DON'Ts for Long Term Care Patients: #ChoosingWisely Canada

I have been a serious fan and also a concerned critic of Choosing Wisely Canada (CWC) over the years. Overall the campaign is excellent, encouraging conversations between patients and providers to help prevent harmful and unnecessary tests, treatments, and procedures.

While I love the new emphasis on the high-level message "More is not always better," my feelings have always been lukewarm on the lists of Choosing Wisely Canada (CWC) recommendations, created by (mostly) physician associations not by Choosing Wisely Canada, as they vary in strength, currency, and courage. For example, the CAEP (Emergency physicians) list is quite clear, direct, and practice changing. The Orthopedics list is irrelevant, and not wisely chosen at all, lacking the moral fortitude to tackle common, high-paying procedures that have limited/no evidence to support them.

The most recent lists reinvigorate my interest! It is exciting to see a list from the Canadian Nurses Association (CNA), as nurses have an incredible role in advocating for patients and in helping patients make decisions. Hospital-based nurses usually know their patients well and might even have a better sense of their goals and needs than would a physician; a nurse's advice can easily sway a patient to see "too much" medicine, but it can equally reassure that patient that a test or other intervention may not be right for them.

Image from unknown source on twitter; quote from an interview with the  Centre for Advancing Health

Image from unknown source on twitter; quote from an interview with the Centre for Advancing Health

Because most mornings I work in a program that is designed to help frail elders avoid unnecessary/ unwanted admissions to hospital, the Choosing Wisely list for Long Term Care (LTC) is extremely relevant to my practice. #1 (see below) resonates particularly with me, so I'm glad to see it is the first on the list. I see countless patients who could (and should) be looked after in their full-care facility but unfortunately they have turned up at the hospital. There are a number of reasons this happens, including the inability of the facility to contact the GP or the GP's inability to attend the patient in an urgent fashion, the family's 'insistence' that the patient be "checked out" at the hospital, a lack of clarity on the patient's goals, unclear understanding of the natural history of their disease, insufficient staffing at the care facility, etc. And sometimes these patients really do need to be at the hospital.

We clearly have a lot to learn both in how we communicate and in how we approach care for patients in long term care. This list is a great addition to the tool kit that might help us give LTC patients the right care for them:

  1. Don’t send the frail resident of a nursing home to the hospital, unless their urgent comfort and medical needs cannot be met in their care home.

  2. Don’t use antipsychotics as first choice to treat behavioural and psychological symptoms of dementia. 

  3. Don’t do a urine dip or urine culture unless there are clear signs and symptoms of a urinary tract infection (UTI).

  4. Don’t insert a feeding tube in individuals with advanced dementia. Instead, assist the resident to eat. 

  5. Don’t continue or add long-term medications unless there is an appropriate indication and a reasonable expectation of benefit in the individual patient. 

  6. Don’t order screening or routine chronic disease testing just because a blood draw is being done.
     

See the list here or download the PDF.

Source: http://choosingwiselycanada.org/recommenda...

No benefit to locked mental health wards: 15yr study

A once 'sound' idea is now in question.

A 15-year study has concluded that there is no benefit in locking up many mentally ill patients.

Looking at about 350k cases, the researchers selected 145 738 cases, matched for propensity around suicide attempts. In open units, elopement and suicide attempts were less frequent than in locked units.

An open-door policy could be preferable for those with depression, anxiety or psychosis, as it promoted a better therapeutic atmosphere and more positive health outcomes

Even if this large study is imperfect, it gives us a perfect illustration that what seems sensible or logical does not necessarily result in the expected outcome. Although it makes sense that locking people up should not only help them stay put but also keep them safe,, that seems not to be the case.

Counterintuitive? Yes. But brains and bodies often do not conform to the rules of logic. This is in part due to the fact that we have only a superficial understanding of the complexity of our behaviours and physiology. 

How else are we hurting people when we think we are helping them? 

The full article is in Lancet Psychiatry

Source: http://www.radionz.co.nz/national/programm...