How doctors discuss major interventions with high risk patients: an observational study
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.38293.435069.DE (Published 20 January 2005) Cite this as: BMJ 2005;330:182
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The study of C F Corke et al, centres attention on a fundamental issue
of the patient-medical relationship. In addition, the answer given by
them, in terms of a structured education programme, contributes to fill an
empty space with practical actions in this field of medical education.
Some kind of approach is also needed in similar but distinct
situations. This is, concomitance of a chronic condition non life
threatening that demands a surgical procedure in patients that are
severe handicapped for a chirurgic solution. Quality of life can be very
affected by frequently episodes of chronic prostatitis with hyperplasia
of the gland, but for instance, a heart with a sequel of great tendency to
arrhythmic crisis becomes the decision for surgical intervention pretty
difficult.
The appropriate information, essential for making a self decision by
this class of patients, require a concerted approach among urologist,
cardiologist and anesthesiologist. In few cases the coordination exists,
but rarely if any time takes place, all the facts concerned are
transmitted to the patients an relatives in an integrated form.
Here we have a problem of patient-medical relationship that can no be
solve with an instructional course, but also with changes in medical
practice.
Competing interests:
None declared
Competing interests: No competing interests
Corke et al discuss the art (and some science) of communication and
decision making between junior doctors and patients and their families.
Nowadays there are many situations where the patient is, or is regarded as
being incapable of making such profound decisions. Dementia frequently
being the cause of this. It is not infrequent that there is no immediate
family, or that immediate family are unwilling to make such decisions.
In situations where this has been forseen, in NSW the office of the
Public Guardian is appointed to look after medical and other affairs. It
has been my experience (quite recently) that the Guardian has not yet even
met their Ward when the Office is called upon to make make medical
decisions. It is interesting to note that The Office is available 24 hrs
a day for urgent consultation in a medical crisis where the patient is
incapable of communicating wishes, and no significant others are
contactable or exist.
I have been told that the Guardians would tend to give "conservative"
opinions or decisions; thus committing an individual to very likely
arduous and uncomfortable treatment with a low likelihood of useful
recovery.
Competing interests:
None declared
Competing interests: No competing interests
This article by Corke et al aroused my great interest. As a consumer
advocate in my country,I have focused on my research on the promotion of
understanding of patient values and perferences in clinical decision-
making. Though this is very difficult topic, it is important and worth
doing so.
Just like many other studies showed, this article also described
that doctors can be of high medical skills but with poor communication
skill to exploring patient's values, funcational status, wishes etc.In
China where healthcare resource is insufficient with a largest population,
many doctors have to meet over 50 patients in the morning, they do not
think they have time to better communicate with their patients,some
doctors think that patients have high expectations from their doctors. But
our investigation showed that 95% patients hope their docotors can spare
more time to talk with them to understand their feelings and perferences
in selection their treatment, particularly when they are in critical
situation or have life-threatened diseases. There exists some gaps between
doctors and patients.
Many studies have also showed that more and more patients nowadays
would like to share decision-making in their treatment. For example, in
our patient investigation survey, there are 85% patients who prefer share
decision-making. As a doctor, in my opinion, besides medical skill,he or
she should first develop a better communication skill, have some knowledge
of psychology and ethics so that they can better understand patient's
value and perference.
Finally, I like this words very much by famous physician William
Osler cited in this article" It is more important to know what sort of
person this disease has than what sort of disease this person has". It is
easy for me to understand its meaning, but difficult for me to convey its
implied meaning into Chinese language. Yet I will try my best to translate
it and let more Chinese doctors understand why understanding patient value
and preference is important.
Reference
[1] Corke CF, Stow PJ, Green DT, Agar JW, Henry MJ. How doctors
discuss major interventions with high risk patients: an observational
study. BMJ 2005; 330:182-4
Competing interests: None declared
Competing interests:
None declared
Competing interests: No competing interests
Once again I find myself needing to respond to the use of actors in
assessing the caring of cancer patients. I fail to understand how it is
possible to accurately reflect or derive any appropriate outcomes based on
scenarios of this nature.
