Friday, 22 August 2008


A lot of decision making I am asked to undertake involves an element of risk management. Whether it's risks of leaving mentally unwell folk in their own home or whether it's around timing of discharge planning (when folks aren't cured but are things "good enough" to go home?), or of course prescribing. Stopping or initiating medication has clinical consequences, and thus risks.

My team has, I believe, a healthy attitude of positive risk taking. External agencies, partner organisations, patient and carer groups and our own Trust Board agree, so hopefully my belief is reasonable.

There are scenarios when I'm twitchy and would see risks as unacceptable. Almost always, since these are discussed as a team with the patient/carers, concensus can be reached and a sensible management plan generated. With prescribing it's a little different since I do that in discussion with the team but prescribe independently. We do have nonmedical prescribers but they're not independent prescribers and I don't envisage a day when nonmedical prescribers will initiate or change medication without discussion with a Consultant Psychiatrist. Currently our clinical governance framework requires this and it's firmly entrenched in our Medicines Management structure, so although nonmedical prescribers support, review, titrate and advise, the initiation or withdrawl of medication always always involves a Consultant Psychiatrist. Almost always it's the Consultant Psychiatrist doing it, since nonmedical prescribing is a tiny proportion of our prescribing.

Prescribing practice is singularly unique in my corner in that the risks (unlike other risks) are almost wholly carried by the Consultant Psychiatrist. It's therefore of interest to me how my colleagues and I prescribe (and an area that's audited and reviewed).

One theme that's arisen has been of varied prescribing of anti-dementia drugs.

I prescribe widely almost wholly irrespective of severity of the dementia (i.e. whether it's mild, moderate or severe I'm keen to prescribe if the medication's of benefit) which is outside the NICE guidelines (technology apprasial TA 111) which directs us to prescribe just for moderate severity dementia. I feel uncomfortable waiting for someone to deteriorate before prescribing, so prescribe for mild dementia. One colleague does not, sticking pretty closely to NICE guidelines. It's hard to say they're doing the wrong thing, it's easier to say I'm doing the wrong thing. Either way, there's a difference in clinical care, depending which of us you see, which is determined by where you live.

So I prescribe a lot of anti-dementia medication. At the other end of the spectrum is a colleague who prescribes far less anti-dementia medication than I do. A potential risk of the medication is to slow the heart rate down (bradycardia). At some point the heart rate is normal and all's fine. At some point it's so slow it's hugely abnormal and you're unconscious. There's a range in between where it's not perfectly normal but it's having no clinical consequences, through to sometimes causing problems, to having ongoing minor problems, to being more serious. This gives a grey area then, at what stage should a doctor no longer offer medication because the possible risk of possibly getting bradycardia may possibly make the heart rate slower and possibly cause serious problems? Some doctors prescribe readily with a pulse rate of 60, some won't prescribe. Either way, again there's a difference in clinical care, depending which doctor you see, which is determined by where you live.

The drugs also ramp up risks of conduction abnormalities within the heart, a lot of elderly folk have ECGs that aren't perfect and aren't totally normal, which of these folk are excluded from having medication? Again, it's up to the doctor to decide what seems too risky, with different clinicians having different views of this.

Postcode prescribing. I really can't see a way around this.


cbtish said...

Prescribing practice...risks (unlike other risks) are almost wholly carried by the Consultant Psychiatrist.

Nah...the risks are almost wholly carried by the patients. Also, capitalizing "Consultant Psychiatrist" makes it look as if you are referring to some unique and god-like being. What you mean is that different consultant psychiatrists might assess risks somewhat differently, so that they are neither unique nor god-like. And a good thing too, I would add.

The Shrink said...

Interesting. I'd still maintain that the risk is carried by the doctor, although adverse outcomes of risk are clearly experienced by the patient.
When it goes wrong, and a risk doesn't pay off, is it the patient who's every criticised or sued for electing to engage in a process that's caused harm?
Thus, I'd say responsibility of risk is with the doctor, consequences of risk are with the patient.

Consultant Psychiatrist was used as a specific term. As most of my posts show, usually I talk of doctors or medics. In this case the specific role was relevant. It's not other Consultants (eg Nurse Consultants dont carry the risk) and not other doctors (eg Staff Grade doctors don't). Hence the capital letters since the term is used as a title, necessitating the capitalisation of the words.
There is method to my madness, you see :)

in-the-margins said...

