Issue 2 / 28 January 2014

IT is generally agreed that effective therapeutic decisions are best made with the full comprehension, participation and support of the patient.

But consider a typical day in hospital practice — how often is this ideal achievable as patients, often with diminished capacity, tumble through the system from decision to decision?

A study published in JAMA Internal Medicine this week and reported in our lead news story, highlights the common scenario of elderly hospitalised patients requiring the assistance of “surrogate decision makers”, and the scant attention given to the support of these surrogates’ role.

The researchers make the point that: “The current hospital structures and routines of daily bedside rounds are built on the assumption that the patient can provide historical information and make decisions independently” creating “substantial barriers to communication for surrogate decision makers”.

Australian experts told MJA InSight that the situation is similar here, starting with the problem that surrogate decisionmakers don’t generally arrive at the hospital with a legal contract, specific instructions and a name-tag. More commonly the “next-of-kin” — a son, daughter or other involved person — is hastily identified and thrown into the spotlight when high-acuity decisions need to be made, making good communication and coherent decision making less than likely.

In the more orderly world of general practice, getting the patient on-board with therapeutic decisions should be easier but it seems that the intimacy of the consulting room raises challenges of its own.

Another of our news stories is based on a qualitative study from Wales, which aimed to discover how family physicians work out whether their patients attending with upper respiratory tract infections are expecting to receive antibiotics.

The study is appealing not just because it conjures up images  of dark-eyed Welsh doctors using lilting tones to assiduously avoid the A-word, but because it demonstrates that the seemingly simple step of understanding patients’ beliefs and preferences before inviting them to share in treatment decisions can be a convoluted and socially laden process.

True shared decision making, in which “patients and clinicians work in partnership to integrate the patient’s values, goals and concerns with the best available evidence about benefits, risks and uncertainties of treatment, to make appropriate health care decisions”, can only happen when good information to guide decisions is available.

This can be a walk in the park when the question is something simple, such as whether to use antibiotics in the treatment of uncomplicated otitis media, but could get complicated in patients with multiple morbidities, where there is limited or conflicting evidence, or for the many Australian patients whose health literacy is poor.

An elegant study published in JAMA Internal Medicine and reported in our News in brief provides an example of the kind of information that could be shared with patients taking warfarin about their particular risks and treatment options for upper respiratory tract infection.

One MJA InSight commentator, Professor Mark Nelson, is less enthusiastic about the ability of the recently published evidence-based guideline for the management of high blood pressure in adults from the US-based Eighth Joint National Committee to guide good decision making.

The committee has taken the seemingly retrograde step of viewing high blood pressure (BP) as a disease in itself rather than a risk factor, and advocating management on a BP threshold basis rather than taking the “more holistic absolute cardiovascular disease risk approach” now recommended in Australia.

Conflicting guidelines aside, the quest to confidently engage patients in making and owning decisions about their health care has to be underpinned by good communication. On that topic, the words of one of the Welsh primary care physicians in the antibiotic study seem like good advice:

“The most important thing I’ve found in all these years of experience [is] if I have a good rapport, then I can get things done”


Dr Ruth Armstrong is the medical editor of MJA InSight.

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