Client-centred care (or patient-centred care or patient preference) is one of the core philosophies underpinning Occupational Therapy. In any modern healthcare practice, it also forms part of the Evidence Based Practice (EBP) equation:
Research + Clinician Expertise + Patient Preference = EBP
How much weight each part of the formula should contribute to the overall treatment ‘answer’ is not clear cut, and when an extreme weighting from one or another element is proposed, it causes ethical dilemmas. Ethical dilemmas cannot be solved alone, but through collaboration with colleagues and professional body standards (such as the RCOT).
I find myself almost never listening to Radio 1 anymore instead tuning in to BBC 6, BBC 2 and even 4… is this a reflection of becoming more interesting or more boring? Or that I need talk radio to keep me awake on the more frequent long car journeys I seem to do now? Either way, in the BBC 4 programme ‘Inside the Ethics Committee’ one episode discusses a woman who wants her leg amputated in order to forego any further knee surgeries. Medical professionals felt that evidence pointed towards continuing to try reconstructing the knee, but the patient felt very unhappy she couldn’t enjoy her previous sporting lifestyle which gave her much meaning and helped her manage her mental health. She would rather have her leg amputated which she perceives would allow her to regain sporting activities again.
The link to it is here: www.bbc.co.uk/programmes/b061tfmp
Spoiler alert: after attempting suicide she is referred to psychotherapy and to a physio to understand that her mobility wouldn’t be back to the way it was with a prosthetic leg. In the end it is amputated and she is happy, participating in extreme sports once again.
It was an interesting situation to consider how much weight should be given to a patient’s own choice. If the patient understands all the options and implications of each, then ultimately it is up to them to make ‘poor’ health choices since we live in a society of free choice (so long as it isn’t impacting anybody else). It reminded me of another article I read where a US surgeon saved a woman’s life using blood transfusions after a car accident, despite knowing she was Jehovah’s Witness. The woman survived as a result but then sued the medial professionals who had saved here life. For her she was now no longer living ‘in a way that pleased God’ and the ability to be rewarded in heaven had now been taken away from her. Life’s rich tapestry!
The programme synopsis:
“A dilemma arises for a surgeon when a young woman called Sarah is referred to his clinic.
Six years earlier, Sarah injured her knee in a skiing accident and the intervening years have been dominated by operations to repair her knee, each followed by months of gruelling rehabilitation. But despite all this, Sarah’s knee remains unstable and painful and it’s taking its toll on her mental health.
Various surgeons have refused to amputate her leg and recommend that she either accept her existing level of disability or agree to further operations.
But Sarah is adamant – she wants her leg amputated. She doesn’t want to live as she is and has lost faith in the medical profession’s ability to give her a knee that will enable her to be active.
The surgeon is caught in a dilemma – he appreciates how she feels but should he amputate her leg?”