I was talking to my psychiatrist about anti-depressant prescribing recently, and she said that whilst 99% of psychiatrists would prescribe an SSRI for first line treatment of depression, the specific SSRI you get is entirely based on what med the doctor 'likes'. And then if SSRIs down cut it, the class of meds you try next will once again be based on teh experience of the doctor. Because there's relatively little information about the comparisons between anti-depressants, and there's (from what I understand) quite a degree of guesswork involved in psychiatric prescribing, the meds you get tend to be based on what your particular doctor has seen work and feels comfortable with, rather than anything else.

And in a CAMHS service, there's the added leap of whether your consultant is going to treat you as an adult at 16/17 on the understanding that your reaction to meds isn't going to suddenly change when you hit 18, or insist on fluoxetine because that's all NICE says should be prescribed for under 18s.

InEx said...

I think I am with cbtish here the true risk is for the most part carried by the patient. Medics are very, very, very rarely brought to account about thier prescribing for individual patients. They may well be asked about particular prescribing trends though. I agree though that there is an great deal of risk management in the medical role.

The Shrink said...

"Medics are very, very, very rarely brought to account about thier prescribing for individual patients."

Are patients brought to account more often? I've never known a patient ever be brought to account. Taken to an extreme, patients elect to go to an out-patient clinic, patients elect to wait to discuss their care, patients elect to hear what a specialist has to offer, patients elect to consider the choices offered to them, patients elect to choose one treatment offered and elect to ask for this, patients elect to accept the prescription, patients elect to go to the chemist for the drugs (which by law have patient information leaflets telling patients about them), patients elect to take the drugs. In this process, if it goes wrong, isn't the doctor just offering a drug to treat something the patient's asking to be treated, but the patient's making oodles of choices that result in them taking the tablets? So shouldn't patients rather than doctors be brought to task, hassled by lawyers over what they asked about, what factors they considered in accepting the medication, harrowed over what they recall from the patient information leaflet they read, hassled over why they didn't then raise these concerns with their GP/Consultant/NHS Direct etc?

Of course I'm being facetious.

My point, though, is that although a case could be made that patients have informed choice and responsibility for their own care, in practice the responsibility of risk lies with the doctor and the consequences of risk lie with patients.

Socrates said...

Hmmm... When I was prescribed Miraclezapine, I wasn't warned that "clinical experience shows that people with an ASD can have an ideosyncratic response to medication" [RCShrinks council document] and an autistic with a major depressive episode is likely to have significantly impaired ability to make informed choices. The patient information leaflet did not say "In seven days you will loose all impulse control in Sainsbury's, try to fight the security guard".

InEx said...

Yes you are being facetious but you can be it's OK and you do have a bit of a point. I would counter that doctors don't always discuss everything all the time with their patients sometimes they just do stuff.....I know it is usually in the best interest of the patient but still....but then again this isn't a perfect world. Oh good grief - I'm being reasonable and I'm supposed to be barmy..........

Socrates said...

Silvawingz, I wasn't being facetious: . I'm afraid my life is a Grand Farce and the only people that believe me are the Legal Aid Board who've thrown me thousands of pounds to pay for Mr Maximus Trouble QC, to deal with it. [This post contains no irony, sarcasm or wit (Except he's not called Maximus)]

InEx said...

Hey Socrates - I didn't mean you - If you look at the times we posted at a very similar time - I was answering the Shrink - (see comment above your original comment)Apologies if I caused you any offence.

Socrates said...

Sorry Silva, overcome by urge to rant, without reading properly...

Anonymous said...

my view is that of a nurse in the community, working with elders and their families. The cost of medications is a big factor for many families. GI side effects are problematic, as is the need for excellent compliance with medication in order to receive the desired benefit. Sometimes it seems that once an elder is started on an anti-dementia drug, there is no reevaluation later on to see if there is still some justification for using it.
Sometimes it seems that elders do better with meds for depression or antipsychotics, given carefullly, to manage behaviors. That can be a more useful way to use resources than in anti-dementia drugs that seem to have no observable benefit to the elder.
Not a scientfic perpsective, but one based on anecdotes. Ideally the prescriber considers BOTH the research and clinical studies AND the particular elder in the consulting room, before making a decision.