Wednesday, September 17, 2008

Titrating Guidance

...Continuing a theme from the post above, Archives of Internal Medicine has an article about 'titrating' guidance for patients who are facing complex medical decisions. It's a thoughtful exploratory piece which prompts clinicians to consider how they counsel patients/families about medical decisions based on a spectrum of risk:benefit profiles of medical decisions (e.g. high benefit, low risk; uncertain benefit uncertain risk; low benefit, low risk). It shares some features with this typology of decision making in Annals of Internal Medicine a few years back.

This article is specifically framed, however, in the context of patients facing highly morbid, life-limiting illnesses (the paper uses a case of a patient with a large stroke and his family facing the decision of providing gastrostomy feeds, etc.). Pursuant to the post above, what is really helpful about this article is that it shares a way of thinking about medical decisions (and our discussions with patients/families about those decisions) that describes some of those background 'emotional intelligence' aspects of these conversations that are not captured by the simple, procedural breaking bad news protocols such as SPIKES. I particularly liked its discussion of scenarios in which any treatment would have limited/zero benefit and there aren't too many 'Big' medical decisions to be made, and the fact that those encounters, even when there are no 'decisions' to be made (other than where someone dies), can be fraught with emotion and peril. A good one for the teaching file, particularly for fellow-level trainees.

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