A 64 year old woman with knee pain: case progression
http://www.100md.com
《英国医生杂志》
1 Department of Medicine, University of Ottawa, 202-1 Stewart Street, Ottawa, Canada, K1N 6N5, 2 Ottawa Health Research Institute, Ottawa Hospital, 1053 Carling Avenue, Ottawa, Canada, K1Y 4E9, 3 Cochrane Musculoskeletal Review Group, University of Ottawa
Correspondence to: ptugwell@uottawa.ca
Last week (5 June, p1362) we presented the case of a 64 year old woman who was concerned about taking paracetamol (acetaminophen) after reading that it could cause liver damage when taken with alcohol at the high doses she required to control her knee pain. Her general practitioner had discussed with her the benefits and harms of paracetamol versus non-steroidal anti-inflammatory drugs, but she felt she needed more information and time before making a decision.
Her general practitioner gave her a patient education decision aid package about paracetamol and non-steroidal anti-inflammatories for osteoarthritis.1 He told her that this material describes the best evidence available today about the benefits and harms of both drugs and would help her work through a decision.2 At home the next day, Mrs Patell finds time to use the decision aid to help her think through how she values the benefits and harms of the two treatment options. She focuses on the decision about whether to switch to non-steroidal anti-inflammatories. The decision aid package guides her through six steps: clarifying the decision; rating the personal value of each benefit and harm; indicating her preferred role in decision making; identifying her unresolved decisional needs; planning the next steps; and, sharing her thinking with her doctor. She schedules a follow up appointment for the next week.
This case is fictional but was developed from several real cases. It was commissioned to contribute to the special issue on harms that will be published on 3 July 2004.
At her next appointment, Mrs Patell brings her decision aid (figure). Her general practitioner reads it over and notices that Mrs Patell wants to make the decision after considering her doctor's opinion. He uses the balance scale in the decision aid as a starting point to focus discussion. He acknowledges that Mrs Patell seems to place more importance on the harms of non-steroidals than on the benefits. Mrs Patell asks if her opinions make sense and what he would advise his mother to do in this situation.
Mrs Patell's decision aid regarding treatment with paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs)
He replies: "We all have our own opinions about how much importance we place on the benefits compared to the harms. If my mother was as concerned as you are about the harms of non-steroidals, it would not make sense for her to take them."
He then discusses the use of paracetamol with alcohol. Mrs Patell says she has cut out her pre-dinner cocktail but still has two glasses of wine with her dinner. She still worries about the risk she is taking but believes that life is not worth living without her wine.
Questions
Based on the importance that Mrs Patell places on the benefits and harms, which option should Mrs Patell choose?
What do you think of the value of such decision aids for patients?
What are the pros and cons of using such decision aids in practice?
Please respond through bmj.com
We thank George Wells and Joan Peterson for help with the calculations.
Competing interests: PT received travel and research support from pharmaceutical companies. AOC receives an unrestricted research grant from the Foundation for Informed Medical Decision Making, which has a licensing agreement with Health Dialog, a company that markets decision aids.
This is the second of a three part case report where we invite readers to take part in considering the diagnosis and management of a case using the rapid response feature on bmj.com. In three weeks' time we will report the outcome and summarise the responses
References
O'Connor AM, Stacey D, Entwistle V, Llewellyn-Thomas H, Rovner D, Holmes-Rovner M, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2003;(2): CD001431.
Ottawa Health Research Institute. A-Z inventory of decision aids. http://decisionaid.ohri.ca/AZinvent.php (accessed 24 May 2004).(P Tugwell, professor of m)
Correspondence to: ptugwell@uottawa.ca
Last week (5 June, p1362) we presented the case of a 64 year old woman who was concerned about taking paracetamol (acetaminophen) after reading that it could cause liver damage when taken with alcohol at the high doses she required to control her knee pain. Her general practitioner had discussed with her the benefits and harms of paracetamol versus non-steroidal anti-inflammatory drugs, but she felt she needed more information and time before making a decision.
Her general practitioner gave her a patient education decision aid package about paracetamol and non-steroidal anti-inflammatories for osteoarthritis.1 He told her that this material describes the best evidence available today about the benefits and harms of both drugs and would help her work through a decision.2 At home the next day, Mrs Patell finds time to use the decision aid to help her think through how she values the benefits and harms of the two treatment options. She focuses on the decision about whether to switch to non-steroidal anti-inflammatories. The decision aid package guides her through six steps: clarifying the decision; rating the personal value of each benefit and harm; indicating her preferred role in decision making; identifying her unresolved decisional needs; planning the next steps; and, sharing her thinking with her doctor. She schedules a follow up appointment for the next week.
This case is fictional but was developed from several real cases. It was commissioned to contribute to the special issue on harms that will be published on 3 July 2004.
At her next appointment, Mrs Patell brings her decision aid (figure). Her general practitioner reads it over and notices that Mrs Patell wants to make the decision after considering her doctor's opinion. He uses the balance scale in the decision aid as a starting point to focus discussion. He acknowledges that Mrs Patell seems to place more importance on the harms of non-steroidals than on the benefits. Mrs Patell asks if her opinions make sense and what he would advise his mother to do in this situation.
Mrs Patell's decision aid regarding treatment with paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs)
He replies: "We all have our own opinions about how much importance we place on the benefits compared to the harms. If my mother was as concerned as you are about the harms of non-steroidals, it would not make sense for her to take them."
He then discusses the use of paracetamol with alcohol. Mrs Patell says she has cut out her pre-dinner cocktail but still has two glasses of wine with her dinner. She still worries about the risk she is taking but believes that life is not worth living without her wine.
Questions
Based on the importance that Mrs Patell places on the benefits and harms, which option should Mrs Patell choose?
What do you think of the value of such decision aids for patients?
What are the pros and cons of using such decision aids in practice?
Please respond through bmj.com
We thank George Wells and Joan Peterson for help with the calculations.
Competing interests: PT received travel and research support from pharmaceutical companies. AOC receives an unrestricted research grant from the Foundation for Informed Medical Decision Making, which has a licensing agreement with Health Dialog, a company that markets decision aids.
This is the second of a three part case report where we invite readers to take part in considering the diagnosis and management of a case using the rapid response feature on bmj.com. In three weeks' time we will report the outcome and summarise the responses
References
O'Connor AM, Stacey D, Entwistle V, Llewellyn-Thomas H, Rovner D, Holmes-Rovner M, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2003;(2): CD001431.
Ottawa Health Research Institute. A-Z inventory of decision aids. http://decisionaid.ohri.ca/AZinvent.php (accessed 24 May 2004).(P Tugwell, professor of m)