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What a pleasure to read the article by Professor Salmon and Professor Hall (February 2004, JRSM1) challenging what has become the sacred cow of patient empowerment. I can comment from the point of view of a retired consultant neuroanaesthetist and a patient.
Preoperative visiting is one of the most rewarding parts of an anaesthetist's life. Patients facing brain surgery are, perhaps, even more nervous than patients facing surgery of other parts of the body. Having had a look through the notes beforehand, I would usually sit and chat for a while. I listened to their fears and anxieties and often heard about their friends and families. Sooner or later I would be asked, ‘Is it safe doctor’? ‘Might I die’? ‘Will my brain be affected’?. Of course they will all have had a similar conversation with one or more members of the surgical team days or weeks beforehand, but the immediacy of the event brings out all the anxieties previously ignored or suppressed. One of the commonest questions was, ‘What do you recommend doctor’? My answer may be thought paternalistic but I usually replied, ‘Well Mr X or Mrs Y, if you were a close relative I would have no hesitation in recommending that you put your anxieties to one side and accept what the surgeons have proposed, and we shall be doing our best to see that you are OK’. One must make a judgment on which patient wants/needs the paternalistic approach and which does not. It is usually perfectly plain after a few minutes' chat.
As a patient after a myocardial infarction and while still in the coronary care unit with almost constant angina, the cardiologist and cardiac surgeon visited me together. My being a doctor clearly influenced their behaviour. ‘Well’, the surgeon said, ‘I think a bypass is both possible and would help’. He then added to me, ‘but you must realize that you may not survive the surgery’. Despite my medical knowledge and experience I wanted the paternalistic approach, so asked, ‘What do you think? Is it worth a go’? I can remember adding that I would rather die in the attempt than live as a cardiac cripple. Their combined opinion was I should give it a go. So I did and that was in 1994.
Another case is slightly different. A young man, a close relative, had been diagnosed as having rectal carcinoma. His surgeon, following current practice, gave him a mass of information including two treatment options. He even provided an explanatory booklet which gave detailed, relevant, outcome statistics of the two options in his own unit. The young man was worried sick. He had no medical knowledge and, in his state of anxiety over the diagnosis, would have been incapable of deciding what to have for breakfast never mind how his cancer should be treated. He showed and told me everything and sought my advice. I simply told him what I would do if I was in his position. Paternalism again but it was what he wanted.
Some patients do wish to make their own treatment decisions. Many, perhaps most, do not. They want to be advised, and doctors should not be bamboozled by the fashion for patient empowerment into ducking this responsibility.