Tuesday, April 11, 2006

Say not the struggle naught availeth

Last year my sister suffered a massive sub-arachnoid haemorrhage, resulting
in a coma for four months. She has made a miraculous recovery, and is now living in her own home with some support. Throughout the course of her illness her surgical treatment could not be faulted, apart for the inevitable time spent waiting.
The aneurysm was embolised, the tracheotomy and PEG tube were duly inserted, and a shunt was fitted when she began to develop hydrocephaly. Technically, the work was faultless, but at every stage, in contact with the doctors, a bleak prognosis was given. Initially, there was much sucking of teeth and shaking of heads as we viewed the large areas of black on the CT scans; and at the end, before the shunt was nserted to relieve increasing intracranial pressure, we were told, "This is just to stop her getting worse. Do not expect any improvement to come from this operation." In the event, as soon as the anaesthetic was out of her system, my sister was sitting up in bed, saying "When do we eat?"

She was an extraordinary case, who defied all the projections. She had an active and supportive family with one daughter who was a physiotherapist and myself, a GP, to support her. We had various special reasons to be optimistic, and she is a fit 65 year old.
We certainly have no concerns at her surgical treatment, although the nursing, leaning and management standards of all three hospitals she was in left much to be desired. I do however have my doubts about the pre-operative doom and gloom that was rolled out.

We all know why the worst case scenario is put forward: it is to prevent the relatives from bringing a legal action along the lines of "You promised that she would get better, and now look at her. We’ll see you in court". The compensation compulsion that exists in a tiny proportion of the population is affecting clinical practice and the communications of the medical profession across the board.
We are giving gloomy prognoses to keep ourselves out of court, but those dire warnings may be also affecting the well being of our patients that should be our primary concern.

There is plenty of evidence that the mindset of the patient affects the outcome of many conditions. "Constitutional optimism" is the term that is usually studied, but the prevailing reactive mood must affect the patient, whether mediated though the prevailing endorphin climate or by any other means. Our communications are powerful. I recall having to deliver lengthy re-optimising sessions to my nieces after each gloomy prognosis was handed out by the surgeons.

Multiplied by the many thousands of such pessimism inducing communications which take place each year, the NHS must be millions of pounds worse off each year as a result poor outcomes induced by gloomy prognoses.

Does it have to be like this? Of course, we are obliged to discuss outcomes with our patients. It is necessary to mention that things can go wrong, and that not every story has a happy ending. We should perhaps also share with our patients and their relatives the undeniable but little-known fact that we are all mortal. But is it not also possible to share with them the fact that the majority of patients who undergo this procedure do benefit, otherwise we would not be doing it? More importantly, can we not communicate also by body language, and by a subtle emotional warmth, our care and our hope for a positive outcome?

Of course we could. And one day happy day in the future we perhaps will recover a genial, human warmth, the radiant mood of hope and confidence that engenders optimism in our patients.

But for the present day, we must risk-manage, we must act and speak defensively, we must draw the cloak of sober pessimism around our cold limbs, and advise our patients of the worst, lest they sue us. And while we are at it, we might as well advise our sons and daughters, for their own good, not to follow our example, but to go into Law.

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