The winter vomiting bug has done its rounds in our household and my daughter was the last to succumb. As I prompted her to drink more, she asked me which was healthier – water or milk? I thought about it for a few minutes and then told her it depends what you want to achieve. If you want to be hydrated, then water is healthier, but if you want calories and protein, then milk is healthier. She immediately declared she was dehydrated and went off to fetch herself a cup of water.
This simple conversation made me reflect on the outcomes we focus on in healthcare. It seems obvious to want to offer patients what they wish to achieve, but there is evidence of a mismatch between what they want and what is genuinely of benefit.
When patients were asked about the benefits of percutaneous coronary intervention (PCI) in stable coronary heart disease, the overwhelming majority believed it would prevent recurrent cardiac events and reduce mortality, rather than the reality that it reduces angina.
There are many examples of patients overestimating the impact of medical interventions, the most significant being cardiopulmonary resuscitation (CPR). We are legally and morally obliged to practise person-centred care, but this includes informing patients of the risks and benefits of all options. Patients are seduced by the success of the sanitised version of CPR they see on TV, rather than understanding the horrors of broken ribs and vomit. No one is spelling out the reality – that when you’re frail, or have comorbidities or advanced cancer, your heart and lungs fail as a result of everything else failing, not as a primary event. In other words, it is time to allow you to die. We need to stop asking, “What is the matter with you?” and start asking, “What matters TO you?”
We need to stop asking, “What is the matter with you?” and start asking, “What matters TO you?”
So, why are patients choosing interventions they may not fully understand or endorse? Much of this relates to the illusion of shared decision making; that if we hand out a patient leaflet, our job is done. But this half-hearted attempt at offering choice is actually worse than our historic paternalistic practice of ‘doctor knows best’. Offering interventions without adequate counselling and guidance can lead to choices patients may later regret (the case for some 20% of respondents in our recent CCG survey of 1,000 people). So, as the NHS enters another decade, it’s time for a realistic conversation with the public about what it can and can’t achieve.
Admitting frail, care home patients who are in their final stages of life is rarely in their best interests. Adding yet another drug for someone with Type 2 diabetes is futile if they are still mainlining sugar. And trawling for people with ‘pre-diagnoses’ will just turn more of us into patients, with no evidence of benefit. These conversations have already started with Scotland’s Realistic Medicine movement. Like any movement, it has to be underpinned by a change in culture that permeates every conversation up to the highest levels.
But our most important conversation is the one we have with a patient. We need to stop asking, “What is the matter with you?” and start asking, “What matters TO you?”
After all, hydration mattered to my daughter, so I didn’t force feed her milk.