Monday 11 October 2010

Paternalistic Healthcare

I started to think this through previously, but derailed into a post about my experiences of GP training and reflection on how clinical focus shifts at different stages of our training and our careers.

My thoughts were on training, particularly my GP training, because one of the teams I work with has recently had animated debate on the topic of paternalistic healthcare. As in, telling patients what they should do.

I work in a world where mostly there're shades of grey. Most folk working in mental illness suss out there's not a magical dichotomy between mentally well and mentally ill, but there's a continuum. No matter how biomedical or psychosocial in their outlook, most folk I work with see medication as not the only treatment/panacea for everything or as useless to all patients all of the time. Whether it's diagnosis or treatment, we're comfortable with managing uncertainty within accepted frameworks. We do shades of grey quite well.

Apart from on this one, it seems.

How paternalistic should we be? It was argued that it's also a continuum and we should be more paternalistic or less paternalistic, taking into account patient factors. Some felt no, we shouldn't be paternalistic at all and that family or IMCAs should take on this role.

If someone's bewildered and all at sea, it was argued that the least restrictive/most proportionate response, acting in their best interests, would be to offer choices to them and if they were unable to make a choice to steer them to what's a good idea. A nurse had an example of a patient they'd seen who was clinically depressed (unable to think, thought they'd been back from their daughter's house 3 days when it had been 9 days, unable and unwilling to eat or drink, demotivated and not leaving the house for weeks, seeing no hope for the future and wanting to be dead).

Depression had caused marked cognitive distortions. After the nurse and I saw him one day, the nurse saw him the next day and again talked through ways of helping him. The patient couldn't make a choice, the nurse met me and arranged for an orodispersible antidepressant so the only choice the patient had to make was whether to take it or not. 2 weeks later things had improved a lot, 4 weeks later he's almost back to normal. The response to medication was unusually good but that wasn't the point, it was that the patient was started on medication through being jollied along into this by his nurse (and indirectly by me, from discussing medication the day before then providing a prescription for him).

A lady with dementia, she's now in respite care, a lot. When at home our support worker takes her out at least once a week. This gives her husband a break but also gives her opportunity for stimulation and lets us get the measure of her functional level/what she can or can't readily do any more. The support worker can get her to do anything. She'll get into her car, pop to the shops, sit and have coffee or something to eat, play a game of bingo or dominoes or snap, have a bath, anything. With respite care or home care or the sitting service we're told she's a "challenging lady" who won't do anything and "is resistive to care."

The support worker and a nurse went to the care home and watched how they treated her. Usually we'd not send two staff but there was a need for a nurse to do some formal Dementia Care Mapping as part of future teaching with that care home anyway. The staff feedback and documentation was interesting. It was clear that carers were offering the lady lots of choices and open comments.

"Do you want to play a game of card?"
"What would you like for lunch?"
"Do you want a drink of tea?"
"You okay there, love?"
"Do you fancy joining the [activities] group this afternoon?"

She sat in the care home, declining everything, "No, I'm alright love, leave me be."
Things were offered and she'd either decline to opt in, or care home staff would see her as not keen to engage so would pass over her. Mostly she was ignored.

Why was she fine with the support worker but not with care home staff? It was a difference of approach. Our support worker would, in her bright and cheery way, suggest, "Come and . . . " or "Come on, let's . . ." and she'd go with the flow and join in.

Rather than choices, to offer direction was helpful. Not for all things, all the time, but there seemed to be a place for directive comments. The lady would never opt in to play a game, but if you said, "Come and have a game of snap with Betty and me," she'd happily walk over and sit down and talk and play. Without being "told" to come and do it, if just offered "Do you want to play snap?" she'd always decline, as she would almost any choice offered to her.

Some of our team illustrated compelling cases where being paternalistic, with some people, some of the time, is a good thing.

Managers will be having a fit.

1 comment:

Dragonfly said...

Sometimes it works. Great post.