Medical decision-making

In general, in Western societies people make their own decisions. Or at least they have the theoretical right to do so. Of course, there are practical limits. On some days I think I’d like to travel to work at the hospital in a soft-top Bentley, particularly (with the hood up) when it’s raining, but the facts that I can’t afford one, I’m only allowed to park in the hospital when I’m on call, and my garage at home isn’t big enough, all mean such day-dreams are brief and I need to keep my bike in working order.

But if someone can afford a Bentley, they’re allowed to have one. Some will envy the person driving it; some think that no-one could afford it as a result of honest and honourable toil; others that such an ostentatious choice of car must be indicative of small man syndrome or other serious character defect (and mean I almost certainly wouldn’t buy a Bentley even if I could afford one).

So financial limitations are part and parcel of life. We won’t get into the weeds of the reality that those who are born poor and socially deprived have all the cards stacked against them, but when something is free and doesn’t hurt other people, then people are able to and expected to make their own decisions.

Making decisions about healthcare

The same usually applies in healthcare. The doctor’s job is to explain the range of possible approaches to a medical problem and the pros and cons of each. Should investigations be done, and what sort of investigations? Should treatments be given, and what sort of treatments? Etc etc. 

Many patients don’t want their doctor to go into the ins and outs of all the possibilities. ‘Tell me what you think should be done’, they say, and a good doctor will do so, checking if they have any questions about what’s been suggested.

Other patients have a different approach. They want to know the details, sometimes to the point where they become overwhelmed, unable to see the wood for the trees. Their approach is not dissimilar to how they might behave in a restaurant, perusing the menu, receiving advice from the waiter, and then making their choices.

All fine and dandy, until it isn’t.

Choosing from the menu

Early this morning I had a conversation with a man admitted to the hospital because his breathing was difficult. He’s in his 90’s, has kidney failure for which he has kidney machine treatment (dialysis) three times a week, and he had a heart attack a few months ago. His breathing is bad because he’s got too much fluid in his lungs, but when we try to remove it by dialysis, his blood pressure drops and we have to stop the machine. There’s only one way this is going to end, and however we play it this isn’t too far away.

He told the junior (resident) doctor who he saw in the Emergency Department during the night that he wanted everything to be done. Yes, he’d like us to attempt to restart his heart if it stopped. Yes, he’d like us to take him to the Intensive Care Unit and put him on a breathing machine if his breathing got worse.

Who decides what’s on the menu?

It’s very irritating, at least I find it so, if you go to a restaurant, consider the menu, make your choice, and are then told it’s not available. Much better to be told in advance. But in terms of medical care, who decides what is available and what isn’t?

A very difficult case we managed in Cambridge in 2011 that eventually went to the Court of Appeal illustrates the difficulties and challenges and is the basis of the present legal situation regarding decisions not to attempt resuscitation (Do Not Attempt CardioPulmonary Resuscitation, DNACPR) in the UK.

Key points, as seen through my pragmatic clinical lens, are:

·      Doctors cannot be required to give treatment contrary to their clinical judgement.

·      Doctors should discuss DNACPR decisions with the patient unless they can robustly argue that the patient might be distressed by being consulted and that the distress will do them harm.

·      A patient cannot direct a clinician to provide resuscitation (or any other particular treatment), although they can refuse it.

·      There is no legal obligation for the doctor to offer to arrange for a second opinion, but it is wise for them to do so when there’s disagreement.

It is on the menu, but you can’t have it

Doctors, like most other people, want to avoid being subject to legal enquiries and proceedings. When faced with a case where they know the end is nigh and escalation of care would be futile, but where the patient and relatives won’t accept this, they may very understandably decide it’s just not worth the hassle of trying to convince that the best plan is for care to be focused entirely on symptom relief. If you want death to be more unpleasant than it need be, you can have this.