Tuesday, 21 August 2007

Ethics

In my neck of the woods, people who developed dementia used to readily get help. Crucially, the patients with Alzheimer's Disease also got medication. All of them could.

The National Institute for Health and Clinical Excellence (NICE) has determined that antidementia medication is now just for those with moderate dementia only.

This puts me in a peculiar position.

I see a patient and diagnose Alzheimer's Disease causing their dementia. This will progress, robbing them of their memory, thoughts and function, then kill them. This is not nice. In many ways, it's a worse diagnosis than cancer. But there's a silver lining . . . we have medication which can help, which doesn't change the underlying course but can delay symptoms for an average of a couple years. And it works. Numerous trials confirm this. NICE say the evidence is that it works in Mild dementia. But the benefit is pretty modest, so it should only be prescribed when dementia is of Moderate severity, not Mild.

Can we tell patients to go away and come back when they've deteriorated so much that we can then start treatment to maintain them at that lower level of function?

I can't. My colleagues can't. Our local GPs don't want us to. Our patient's don't want us to. Their families don't want us to. Our PCT is surprisingly supporting of my practice and is ambivalent about this NICE guidance.

So what do we do?

Everyone who could profit from the medication is given a trial of the medication and reviewed. If they have been assessed as having Mild dementia and the odd person queries prescribing, well, let's say they've got Moderate dementia then. Just that they're in the fortuitous position of faring rather well in a few domains to bump up their score. Hurrah.

It's grim that medics are bending the truth, but if it's necessary for our patients to get the care they deserve, is this the right thing to do?

5 comments:

Milk & Two Sugars said...

I'm not accustomed to defining 'right' and 'wrong' based upon my government's perception of it. In your position, I'd give the drug with genuine pleasure.

Zarathustra said...

NICE guidelines or no NICE guidelines, I know what I'd want you to do if it was me that had been diagnosed with Alzheimers.

Advanced Practitioner said...

My mother-in-law had Alzheimers, I wish this medication had been available when she first showed signs of dementia. Alzheimers is a savage disease and I thank god there are doctors like yourself who know NICE have got it wrong!!

Xavier Emmanuelle said...

You're acting in the best interest of your patients, and not harming anyone in the process, so I don't see how it could be judged as wrong even though you're going against government policy.

Cal said...

I would like to think that you were doing all you could to help these patients.