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Reply to Dr. Smalbrugge
Dutch nursing home physicians would need to consider a less paternalistic approach to their care?
Reply to Professor Lamberts
A Dutch treat?
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Margaret R. Helton, Chapel Hill, NC, USA Physician, Univ North Carolina
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We have been made keenly aware of the concerns raised by the suggestion that some Dutch nursing home physicians exhibit paternalism towards their patients. Any action that is justified on the grounds that the person affected would be better off as a result of this action, even if the person in question might not prefer to be treated this way, is an instance of paternalism (1). The paternalistic model assumes physician and patient share values and therefore the physician can determine what is best with limited patient participation. When balancing between patient autonomy and patient's best interest, the paternalistic physician's main emphasis is toward the later (2). But even couching it in this fairly favorable light, there is general agreement that paternalism is no longer an acceptable model as it is no longer tenable to assume that the physician and patient espouse similar values and views and the legitimacy of such a decision is an important ethical point in the discussion of care for nursing home patients. We are pleased by the vigor of these discussions. We agree that the Dutch model is closer to the ideal decision making model espoused by Quill and Brody than the usual American approach (3). We were merely pointing out that some of the comments made by Dutch physicians suggested there might be room for improvement in the exchange of ideas with patients and families. We agree with the comment that futility is seen differently in the two countries. We agree with suggestions that US physicians need to play an expanded role in determining futility (4). These are important issues of medical practice and medical integrity and especially critical in the care of our most vulnerable patients. We look forward to these continued discussions. Sincerely, Margaret Helton, MD Chapel Hill, NC 1. Dworkin, Gerald, "Paternalism", The Stanford Encyclopedia of Philosophy (Winter 2005 Edition), Edward N. Zalta(ed.),URL=http://plato.stanford.edu/archives/win2005/entries/paternalism/. 2. Emanuel EJ, Emanuel LL. Four Models of the Physician-Patient Relationship. JAMA 1992;267:2221-6. 3. Quill TE, Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med. 1996;125:763-769. 4. The Physician's Role in Determining Futility. JAGS 1994:42;875-878. Competing interests: None declared |
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Martin Smalbrugge, Amsterdam, the Netherlands Nursing home physician, Department of Nursing Home Medicine, EMGO, VU University Medical Center, Cees MPM Hertogh
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Cross-cultural studies can provide both a better understanding of differences between countries and refreshing new views on the usual practices. The study by Helton et al., which explored differences in treatment decisions between US and Dutch nursing home (NH) physicians when demented nursing home patients develop pneumonia is a fine example of such a cross- cultural study.[1] Although both US and Dutch NH physicians shared the belief that nonaggressive care was sometimes appropriate when demented nursing home patients developed pneumonia, important differences with regard to treatment decisions were observed. Firstly, differences existed in views on physicians’ patient care roles. Dutch physicians were more active and assumed primary responsibility for treatment decisions, whereas US physicians were more passive and followed family preferences. Secondly, important differences were observed in the way family wishes were perceived. US physicians often felt a sense of threat, whereas Dutch physicians didn’t feel threaten and sometimes didn’t even follow the family wishes when they perceived these wishes not to be in the best interest of their patients. And finally, treatment decisions of Dutch physicians were often based on an intimate knowledge of their patients, whereas US physicians mostly reported limited knowledge due to lack of contact time. Based on these results, the authors suggest in their discussion that Dutch NH physicians exhibit paternalism toward patients and their families and would need to consider a less paternalistic approach to their care. Introduction of the ‘enhanced autonomy’ model of Quill and Brody could improve the Dutch decision making process and is advised.