Can doing nothing sometimes be the best approach?
Is there a more misunderstood medical intervention than resuscitation? It is a treatment that promises so much. Many take it as a sign that doctors are doing everything they can to keep vulnerable patients alive. The reality is quite different.
This was Isabel Hardman writing in The Times following the outrage expressed over the campaign to discuss with patients, their wishes in the event of a crisis resulting in a decision as to whether or not to rescucitate.
Ms Hardman goes on to extol the necessity for broaching the subject of DNR with patients and their families, while they are able to consider their options in a cool, objective context.
Taking the issue of patient involvement a step further is a new campaign launched by the Academy of Medical Royal Colleges called Choosing Wisely. Its premise is that patients should be encouraged to ask if tests are really needed, that doctors should discuss potential harms of treatment with patients, and the campaign calls for experts to develop lists of common practices that should be stopped.
Originally a US initiative, now launched in the UK, the aim is to encourage and support doctors to stop using interventions which have no benefit, and to help tackle the threat and waste of resources posed by over-diagnosis.
Unnecessary care occurs when people are diagnosed and treated for conditions that will never cause them harm. As geriatricians we are only too familiar with the harmful effects of polypharmacy, be it drug-induced hypotension leading to falls or recurrent hospitalisations due to adverse drug reactions. A culture of ‘more is better’, has significantly undermined the age old tradition of ‘Do no Harm’.
Participating organisations will be asked to identify five tests or procedures commonly used in their field, the necessity of which should be questioned and the risks and benefits of which should be discussed with patients before using them.
The findings will be compiled into lists and it is suggested that the “top five” interventions for each specialty should not be used routinely or at all.
The campaign’s objective is “to translate the evidence into clinical practice and truly wind back the harms caused by too much medicine.”
The twin of over-diagnosis is, of course, under-diagnosis, under-treatment and under-care. It is probably most obviously prevalent in mental health services and, to some extent, in older people in a slightly different context.
The initiative raises certain questions. Is this new movement the beginning of a cultural shift towards shared decision-making, rather than merely identifying a “do not do” list? Will NICE and other organisations be crucial in developing such tools?
Getting this nuanced narrative correct for the media and the public is crucial. At a time when the NHS is in a transitional phase (again), will this movement not be perceived as a top down cost cutting measure?
Alternatively, could this be the biggest step towards patient-centred medicine in the UK or could it fizzle out in a bout of squabbling over the necessity of this treatment or that?
The only way it can succeed is if it genuinely involves patients at every stage and every level. It should raise awareness among doctors of the real benefits and harms of treatments and care pathways and support them in discussing prospective interventions with patients in a way that meets their concerns, goals and preferences.
The British Geriatrics Society has been working with the Picker institute towards developing Patient Reported Experience Measures (PREMs). Could this become a key quality measure?
It will mean establishing mutual trust and treating guidelines as advice and not as tramlines. We need to re-establish the value of wisdom and kindness and look at how best to teach and disseminate these, as well as teaching and disseminating the best evidence to guide practice.
Geriatricians are well placed to do this. This is a movement to which geriatricians could give a serious thought.
Consultant Physician and Geriatrician
University Hospital of North Staffordshire, Stoke on Trent and an Honorary Clinical Lecturer at Keele University