From: Andreas Laupacis & Jennifer Gibson (HealthyDebate.ca)
“Patient-centred care” is on everyone’s lips these days. But, do we all agree what it is and when it has been achieved? And does patient centredness create new ethical dilemmas for patients and providers?
The University of Toronto Joint Centre for Bioethics (JCB) and Healthy Debate are partnering to explore some of the practical and ethical implications of patient-centredness.
We would like to explore two major themes: i) what patient-centredness means to different people within health care; and ii) how we can use examples of ethical dilemmas around patient centredness to understand the different perspectives and get closer to the goal we all want – a health care system that serves the needs of patients.
Patient-centredness varies, depending on one’s perspective
Patient-centredness can mean different things to different people.
For patients, it can mean that the care they receive reflects their values and preferences and they feel they are treated as a whole person.
Clinicians may see patient-centredness as advocating for their patients to ensure their needs are met.
Organizations within health care, such as family health teams and hospitals, may consider themselves patient-centred when they involve patients on committees and use the results of patient satisfaction surveys to inform their decisions.
Policy makers sometimes describe patient centredness as a measure of health system performance or as a principle to strive for when designing health services within the budgets they have been allocated.
Public health practitioners may feel that patient-centredness should be less concerned with meeting the desires of individual patients and more concerned with addressing the social determinants of health, which they argue would prevent many citizens from becoming patients in the first place.
These are all legitimate views. Let us know what patient-centredness means to you.
Ethical dilemmas associated with patient-centredness
Dilemmas around patient-centredness arise all the time in health care but tend not to be acknowledged. Here are two examples:
Sick, frail patients are lined up in stretchers in the corridors of the emergency department because there are no beds in the hospital. The hospital administration pressures doctors to discharge admitted patients as quickly as possible to free up beds. A doctor discharges an 85 year old recovering from pneumonia back to live with his 84 year old wife with early dementia, even though the doctor realizes that the homecare supports they need aren’t yet in place. What is patient-centred for the patient waiting for a hospital bed is clearly not patient-centred for the gentleman recovering from pneumonia.
A patient with advanced breast cancer who is not responding well to chemotherapy wants to try high dose intravenous vitamin C, administered in a complementary medicine clinic, and would like her doctor to order the blood work that the clinic requests so that it is paid for by the provincial health insurance plan. Her physician says he has reviewed the evidence and has found that the treatment does not appear to be effective, and has rare but potentially serious side-effects. The patient understands the risks but says she would like to try it – nothing else seems to be working anyway. He says he can’t be involved in facilitating a treatment that he doesn’t think is in her best interests. Does patient-centred care mean agreeing to what patients want even if it runs counter to clinical judgment?
Over to you: patient-centredness in your voice
The partnership between the Joint Centre for Bioethics and Healthy Debate over the next year will involve a combination of lectures and symposia hosted by the JCB, and articles and on-line discussions on Healthy Debate. We haven’t sorted out the details and are hoping that you will help us out.
What does patient-centredness mean to you? No matter what perspective you bring – patient, caregiver, clinician, policymaker, citizen – we’d like to hear from you. Tell us how you define patient-centredness. Do you think there are limits to how patient-centred the system should be? Tell us also about where you have observed or experienced ethical dilemmas associated with achieving patient-centred care. If you choose to share your views on Twitter, please use the hashtag #PCCethics so we can be sure to see your tweet. Your comments and experiences will inform how the JCB and Healthy Debate explore this issue over the next year.
To participate in this debate, head over to HealthyDebate.ca and join the conversation.
Jennifer Gibson is Director of the University of Toronto Joint Centre for Bioethics. Andreas Laupacis is a physician at St. Michael’s Hospital in Toronto, and editor-in-chief of Healthy Debate.