Towards the end of our lives we are likely to take more medicines than we ever have before. Many of us will end up taking a dozen or more drugs a day. Is it necessary? A new initiative backed by prestigious medical colleges and a range of health and patient-related organisations wants patients to realise that it’s often not — that it’s one of many situations where more medicine may not be better.
The initiative, Choosing Wisely UK, is part of a global project starting in North America that aims to improve conversations between patients and doctors and to challenge the idea that, in the case of medical intervention, just because we can, doesn’t always mean we should. Specifically, the campaign is encouraging patients to get the best from their doctors and nurses by asking these five questions:
The campaign has come up with a list of treatments or procedures that are of questionable value and whose use should be discussed carefully with patients. The list was compiled from suggestions by the Royal medical colleges – each was rigorously researched and cross-examined by some of the most eminent doctors in their specialty and then cross-referenced with National Institute for Health and Care Excellence (NICE), which provides doctors with guidance on treatments.
The example about excessive medicine at the end of life came from the Royal College of General Practitioners. Its submission said: ‘If you are particularly frail or have been told you have less than a year to live you should try to decrease the number of medicines you take to only those used to control your symptoms.’
The prescription of many medicines has little utility in many such patients for whom the focus should be on quality of life. A decrease in such prescription medications reduces the risk of unwanted side effects, adverse drug reactions and unanticipated drug interactions. Such adverse drug reactions account for 10 per cent of visits to A&E and the risk of interactions increases with increasing age, eg a 36 per cent risk in all those over 80 years. With every additional medication the risk of interaction increases. With six or more medications there is an 82 per cent likelihood of an interaction affecting 20 per cent of all patients.
These drugs may be started with good reason but, once started, are much harder to stop – perhaps because doctors and patients are fearful of the possible consequences. Of course, it is up to the doctor to exercise discretion, but patients can have a role here too by challenging their doctor.
Another example, this from the Royal College of Emergency Medicine, is: ‘Having fluids administered directly into a vein while under the influence of alcohol will not make you feel better any more quickly.’
This is because the use of intravenous fluids (a drip) does not make a real difference to the patient’s outcome. Any fluids administered as a drip, which therefore bypasses the body’s usual route for absorbing fluids, are drugs, which therefore need appropriate medical and nurse monitoring, are more costly than tap water and are not without the risk of causing harm, such as injury to blood vessels, infection, salt and water imbalance.
This is not about cost-cutting or denying patients treatments, but about improving conversations between doctors and patients and thus preventing harm from potentially unnecessary tests and treatments. Whether patient or doctor, we all have a duty to be good stewards of the precious resources we have.
Ultimately, this is what healthcare professionals refer to as ‘shared decision making’, summed up by the phrase ‘no decision about me, without me’. A doctor can only know which course of action is right for a patient after a discussion about their preferences, their experiences of their illness, their social circumstances, their support needs, and their attitudes to risk and what being well means to them. One size does not fit all.
It is hoped the launch of this campaign will stimulate such discussions between patients and doctors.