[2] However, the model Quill and Brody propose closely resembles the way Dutch NH physicians are working nowadays and therefore will not alter the alleged ‘paternalistic’ acting of Dutch NH physicians. In our opinion ‘paternalism’ does not appropriately describe the practice of Dutch NH physicians. The main problem here is a difference in perceptions between the US and the Netherlands about the physicians’ role and the physicians’ professional autonomy. Is the role of the physician merely to offer opportunities for diagnosis and treatment, and does the patient or the surrogate decision maker have the right and the duty to choose one of the opportunities (US)? Or is the physician’s role to not merely offer opportunities for diagnosis and treatment but to also advise which choices are the best (the Netherlands)? In the Netherlands patients feel entitled to receive professional advice from their physicians and physicians invest a lot of time and effort in advance care planning with patients and their surrogate decision makers. These circumstances direct physicians to another way of practicing than in the US. Yet there also is another cultural difference that plays a role here. We believe that physicians (but also patients and surrogate decision makers) in the Netherlands have a different view on futility than their US counterparts. In the Netherlands the appropriateness or futility of medical interventions is always related to the overall goal of care as documented in the individual care plan that is agreed upon by the patient and his health care proxy.[3] Further exploration about how physicians, patients and surrogate decision makers are thinking and discussing about ‘futility’ of diagnostic and treatment options in patients with dementia who develop pneumonia in both countries would be very useful. [1] Helton MR, van der Steen JT, Daaleman TP, Gamble GR, Ribbe MW. A cross-cultural study of physician treatment decisions for demented nursing home patients who develop pneumonia. Ann Fam Med 2006; 4(3):221-7. [2] Quill TE, Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med 1996;125:763-769. [3] Hertogh CMPM, Ribbe MW. Ethical aspects of medical decision-making in demented patients: a report from the Netherlands. Alzheimer Dis Assoc Disord 1996;10:11-9. Competing interests: None declared |
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Margaret R. Helton, Chapel Hill, NC, USA Physician, UNC
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Dear Professor Lamberts, Thank you for your interest in our article. As a family physician myself, I admire the role of the huisarts in the Dutch system of medicine and on behalf of my co-authors I welcome your comments and admire your perspective. In both the Netherlands and the US, family physicians provide a broad range of care. Our intention was not to compare family physicians in the two countries, rather we were interested specifically in the management of patients with dementia who reside in nursing homes. It just so happens that in the US, physicians who care for such patients are family physicians and internists and in the Netherlands such care is the domain of the nursing home physician. Whether or not our conclusions apply to the Dutch huisarts caring for a demented patient outside a nursing home is unclear. For that matter, the conclusions may not apply to American physicians who are providing home care either. We focused on nursing home care because that is a setting where hospital transfer seems often unnecessary, given the treatment capabilities already in place in such an institutional setting. You explained that in the Netherlands the vast majority of patients with pneumonia and/or dementia reside at home and that the central role of the huisarts allows the majority of patients with dementia to die at home. I will need to confer with my Dutch colleagues on those figures, but in the US most patients with dementia die in a nursing home. Nursing home patients with dementia have an incident rate of pneumonia of 370 per 1000 patient years (Muder, et.al) which is higher than the rates of 36-46 per 1000 patient years that you quoted. It may reflect the fact that the patients in nursing homes are more severely afflicted with dementia and have a higher likelihood of pneumonia. We did indeed touch briefly on the subject of euthanasia, mainly to provide societal context in the realm of end-of-life care. We do understand that this is primarily the realm of the huisarts and that it is uncommon for dementia to be the primary indication. We appreciate your vigorous argument that Dutch huisarts are not paternalistic. We have learned in the past week that the word “paternalistic” comes across as more negative in Dutch than in English, where it can actually reflect some amount of beneficence. Had we known how the word would be perceived to a Dutch reader, we might have chosen the word “directive” rather than “paternalistic.” Such are the nuances of language. However, it must also be recognized that many of the Dutch physicians did make comments that could be perceived as presenting a position of non-negotiation. It is our hope that vigorous discussions on these issues can lead to better care on both sides of the ocean. We admire the Dutch system of health care – the central role of the huisarts and the unique arrangement of having physicians trained specifically for nursing home care. We hope to draw lessons from both. Thank you again for your comments. Sincerely, Margaret R. Helton, MD University of North Carolina Chapel Hill, NC Competing interests: None declared |
