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BMJ 2001;323 ( 1 September )

Editor's choice

Choice is hard

"There is considerable evidence that patients want more information and greater involvement [in medical decisions that affect them]." It doesn't follow, however, that providing the information, and eliciting informed choices, has to be easy.

Gwen Sayers and James Mair, for example, complain about a form their hospital has developed for seeking relatives' consent to an autopsy (p 521). The form leaves little room for "ambivalence, criticism, or later complaint." But they are bothered by the human cost of asking relatives to consider the constituent parts of their loved onestissues, fluids, and organsin the way "they might select football teams on a pools form." Their solution is to leave relatives to fill it in themselvessomething they concede amounts to a cop out.

Liam Farrell would probably agree (p 521). He describes how his ability to break bad news is tested by his band's need to get rid of its guitarist. He crumbles before the mute appeal in his fellow musician's eye: "It felt like kicking a spaniel." He fails. A N G Clark similarly failed in his attempt to tell an elderly patient that he didn't have long to live (p 489). His story illustrates the power of denialand Clark never again tried to tell an elderly patient the truth about a fatal illness.

It seems too that British palliative care specialists don't usually seek patients' consent when they use "off label" drugs. Hilary Pavis and Andrew Wilcock's survey suggests that doctors don't want to make their patients anxious (p 484), and that explicit consent is not necessary for therapeutic practices advocated by a responsible body of professionals.

But that's not the spirit of the times, and others discuss ways of helping patients become better informed. Katarina Westberg and colleagues tested two strategies for getting patients' informed consent to take part in training medical students (p 488). They found no difference between asking patients' consent on the day they came to a gynaecology clinic and asking them in advance. "Arguments for not informing patients in advance seem to be based more on prejudice than on empirical evidence."

Finally, two further randomised trials test the effect of a multimedia, interactive decision aid on patients' decision making about hormone replacement therapy and benign prostatic hypertrophy (pp 490,493). In both conditions the decision aid helped patients reach a decision. In his accompanying editorial Richard A Deyo (from whom the opening quote comes) says that such aids represent a real advance (p 466). "For now the revolutionary contribution of these new aids lies simply in making it clear that there often is a choice."

Footnotes

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© BMJ 2001

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Related editorials in BMJ:

A key medical decision maker: the patient.

Richard A Deyo
BMJ 2001 323: 466-467. [Full text]  

Other related articles in BMJ:

PAPERS
Prescribing of drugs for use outside their licence in palliative care: survey of specialists in the United Kingdom.

Hilary Pavis and Andrew Wilcock
BMJ 2001 323: 484-485. [Full text]  

PAPERS
Getting informed consent from patients to take part in the clinical training of students: randomised trial of two strategies.

Katarina Westberg, Niels Lynøe, Ann Lalos, Mats Löfgren, and Mikael Sandlund
BMJ 2001 323: 488. [Full text]  

FILLERS
A patient who changed my practice: To tell or not to tell.

A N G Clark
BMJ 2001 323: 489. [Full text]  

PRIMARY CARE
Randomised controlled trial of an interactive multimedia decision aid on hormone replacement therapy in primary care.

Elizabeth Murray, Hilary Davis, Sharon See Tai, Angela Coulter, Alastair Gray, and Andy Haines
BMJ 2001 323: 490. [Abstract] [Abridged text] [Full text]  

PRIMARY CARE
Randomised controlled trial of an interactive multimedia decision aid on benign prostatic hypertrophy in primary care.

Elizabeth Murray, Hilary Davis, Sharon See Tai, Angela Coulter, Alastair Gray, and Andy Haines
BMJ 2001 323: 493. [Abstract] [Abridged text] [Full text]  

PERSONAL VIEWS
Getting consent for autopsies: who should ask what, and why?.

Gwen M Sayers and James Mair
BMJ 2001 323: 521. [Full text]  

SOUNDINGS
Breaking bad news.

Liam Farrell
BMJ 2001 323: 521. [Full text]  

ALL INFORMATION, DATA, AND MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR GENERAL INFORMATION PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE KNOWLEDGE OR OPINIONS OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED AS PROVIDING MEDICAL OR LEGAL ADVICE.  THE DECISION WHETHER OR NOT TO VACCINATE IS AN IMPORTANT AND COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN CONSULTATION WITH YOUR HEALTH CARE PROVIDER.