Shared decision making in action

Shared decision making based on both evidence and patient preference is popular in the medical literature of late.  I don’t understand why anyone would object.

 

Alex was eight, and on my after-hours on-call schedule for ‘fever and cough, ? pneumonia’ at the request of his mother. Before I entered the room, a review of the chart told me he was generally healthy youngster other than seasonal allergies controlled with intermittent over-the-counter antihistamines like loratadine, and that he had mild intermittent asthma for which he used an albuterol metered dose inhaler before exercise in the winter months. He and his family had become patients three years earlier after they moved here from Minnesota.

Alex said he was there because the more he coughed, the worse he felt. Mom explained that he had started with what she had initially thought was allergies or a simple cold 9 days earlier, with some sneezing and stuffy nose and scratchy sore throat, but no fever or cough. She had restarted his loratadine but had initially held off on the albuterol because his peak flows were fine. Things had smoldered along until four days ago when he had started a dry or tight cough and complained that his chest burned when he breathed. Despite still normal peak flows and no noted wheezing, she had started his albuterol inhaler, without any noted improvement. Yesterday he had had mild temperature elevations of 100.8 and had seemed ‘off’ to her. She had not checked his temperature at home today. 

His pulse and respiratory rate and oxygen saturation were perfectly normal, his peak flow was at his normal baseline, and he had no fever in the office (though he had had a dose of acetaminophen 2 hours earlier). I wondered if he was slightly pale, but had never seen him before and nothing to compare to. His ears were clear, he had some clear nasal and post nasal drainage, his oral exam was normal, and he had good breath sounds throughout his chest, without wheezing, crackles, rhonchi or dullness. He spoke in normal full sentences. He had a few ordinary lymph nodes in his neck. There was no rash. In short, he looked like a child who felt less well than usual from either a viral or allergic respiratory process. There was certainly no evidence on exam of a bacterial infection.

I explained my findings and my assessment: a child with a benign and probably self-limited process, who looked pretty good. At that point I did what seems obvious to me - but based on what I read and hear about the craze for shared decision making - is not all that common. I asked: “Tell me what your concerns are.”

She told me that he had had two episodes when he was younger of viral illnesses that suddenly became worse, both resulting in emergency room visits, prednisone, and antibiotics. They had both started with a mild respiratory process like this, and both times the first sign of a problem was increasing cough and fever late in the illness. They were planning a trip in a week and she was concerned that he might suddenly get worse while they were traveling. “I agree, he looks fine today, but I remember how awful he looked and how fast it happened. Is there anything I can do to prevent that?”

(The information about the prior episodes was in a medical record elsewhere, not in the chart in our office, an example of the idiocy of tying the patient record to the provider rather than to the patient. But that is a discussion for another day.)

After confessing that I could neither accurately predict the chance of a sudden worsening, nor reliably prevent it, I offered the following options:

  • We could watch and continue her excellent symptomatic management, knowing that statistics were on our side: generally, one out of twenty children in this setting develop a bacterial pneumonia. Of course, if he got worse, they were destined for a disruptive and potentially expensive emergency room visit out of state.
  • We could provide a prescription that she would hold onto and talk about how to decide what the criteria for filling it would be, so that if he did get worse, she would be equipped to respond quickly and with less disruption.
  • We could start him on treatment now, knowing that it might not be necessary, that there was a risk of complications from antibiotics, and that it might not prevent a worsening that required a trip to an Emergency Room.
  • We could get a blood test and chest x-ray, that would be very unlikely to help us make a decision.

She was worried that a prescription from Maine wouldn’t be valid in Oregon, so I reassured her about that.  She said the idea of having the prescription but not filling it yet seemed to make the most sense. If he didn’t need the antibiotics, he wouldn’t be getting them, but it would be easy to start treatment if he got worse. We talked about how to decide (more fever, less appetite or energy, falling peak flows, more respiratory complaints) and about calling to discuss it with us if it wasn’t clear.

I got a post card from her two weeks later, from Oregon. “Alex is fine. He never needed the antibiotics, so I’m glad we didn’t treat HIM. I can’t tell you how reassuring it was to know that I could treat him if I needed. Thank you for how you treated ME.”

Every time I read an article or hear a talk about shared decision making, I think to myself: “Isn’t it obvious?”


 

Links to more on this topic::