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The Salzburg Statement: Patients Must Be Involved In Healthcare Decisions

Last Thursday at the headquarters of the British Medical Journal in London, an important announcement will be made about patients’ rights to be actively involved in decisions about their treatment. Below is the press release about it.

The subject is shared decision making, which we’ve been posting about recently (series here; initial post here.) Developed by the participants in a Salzburg Global Seminar last December, the document is called the Salzburg Statement. The pivotal distinction here is the difference between informed consent, in which the physician assesses the options and selects one, and gets your consent to do it; and informed choice, in which clinicians tell you the options, with all the pros and cons, and let you choose, based on your preferences.

Click the image to download. (It’s an A4 PDF; to print, those using letter size paper should select “Page Scaling: Fit.”)

Here’s today’s press release:

Patients and clinicians must share healthcare decisions, say experts

Clinicians have an ethical imperative to share important decisions with patients, and patients have a right to be equal participants in their care, say a group of experts today.

In December 2010, 58 people from 18 countries attended a Salzburg Global Seminar to consider the role patients can and should play in healthcare decisions. Today, they publish a statement urging patients and clinicians “to work together to be co-producers of health.”

It comes as the government in England finalises plans to give people more say and more choice over their care than ever before.

The experts argue that much of the care patients receive is based on the ability and readiness of individual clinicians to provide it, rather than on widely agreed standards of best practice or patients’ preferences for treatment.

Results from the 2010 Cancer Patient Experience Survey seem to support this view. It found significant variations in the choice and information patients are given, and their involvement in decisions about treatment.

The experts also say that clinicians are often slow to recognise the extent to which patients’ wish to be involved in understanding their health problems, in knowing the options available to them, and in making decisions that take account of their personal preferences.

As such they call on clinicians to stimulate a two-way flow of information with patients, to provide accurate information about treatment, to tailor information to individual patient needs and allow them sufficient time to consider their options. In turn, they urge patients to ask questions and speak up about their concerns, to recognise that they have a right to be equal participants in their care, and to seek and use high-quality health information.

They also call on policymakers to adopt policies that encourage shared decision making and to support the development of skills and tools for shared decision making.

One of the signatories, Professor Glyn Elwyn from Cardiff University, says that despite considerable interest in shared decision making, and clear evidence of benefit, implementation within the NHS “has proved difficult and slow.”

Angela Coulter from the Foundation for Informed Medical Decision Making agrees and points to recent evidence showing that most patients want choice, but that many clinicians remain ambivalent or antagonistic to the idea. She believes the government’s new commitment to shared decision making presents a challenge to entrenched attitudes and the need for big change in practice styles.

The BMJ is hosting an expert roundtable event to discuss shared decision making at 3pm on Thursday 24 March 2011. Following the roundtable, at 5.30pm Muir Gray and Gerd Gigerenzer will be launching their book: “Better doctors, better patients, better decisions: Envisioning health care 2020.”

Any journalists wishing to attend these events, please contact Emma Dickinson on +44 (0)20 7383 6529, Email: edickinson@bmjgroup.com

Contact:
Professor Glyn Elwyn, Department of Primary Care and Public Health, Cardiff University, Cardiff, Wales
Tel: + 44 (0)29 20 68 71 95
Email: elwyng@cardiff.ac.uk

Click here to view the full statement: http://press.psprings.co.uk/bmj/march/Salzburg.pdf
Click here to view more details about the Salzburg Global Seminar: http://www.SalzburgGlobal.org/go/477

*This blog post was originally published at e-Patients.net*


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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

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As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

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