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Henk Lamberts, Amsterdam, The Netherlands Emeritus Professor of Family Practice, AMC/University of Amsterdam
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International comparisons in Family Practice are important, and Helton et al provide an interesting example, and food for thought concerning (the backgrounds of) the differences in treatment decisions by physicians in the US and the Netherlands.1 However, whether or not their data and conclusions apply to family physicians (FPs) remains to be seen. This is especially true for the Netherlands, since the used data are those of specifically trained nursing home physicians treating nursing home patients. Of course, there is nothing wrong with these data as such, but they should have been positioned within data on the general care for the old (over 75) with dementia and pneumonia. Many differences and similarities are to be attributed to health care systems and the role of family practice in it.2 Dutch family practice data – in the public domain, and easily accessible – indicate that in the Netherlands, the vast majority of patients over 75 with pneumonia and/or dementia are treated at home.3 The prevalence of dementia and pneumonia in this age group is 36, and 46 per 1000 patient years, respectively. Referrals to a specialist, a hospital or a nursing home occur in 18% of episodes of dementia, and in 16% of pneumonia. In a 10-years time window, the average duration of episodes of dementia (n=223) was 535 days, which shows that family physicians can and do take care of the majority of their demented patients for a long period of time. The medication prescribed in dementia is practically limited to Pipamperone and Haloperidol, usually for a month or less. In the vast majority of the episodes of pneumonia (n=1702) the treatment consisted of amoxycilline (with or without clavulane), tetracycline, adrenergics and corticosteroids. Pneumonia and dementia share a substantial comorbidity: heart failure, hypertension, diabetes, cystitis, constipation, bed sores, and depression. Nevertheless, pneumonia and dementia themselves occur practically unrelated: the Odds ratio for their comorbidity is 2.0 (1.4-3.1). As a consequence of the central role of family practice in The Netherlands, the majority of these patients eventually die at home. The authors correctly touch on the subject of euthanasia. In the Netherlands, euthanasia is usually taken care of by the FP; the annual average is 1 patient per year in a practice of 2200 listed patients. In our database (10 years) no cases could be identified in which dementia was the indication (as opposed to any of the comorbid conditions). Increasingly, palliative home care is adopted in which dehydration in a (practically) unconscious patient eventually results in death. This, of course, requires an extended period of care, during which nursing help is provided. I certainly would not agree that Dutch FPs are more directive in their communication, or would show more paternalism toward patients and their families than do their US colleagues. Patient autonomy plays a central role in Dutch family practice, and I am convinced that ‘the duty of beneficence’ beyond it is, and should not be adhered to by FPs. Robert Veatch has contributed vigorously to the beneficence debate in the US, and I would recommend his views for any FP, and, in fact, for any physician.4 References: 1. Helton MR, Van der Steen JT, Daaleman TP, Gamble GR, Ribbe MW. A cross-cultural study of physician treatment decisions for demented bursing home patients who develop pneumonia. Ann Fam Med 2006;4:221-7. 2. Okkes IM, Polderman GO, Fryer GE, Yamada T, Bujak M, Oskam SK, Green LA, Lamberts H. The role of family practice in different health care systems. A comparison of reasons for encounter, diagnoses, and interventions in primary care populations in the Netherlands, Japan, Poland, and the United States. J Fam Pract 2002;51:72. 3. Okkes IM, Oskam SK, Van Boven K, Lamberts H. EFP. Episodes of care in Dutch Family Practice. Extended Version. Epidemiological data based on the routine use of the International Classification of Primary Care (ICPC) in the Transition Project of the Academic Medical Center/University of Amsterdam (1985-2003), Extended Version. To be downloaded at: www.transitieproject.nl 4. Veatch RM. Doctor does not know best: why in the new century physicians must stop trying to benefit patients. J Med Philos 2000;25:701- 21. Competing interests: None declared |
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