Over to you
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A dangerous cough
I must take issue with one of the usually excellent learning points associated with a case report published in Casebook 20(2) entitled “A dangerous cough”. You recommend: “When administering anaesthesia during an elective procedure, it is preferable to stop should you encounter difficulties and reassess for surgery at another time.” Although it is apparent that this would have been the correct course of action in the case described, this is not always so.
Can I suggest the slightly more verbose but much more accurate:
"If you encounter problems that you cannot be completely confident you have diagnosed accurately, and resolved fully when a patient is under general anaesthesia for an elective procedure that has not yet started, you should consider abandoning the procedure and waking the patient up."
Dr William Harrop-Griffiths
Consultant anaesthetist, UK
All in the detail
I am having increasing difficulty relying on Casebook for considered advice. The editorial standard is at odds with the excellent verbal advice I have received from the organisation over the last 20 years or so. What amounts to an apology regarding poor DNACPR advice given in January this year appears in the same edition as the following example of clumsiness: “Your first obligation is to act in the patient’s best interests and you should not be pressured by the patient into doing anything that is counter to this” (learning points, “A dangerous cough”, Casebook 20(2), May 2012). This seems to suggest that the patient does not know what their best interests are but the doctor does.
Modern medical ethics tend more towards the notion that if a patient is able to make a decision regarding their own best interests it is not for the doctor to paternalistically impose their own views of best interests on them: “A person is not to be treated as unable to make a decision merely because he makes an unwise decision.” s1(4) Mental Capacity Act 2005.
In the instant case I would have hoped that the advice given by the MPS would have been along the lines of: "Your first obligation is to act in the patient’s best interests and you should not be pressured by anyone else into doing something that is counter to this."
In this case, more comprehensive preoperative assessment may have led the anaesthetist (in consultation with the surgeon) into concluding that the surgery would be safer once the chest infection had fully cleared. Presented with this information the patient would very likely agree to the postponement. If she felt her best interests were served by proceeding anyway the anaesthetist and surgeon would have the opportunity to seek second opinions from colleagues. A doctor is under no obligation to provide treatment he feels would be detrimental to the patient’s health simply because the patient demands it.
This seems to suggest that the patient does not know what their best interests are but the doctor does
The notion that a vaginal hysterectomy under spinal anaesthesia might have been a reasonable alternative in the presence of pneumonia is a contentious point (particularly in an elective setting) that detracts from the otherwise sound advice regarding good communication.
Also, condensing what appears to be a very complicated case into a single glossy page might look attractive but for those experienced professionals reading the piece it usually leaves more questions than it provides answers. The poor writer has a Herculean task on his hands. Perhaps a much fuller summary could be provided online as might be found on Westlaw.
I do feel that the glossy Casebook does something of a disservice to MPS. There should be greater use of references and quotations from statute, case law and guidelines from professional bodies and considerably less reliance on well meaning, but sometimes ill-considered, bullet points.
Name and address supplied
Regarding your point about patients’ best interests, from a medicolegal standpoint you are of course correct – and no authority can impose treatment on them against their wishes, save under the provisions of mental health legislation.
However, the principle applies to the patient’s rights, and not the doctor’s responsibility; in other words, the patient cannot insist on being provided with inappropriate or negligent treatment simply because they believe it will be in their best interests to have it. The doctor has responsibilities and duties both in law and – in the UK at least – as imposed by the GMC to exercise their judgment and professionalism in assessing what treatment options are appropriate for the patient’s condition. After a proper informed discussion it is then for the patient to decide which option is best for them.
I agree with your comment about the wording of the first learning point; precision and detail can be lost at the expense of limitations on space. I also recognise that in seeking to provide material that is interesting, practical and relevant to the very wide range of doctors who receive Casebook, we do not always provide the level of detail in case reports which an experienced specialist in your position might wish.
The principle applies to the patient’s rights, and not the doctor’s responsibility
We have recently started publishing more specialty specific material, including an anaesthetic e-bulletin, and would welcome ideas for topical issues to cover in future editions.
Casebook does not purport to be an academic or peer-reviewed journal; the case reports are based on MPS cases from around the world but, unless otherwise stated, facts are altered to preserve confidentiality and to focus on generic learning to be gained rather than clinical detail. We do include some links to relevant reference material and guidelines (bearing in mind the worldwide spread of members) but quotes from statute and case law have not been considered to be a natural fit with the overall nature and purpose of this publication. We do publish a wide range of country specific factsheets, which include greater reference to statute and guidelines.
Dr Stephanie Bown, Editor-in-Chief