Both Andy Webster and myself have touched on this aspect. My personal view
is that it is rather unfair to expect the patient to make the judgement in
acute complex decisions, especially where we are struggling to make a
decision. That's tantamount to passing the buck, isn't it? In general, my
approach to these matters, is that the physician should make his decision
firstly, then "offer" this to the patient accompanied by his rationale for
such an approach. The patient is then involved and informed but is not
burdened with making the decision for the physician! It's slightly different
in elective decisions, when the patient can spend weeks getting informed,
and really gets involved in a decision.
In MI thrombolysis it is worth briefly mentioning a risk of stroke, as some
patients are terrified of stroke, and might even prefer a larger MI! But I
would never expect a patient to make this decision; I would "sell" it to
them, almost as a fait accompli, but they are free to refuse therapy if they
so desire. However in John's case, both negative outcomes are similar, i.e.
haemorrhagic stroke versus embolic stroke. It's certainly a close decision,
and I suspect there is little good science or evidence to guide us, so it
might be unfair to expect the patient to judge. Having said that, some
patients, especially those with chronic illnesses that require patient
"input" such as renal or diabetic, are incredibly sensible and might have
strong views. John's patient might have a clear understanding of his AVR and
anticoagulation, but will probably not be very knowledgeable outside of this
area, i.e. temporal lobe contusion, so he might require our help and
guidance.
Adrian
----- Original Message -----
From: "s.carley" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Monday, October 14, 2002 10:59 AM
Subject: Re: Anticagulation and Head injuries
> Not sure if GCS 15 and / or has capacity to understand but has anyone
> thought of explaining the risk/benefit to the patient +/- family (not sure
> of age either). As there is no definitive answer an explanation of the
> dilemma may be appropriate. After all, it is the patient who is ultimately
> going to undergo the risk.
>
> Simon
>
> Simon Carley
> SpR in Emergency Medicine
> [log in to unmask]
> Evidence based emergency medicine
> http://www.bestbets.org
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