'still' in control of such interaction. It might be that, perhaps, patients are already "powerful" enough to make up their minds well before that very first encounter. After all, it is the patient and only the patient who decides why, when and how to arrange an appointment with the doctor. Personally, I thrive to remember this reality, particularly when Iam running half and hour late in my afternoon surgery and my own humble priorities get in the way and struggle to take preference. |
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Michael H K Irwin, Retired GP 9 Waverleigh Road, Cranleigh, Surrey GU6 8BZ
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Editor Surely the best example of "Engaging patients in medical decision making" (1) is the completion of an advance statement (advance directive or living will), with the help of one's GP, which lets medical personnel, relatives and friends know an individual's preferences about the future medical treatment that person would like to have or wish to refuse if he/she is in a situation which prevents them making their views known (eg: when suffering from Alzheimer's disease or having severe brain damage after a stroke or an accident)? Unfortunately, the traditional opposition to advance statements has regarded such documents as being "pro-death", but, as they can be written stating that one wants to stay alive, with life-prolonging measures, for as long as possible, advance statements are only expressing "pro-choice" wishes for the time when someone can no longer communicate effectively. No adult is forced to write pro-choice advance statements. I believe all medical personnel should make advance statements, thus setting an example for others to follow, because they might be of great assistance one day for one's personal doctors. Michael H.K Irwin (1) Kravitz R.L, Melnikow Joy Engaging patients in medical decision making. BMJ 2001 323:584-5 (15 September) |
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Syed Shahid Mahmood, Consultant and a/ Chief of Anesthesia and ICU. King Fahd Military Medical Complex,Dahran,KSA.
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Patients should have full rights to decide the choice of treatment if they have been informed why, what and how about the medical problem. I find it easier if I explain to the patient in brief the type of anesthesia offered to them in my preanesthetic visit. Awareness among patients is increasing in developing countries, specially in oil rich countries. Most of the time they have questions and counter questions and I have to answer those queries for them. Preanesthetic visit is many times longer than the duration of anesthesia and operation. Anesthesia evaluation form gives them brief information and diagragmatic representations of different kinds of anesthesia, and it is circulated much in advance in elective cases. It is worthwhile. Patients should be given enough information and they should be allowed to, in our case, choose the type of anesthesia they opt for. This gives feeling of immense satisfaction to the patients and to us. |
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Stuart Weatherby, Specialist Registrar Neurology, and Consultant Neurologist North Staffordshire Royal Infirmary, England, Simon Ellis
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Dear Editor, The recent editorial1 about the process of engaging patient's in medical decision making highlights the importance of respecting patient's preferences. However, decisions related to health care are often complex and the time available to select treatment options is frequently limited. An example of this is the consideration of thrombolysis for acute cerebral ischaemia. The decision involves the acceptance of short-term risk for longer-term gain.2 Patients may be ambivalent about such trade offs. We undertook a study to explore patients' views in this area.3 It has been demonstrated that acute treatment of cerebral ischaemia with rt-PA reduces the incidence of disability at 3 months but at the risk of more symptomatic intracerebral haemorrages.4 Mortality is not significantly altered. We sent an information sheet and questionnaire to patients who had attended a neurovascular clinic (at risk population). The questionnaire set out in simple terms the results of the NINDS4 study, including the statistics regarding improved outcome and risk of haemorrhage. 45% of our population at risk would have wanted thrombolysis if they had had a stroke, 17% would not, but importantly 39% did not know. Of the undecided group 57% wanted their doctors to decide while only 13% wanted their next of kin to decide. Faced with a difficult decision, even when patients make the decision in the unpressurised environment of their own homes with all the time they need, a sizeable minority cannot make a decision and of these the majority would want their doctor to decide. When deciding on models of engaging patients in medical decision making provision has to be made for the minority of patients who prefer a paternalistic approach. References 1 Kravitz RL, Melnikow J. Engaging patients in medical decision making. BMJ 2001;323:584-5. 2 Lindley RI. Thrombolytic treatment for acute ischaemic stroke: consent can be ethical. BMJ 1998;316:1005-7. 3 Ellis SJ, Matthews C, Weatherby SJ. Informed consent is flawed. Lancet 2001;357:149-50. 4 The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581-7. From:- Stuart J.M. Weatherby, Specialist Registrar in Neurology, North
Staffordshire Royal Infirmary, Stoke on Trent ST4 7LN.
Simon J. Ellis, Visiting Professor in Neuroscience, Staffordshire
University, Consultant Neurologist, North Staffordshire Royal Infirmary,
Stoke on Trent ST4 7LN
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