Clinical decision making in dementia: mapping the minefields
2015; Royal College of General Practitioners; Volume: 65; Issue: 637 Linguagem: Inglês
10.3399/bjgp15x685981
ISSN1478-5242
Autores Tópico(s)Ethics in medical practice
ResumoThere is a scene in the 1970 World War II film Kelly’s Heroes when our platoon of heroes is seen ambling across a peaceful rural countryside. Suddenly the lead soldier steps on a mine. A routine stroll has changed into survival in the middle of a minefield. How will they navigate a safe path out? How will they cope as the inevitable enemy troop lorry approaches? Clinical decision making at the end of life for care home residents with advanced dementia can be problematic. A stable situation, a routine medical stroll, can turn into a minefield if a critical clinical decision must be made in a rush. One hopes that Do Not Resuscitate (DNR) decisions will usually already be recorded but even this is not always the case. There are of course more everyday decisions about escalation of care in response to exacerbations of chronic conditions or acute presentations such as serious infections. We may be faced with a decision whether to admit to hospital or to provide appropriate medical intervention including symptom control and nursing care in the residential home. Since 2004 the UK Department of Health has had an explicit aim to reduce acute admissions.1 But Harrison reminds us not to ‘assume that fewer admissions or referrals are necessarily better’.2 We may feel an ever-increasing pressure from such policies. Admission avoidance may be reflected in local Directed Enhanced Services (DES) often lacking evidence of patient benefit. The 2010 King’s Fund report Avoiding Hospital Admissions …
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