There seem to be many layers and themes to this thread. It was fascinating reading this after a busy day working in the swamp of uncertainty (in palliative care). Perhaps others have come into the discussion also from a day in the rocky sunlit uplands of cardiology or critical care!

One thought which I had was "what do we mean by care?". For Ceri, arriving at hospital within one hour of the onset of chest pain for thrombolysis, seems (quite rightly I agree) to be the goal of care. We "know" through RCT type research that thrombolysis is effective in the treatment of an acute MI and we have come to believe, through a pragmatic assessment of what is possible, that thrombolysis within 1 hour of the onset of chest pain is "best practice". Creativity is needed in reaching this goal for the individual patient (Although the new protocol driven emergency care procedures following the "death of out of hours general practice", maybe see creativity as dangerous - but that is not the point I want to make).

Seeing a patient today with complex chest pain from mesothelioma who becomes confused on opioids, has anxiety over his diagnosis/prognosis, which is leading to worsening breathlessness, my goal cannot be "to deliver the treatment four times daily on time", because I don't know what will work. It needs my creativity, based on my knowledge/ experience, that of colleagues in the multidisciplinary team and a good deal of luck (is this something like professional artistry?) to reach the goal, which has been agreed with the patient and his family, to try and make his pain at least a little better.

So in the first scenario the goal is clear and achievable and we don't really worry ourselves about whether it will benefit this patient or not (in trying to acheive the goal). If it doesn't work, we get out our new protocol called "managing arrhythmias" or "treating acute heart failure" (I know the treatment may cause arrhythmias too). In the second scenario from palliative care, the goal is clear but the way to achieving it is much less clear.

Modernity in medicine (in its EBM incarnation) suggests that with more RCTs palliative care can too move into the zone of regularity and certainty at least in defining my goals of best practice. Unfortunately I am an unbeliever. Best practice for me (I think) is trying to listen, think, not make assumptions, let others challenge the assumptions I inevitably make....oh yes and use the technical-rational stuff which I constantly try to update and reflect on within the context of the swamp. The swamp will always be the swamp. Perhaps this is the care which Sarah's husband noticed was lacking?

Dan



Dr Dan Munday
Consultant/Honorary Clinical Senior Lecturer in Palliative Medicine
Coventry PCT and
Centre for Primary Health Care Studies
University of Warwick

email [log in to unmask]
Tel 024 76246858
>>> [log in to unmask] 05/25/04 19:44 PM >>>
In a message dated 25/05/2004 14:32:49 GMT Daylight Time,
[log in to unmask] writes:

> He describes the faces of the drivers as like those "going to a funeral".
> Such is the result when we deny the creativity that is our humanity.
>
>

Hang on a minute, according to your argument they are going to work and being
creative at the same time........

To come back to a previous point of debate, surely you need creativity to
ensure regularity!
Getting an innovative procedure into routine clinical practice necessitates
creative adjustments in clinical microsystem behaviour.

Ensuring that thrombolysis is regulary administered within 1 hour of arrival
in A&E with an MI infers many creative changes from the prior status quo. The
'knowledge' about a patient's MI is distrubuted more widely - among nursing
and other healthcare professionals - after due discussion and dialogue among
the clinical team. 'Just do it,' as Anita pointed out, results from prior
agreement as to what 'it' is. A final common vocabulary perhaps?

Ceri