The choices patients make

Ten choices I‘ve made with my patients this year.

1. Sidney is 97 and has dementia and chronic lung disease. He was in hospital for nearly a month before Christmas with a chest infection and has come home feeling very weak. He has taken to his bed. I was called to see him and he has another chest infection. The choice we have to make is whether he should go back to hospital or whether I should treat him at home, knowing he might well die. He decides to stay at home.
2. Anna is 66, she has severe bronchiectasis which affects her lungs and makes it very difficult to breath. She has been on the intensive care unit (ICU) 3 times in the last year because of infections. She came to see me with flu-like symptoms and deteriorating breathlessness, she knows another ICU admission is likely. We discuss whether she would like to be resuscitated in the event of a cardiac arrest. She says, to me and her husband, “there is almost nothing left to resuscitate, no thank you doc.”
3. Beryl has throat cancer. She has had surgery, radiotherapy and chemotherapy over the last 18 months. A CT scan last month showed the cancer had spread to her right lung. The oncologist has recommend surgery to remove the affected part of the lung. She doesn’t think she can cope with more surgery. We discuss the options. She decides to go ahead. See the excellent Atul Gawande for more on these dilemmas http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande
4. Cheryl has poorly controlled diabetes and is severely obese. She is also very anxious and rarely leaves home because of panic attacks. She is terrified of needles. Without insulin it’s very likely her kidneys will fail and she will go blind. We discuss the options. In spite of her needle phobia she agrees to see the surgeons to discuss a gastric bypass operation which might improve her diabetes sufficiently to avoid the need for insulin.
5. Mohammed has severe pain in his knees due to osteoarthritis. His family have encouraged him to see a surgeon to consider a knee replacement. He comes to see me to discuss the options. With physiotherapy he could reduce the pain and have a few more years before needing surgery. He decides to see the physiotherapists.
6. Maisy is 4. Her mother is keen for her to have a flu vaccine; she’s very worried about all the flu going around at school. We discuss the risks and benefits in detail. She decides it is not necessary.
7. Smantha is 36, she’s had a coil in for the last 4 months for contraception but the irregular bleeding is distressing her. She comes in to discuss the options. I reassure that this often settles down and we decide to try something to reduce the bleeding in the meantime.
8. Lucy has become increasingly psychotic over the Christmas break and her family are worried about her. I visited her at home with a psychiatrist and social worker to perform a section assessment to consider compulsory admission to a psychiatric unit. After careful consideration of all the options, we agree that the home care team, with my support will look after her at home.
9. James has had a relapse and started drinking heavily again. He comes to see me for another detox. We discuss the previous attempts and present options. Previous detoxifications haven’t been successful. We agree that he will see the alcohol counsellor this week and make a plan with the specialist alcohol team.
10. Eric has motor neurone disease. He is becoming gradually paralysed and can only manage soft or pureed foods. At a multidisciplinary meeting we discuss placement of a feeding tube that will be placed directly into his stomach through the abdominal wall. This is to prevent him choking on is food as his swallowing muscles become weaker. He wants to continue eating by mouth for as long as possible in spite of the risks.

These are the kind of choices that patients make with their doctors and nurses every day. They depend on a relationship of trust and mutual understanding which develops from continuity of care.

We know that overwhelmingly patients choose to see their own doctor and have treatment in their local hospital. By converting the NHS from a public service into a competitive business the choices that really matter to patients will come secondary to business interests.

The only choice the government are interested in is ‘provider choice’, which is a mechanism for stimulating markets and undermining the principles of a public NHS provided according to need.

To preserve an NHS where patients choices come first:

• send your views to info.whitepaper@bma.org.uk
• join Keep Our NHS Public
• find out more from the NHS Support Federation