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At the heart of general practice since 1960

In praise of the Billy Elliot stool

Three GPs share their approach to a practice dilemma

Patient wants me to make life and death decision

Case history

Mr A has osteoarthritis of the spine and hip; he also has IHD but rarely gets angina as the pains in his back and legs stop him first. Despite this he is fitter than his wife who also has arthritis and relies on him to look after her. He has seen both vascular and back surgeons; the consensus is that he may benefit from surgery for spinal stenosis, but the operation carries a small risk of death or paralysis, and is not guaranteed to relieve his symptoms. The surgeon has spelt out his advice in full in his letter to you, so you go through it with them again. Mrs A then asks: 'What do you think he should do, doctor?' You say that it has to be Mr A's decision, and are shocked when he shouts: 'That's ridiculous, you're my doctor, it's your job to decide what's best for me.'

Dr Keli Thorsteinsson

'Actually I might say I'm going to have to ask you to leave'

Whenever things seem to be going badly, I find most people respond positively to a calm, professional attitude. However hard it may seem at the time, I do try to give the patient the benefit of the doubt. There must be some reason for an outburst like this. The touchy-feely VTS-purified part of me thinks that perhaps Mr A is worried about his wife if he dies or that he may become an invalid and a burden on her. I would put this to him and with any luck he should start to calm down.

Whatever happens, this is going to be a long and difficult consultation and I need to accept that and deal with it. If and when he calms down, I might try to help him with his choices. I would inform him that surgery for spinal stenosis is usually symptomatic only.

I would make sure he really understands that there are other options, including step-up in analgesia, nerve blocks and physical therapy. I could suggest he start thinking about his wife's care (and his own) in the long-term. I would offer them the advice of the health visitor or a nursing assessment by the district nurse.

Of course, this is exactly the sort of patronising behaviour that may spark another outburst. In any case, he needs to understand that I don't see it as my remit to take major life-and-death decisions for fully competent adults.

If Mr A remains angry, there is a fall-back position. Namely, along the lines of: 'I am sorry, but I've tried my best to help you and give you advice. I don't think we are getting anywhere and I am going to have to ask you to leave.' Actually, I might try this approach before my next regular heartsink sits down.

Keli Thorsteinsson is originally from Iceland, completed VTS in the UK in 2001 and joined a Shrewsbury town-centre practice in January 2004

Dr Tonia Myers

'Doctors are no longer allowed to make decisions for patients'

I would let Mr A get it off his chest and I would sympathise with his dilemma. I would explain that in today's society doctors are no longer allowed to make decisions for their patients. Surgeons must protect themselves against litigation and explain all the possible risks, so that patients can give informed consent.

I would reiterate that he is not a good surgical risk and that surgeons understandably will not operate on OEcardiac patients unless absolutely essential. It will be useful in helping Mr A judge the pros and cons if the surgeon has actually quantified the odds of improvement or deterioration as a percentage.

If pushed, I will come off the fence and say that though I cannot make his decision for him, I would be prepared to tell him what I would do in his shoes. In view of his age and general health, I would try to avoid surgery if humanly possible and explore every other avenue first.

I would suggest referral to a pain specialist to see whether Mr A was suitable for an epidural injection or similar technique. In the meantime I would review and increase his analgesia to the maximum tolerated doses. Sometimes patients with chronic pain do not like taking painkillers. I would persuade him that taking analgesics regularly is much more effective than taking one now and again, and is a far better option than surgery.

I would suggest a low dose of amitryptilline as an adjunct to his analgesia, explaining that although in higher doses it is used as an antidepressant, when used in chronic pain it may reduce the need for painkillers and help sleep.

If all avenues have been exhausted and Mr A's quality of life is still unacceptable, then is the time to think seriously about resorting to surgery

Tonia Myers is a GP in Highams Park, London

Dr Harry Brown

'Patient and his wife plainly want you to take control'

In the modern world of general practice it is considered good practice to treat the patient as a partner and involve them in the decision-making process. This patient and his wife plainly does not want that approach and wants you to take control. At this point in the consultation, it's important to defuse the stress, anger and uncertainty that both the patient and his wife are experiencing. I would say something along the lines of: 'Thanks for the vote of confidence but it is also my job to provide you with an impartial look at the risks and benefits of the procedure.'

Equally, I would say that at the end of the day Mr A has to make the final decision, there is no rush and you are there to help guide him to make that decision. Being their GP, you should hopefully be aware of their domestic situation, their thought processes and the stress and anxiety they are undoubtedly experiencing over the prospect of having major surgery.

Once the heat of the situation is defused, I would ask if anything is specifically worrying either Mr and Mrs A and explore their anxieties if any arise. For example, how would Mrs A cope without the aid of her husband in the post-operative period and during the time of rehabilitation? I would then proceed to discuss the pros and cons of the surgery but not make any definite recommendations at that time.

I would ask them to think about it and make them an appointment for the following week. I would offer a copy of the hospital letter to take away with them and suggest that if they want, they can bring a member of the family or a friend along to the next consultation.

As a final suggestion, they could write down some questions or issues they want to raise with me next week and bring the list with them.

Harry Brown is a GP in Leeds and is a trainer

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