Analysis

Guidelines for treating risk factors should include tools for shared decision making

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i3147 (Published 14 June 2016) Cite this as: BMJ 2016;353:i3147
  1. John S Yudkin, emeritus professor of medicine1,
  2. Jayne Kavanagh, lead of medical ethics and law unit2,
  3. James P McCormack, professor3
  1. 1Division of Medicine, University College London, London, UK
  2. 2Academic Centre of Medical Education, UCL Medical School, Royal Free Campus, London, UK
  3. 3Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
  1. Correspondence to J S Yudkin j.yudkin{at}ucl.ac.uk

Fully informed decisions cannot be made unless guidelines consider the effect of treatment on healthy life expectancy, say John S Yudkin and colleagues

In a recently published case report titled “The tyranny of guidelines,” Sarosi recounts the story of an 86 year old man living on his farm in Wisconsin and caring for his 92 year old brother with early dementia.1 Six years earlier he had been started on an angiotensin converting enzyme inhibitor and metformin after a health check, with other oral drugs subsequently added. But, when his family practice was taken over by a large organisation, he was given a copy of the American Diabetes Association guidelines and started on insulin because his haemoglobin A1c concentration was 8.5%; his antihypertensive dose was also doubled because his blood pressure was 154/92 mm Hg. Three weeks later he was admitted to hospital hypotensive and hypoglycaemic, with a hip fracture and a stroke. Both he and his brother subsequently needed residential care. The author pointed out that the guidelines stated: “Older adults who are functional and cognitively intact and have significant life expectancy should receive diabetes care with goals similar to those developed for younger adults” (HbA1c 7% and blood pressure <140/90 mm Hg).2

Importance of individual benefit

The clinicians might claim that they were only following guidelines. But, when linked to quality measures and reimbursement, guidelines can morph into orders. These guidelines suggest a target HbA1c below 8% and blood pressure <140/90 mm Hg in elderly patients unless their health status is “very complex/poor … (long term care … end-stage chronic illnesses or moderate-to-severe cognitive impairment)” with limited remaining life expectancy.2 And though the American Diabetes Association and the European Association for the Study of Diabetes recommend that “where possible, such decisions should be made with the patient, …

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