As patients, we continually strive to 'see' our oncologists and medical
professionals as people. We value their compassion, their humour and their
understanding. We appreciate the significance of treating, over time,
patients who will not survive. We have a great need for the human element
because that is the real part of the path we are taking and our
oncologists are part of that path.
I urge you to consider how patients feel when studies are completed with a
surrogate patient.
Competing interests:
None declared
Competing interests: No competing interests
Editor
I read the article by Corke et al [1] with great interest. As a
trainee in Geriatric Medicine, similar "no-win" scenario described by the
authors is not uncommon in my daily practice. I can appreciate the
difficulties a doctor faces in such scenario.
It is not surprising that doctors are poorly equipped with
communication skill in exploring patient's functional status, values,
wishes and fear as traditional medical training give emphasis on knowledge
based assessment. Acknowledging this, in UK many clinical schools have
introduced the communication skill training in their curriculum. This
hopefully will produce doctors who are good communicators and comfortable
in discussing their patients' concern in various aspects.
Medical practitioners must have a balanced approach in following
between ethical principles (the principle of beneficence –to do net good;
the principle of non-maleficence – to do no harm; the principle of respect
for the patient’s autonomy; and the principle of justice) and patients'
wishes. At the same time, no lesser emphasis is justifiable in knowledge
aspect of a doctor in medical education. It is surprising how one can
practise medicine with very little knowledge but it is not astonishing how
badly he or she may do it.
In my opinion, working together with our patients, their relatives
and colleagues from other allied health professions is the way forward in
promoting better communication and effective health care which will be
valued by our patients and ourselves.
Reference
[1] Corke CF, Stow PJ, Green DT, Agar JW, Henry MJ. How doctors
discuss major interventions with high risk patients: an observational
study. BMJ 2005; 330: 182-4
Competing interests:
None declared
Competing interests: No competing interests
Patients at times may find it difficult to make a decision about the
management of their illness. As treatment options become more technical,
the consequences of a given treatment choice become more difficult for a
layperson to understand. Decision-making especially becomes a dilemma
where choices have to be made among different therapeutic options for
critical or life threatening illnesses and the degree of uncertainty of
the outcome is high. The question for the patient usually is to either
decide alone (sometimes with family input), let the doctor decide alone,
or make a shared decision. In the case of major illness, patients feel
that they should be involved but ultimately the physician’s opinion is
considered more important. [1] Research evidence also shows that patients
who are women, born abroad, older, and less educated, tend to leave
decisions to the doctor alone. [2] On the other hand, most patients also
prefer that the decision be shared equally between them and their
physician. [3] The situation however, becomes increasingly complex when
there is a decision conflict and serious when either the patient or the
physician declines to discuss their preferences for treatment outcomes and
leave the decision in the hands of each other. [4]
Patients deserve a clear and complete understanding of the proposed
therapies and their effects on health outcomes. Some patients will want
to know all the details, while others will prefer to forego the details
and rely solely on their physician’s advice. This places a heavier
responsibility on the physician to help the patient comprehend what
options are possible and the implications of all the given choices.
Sometimes physicians’ lack of knowledge or inexperience may drive them to
avoid giving a specific advice, hence place heavier responsibility on the
patient. More disturbing is the reality that consequences of litigation
and liability [5,6] and patients’ unrealistic expectations, have markedly
severed physicians’ clinical decision making abilities.
In today's health care systems, though doctors have become
therapeutically more potent in large measure, they have ceased to give the
patient what they want. There's a need to go back to practicing medicine
by the principles of great physicians and scholars, whereby the duty of a
doctor is to diagnose and explain, with explanation being the real
business of medicine. [7] What the patient wants to know is the name of
the illness, what caused it, how is it likely to turn out, and, most
important of all, the efficacy of the medicine/therapy being prescribed.
