Thursday, 6 January 2011

Decision making

Towards the end of last year I generated a number of letters purely explaining decision making.

One was to a patient's wife, one to a GP and one to a clinical team on a general hospital's orthopaedic ward.

In all 3 cases the patient had been jointly seen by a CPN and me, investigations done, a diagnosis made, explanations given and appropriate management put in to place. But in all 3 cases there was a desire by another party, not the patient, to have more information. The theme was "why" with a desire to know why management was suggested as it was.

Now in all 3 cases the request for more information was polite and inquistive, rather than a forthright demand for explanations, so I'm more than happy to oblige. Sharing reasoning can only be a good thing. The original assessments and letters were extensive; typed up they were a minimum of 5 pages each. The management plans at the end were explicit and numbered, with from 7 to 11 action points in each case. With so much information, it's no surprise that folk want to know a little more about details of specific bits of this.

The wife sought to know why her husband's dementia medication was being withdrawn. The severity of his dementia, the side effects he was experiencing, the risks he'd shown (with ECG changes and collapses), the changes over time on the medication with no benefit seen by us or his wife, the diagnosis (he came to me on medication for Alzheimer's dementia but clearly has vascular dementia, which kind of accounts for why the drugs haven't worked) made decisions on the use of the medication pretty clear cut. Since he's off it he's fantastically better, his mood's settled/undistraught, his thinking's better with less preoccupation and his presentation's better with more successful acceptance of interventions, support and reassurance from his wife. But on stopping his medication his wife, not unreasonably, worried about this and sought more information. She explained how I'd spent an hour reviewing her husband with her, but only 10 minutes talking about medication. She's right, that's pretty much how time was spent. "Only" 10 minutes on why medication's not helpful is to my mind a reasonable amount of time to spend on sharing reasons and understanding, but a carer's mind is a whirl when a Consultant's questioning and investigating and formulating and changing stuff, so it's no surprise she mulled it over then wanted more information. It was no trouble to write to her, my secretary copying and pasting from the GP letter on file, detailing the 11 factors we'd considered that concluded in withdrawl of medication being appropriate. On subsequent review she's been very happy with it all.

The GP and surgical team both sought to know why his patient wasn't getting antidementia medication. It's a GP I know well and with her patient this had been explained but the patient's husband had turned up to the GP with lots of stuff clipped from papers and printed from the internet. The GP wasn't clear on how it all fitted with the current best practice and whether we'd considered relevant factors. On going through the notes it was clear we had, with over half a dozen specific statements about prescribing decisions in one letter alone and almost a dozen factors specified that influenced decisions on the patient's needs and consequent care planning. I liked this one, it was a chance to share with a colleague the reasoning behind prescribing decisions, the evidence base supporting this and the patient factors that impacted upon this. The GP gained understanding around how developing abnormal heart rhythm impacts on risk of medication causing serious harm. Similarly with the ward team.

I guess that like most clinicians, I favour spending most of my time speaking with patients and improving things with them. But sometimes it's also satisfying to have gentle challenge, stirring thoughts on decision making, to organise a response that articulates the contexts and evidence and findings and formulations and risks and degree of benefits and consequences, then share how these have been weighed up and how conclusions have been made.

All 3 times it was joint work with a CPN and others so the responses had effectively a case conference before responses were generated and this open discussion of how we worked and what we did is healthy for our team, reflecting on how we've worked.

So although I favour clinican contact and wouldn't want to navel gaze all the time, having gentle challenge/inquisitiveness to stir reflection of decision making is welcome and, to my mind, keeps us sharp in looking at how we work.

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