It is certainly not enough to prescribe pills/treatment in a way of
avoiding a more time consuming analysis and treatment. Physician’s
attitude has been shown to strongly influence patients’ decision making
about their diseases, to the extent that many patients prefer that their
physician make the actual treatment decision. [8] Regardless of the
seriousness of the illness and the degree of uncertainty of outcomes, the
challenge remains to develop and implement shared decision making models
that incorporate both physician’s expertise as well as patient’s values
and preferences. [9]
References
1. Ende J, Kazis L, Ash A, Moskowitz MA. Measuring patients' desire
for autonomy: decision making and information-seeking preferences among
medical patients. J Gen Intern Med. 1989 Jan-Feb;4(1):23-30.
2. Chamot E, Charvet A, Perneger TV. Women's preferences for doctor's
involvement in decisions about mammography screening. Med Decis Making.
2004 Jul-Aug;24(4):379-85.
3. Steginga SK, Occhipinti S. The application of the Heuristic-
Systematic Processing Model to treatment decision making about prostate
cancer. Med Decis Making. 2004 Nov-Dec;24(6):573-83.
4. Corke CF, Stow PJ, Green DT, Agar JW, Henry MJ. How doctors
discuss major interventions with high risk patients: an observational
study. BMJ 2004; 0: bmj.38293.435069.DEv1
5. Eisenberg H. Malpractice pressure: dirty tricks lawyers play. Med
Econ. 1982; 3:132-51.
6. Merrill RE, Wiggins J. On physicians and litigation. J Okla State
Med Assoc. 1991 Apr;84(4):165-9.
7. Roy Porter. Medicine and the People. In: The Greatest Benefit to
Mankind. 1st American Ed. New York, NY: WW Norton & Company. 1998:668
-709.
8. DiMatteo MR, Sherbourne CD, Hays RD, et al. Physicians'
characteristics influence patients' adherence to medical treatment:
results from the Medical Outcomes Study. Health Psychol 1993;12:93-102.
9. Whitney SN. A new model of medical decisions: exploring the limits
of shared decision making. Med Decis Making. 2003 Jul-Aug;23(4):275-80.
Competing interests:
None declared
Competing interests: No competing interests
How doctors discuss major interventions with high risk patients
Editor - Corke et al. find that only a minority of physicians taking
part in the study gave advice to their patients even when they were asked
for it.1 As indicated by the authors this behaviour resembles the model of
informed decision making according to which physicians should provide
factual information but refrain from any value judgements which may
influence the decision. One underlying assumption of the model of informed
decision making is that information enables patients to control healthcare
decisions. However, empirical studies show that although the vast majority
of patients want to be informed about their health state and medical
procedures only a minor proportion wishes to take responsibility for
treatment decisions.2
Seeking advice is characteristically for patients not only prior to
major interventions. In a recently conducted qualitative study we explored
preferences concerning participation in decision making of patients with
long standing rheumatoid arthritis.3 All patients taking part in this
study wanted advice and most of them left treatment decisions to their
physicians. Expert knowledge and clinical experience of physicians
regarding the likely effects of a treatment were cited as reasons
underlying the patients’ wish for advice.
The provision of factual information and advice based on clinical
expertise are aspects of the decision making process recognised by the
concept of “shared decision making”.2 This approach provides a basis for
autonomous decisions of patients taking into account technical as well as
value related information. We agree with the authors that communication
skills are important to implement such an ideal of decision making.
However, given the powerful position physicians hold in the process of
decision making and the narrow ridge between ethically acceptable advice
and unacceptable manipulation physicians must also reflect their own
health related values and the role these preferences should play in the
decision making process. Therefore physicians not only need teaching in
communication skills but also with respect to moral aspects of health care
decision making to be able to deal with patients who need to make tough
decisions in a professional and ethically acceptable manner.
Literature
1 Corke CF, Stow PJ, Green DT, Agar JW, Henry MJ. How doctors
discuss major interventions with high risk patients: an observational
study. BMJ 2005;330:182-4.
2 Charles C, Gafni A, Whelan T. Shared decision-making in the medical
encounter: what does it mean? (or it takes at least two to tango). Soc Sci
Med 1997;44:681-92
3 Schildmann J, Gruenke M, Vollmann J: Shared decision making? a
qualitative study on ethical aspects of decision making in rheumatology
(unpublished manuscript).
Competing interests:
None declared
Competing interests: No competing interests