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Shared decision-making
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  1. Abi Berger
  1. Correspondence to Dr Abi Berger, London, UK; bmjsrh{at}bmj.com

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This is the tale of three men and the amazing capacity of the human body to survive and heal. It’s also a tale of shared decision-making. The first two men are patients I’ve been trying to support to stay out of hospital; the third is my partner.

In January I was involved in looking after two frail elderly patients, both living alone with permanent catheters in situ. The first was a vulnerable man. He speaks little English, and he is deaf so he cannot use the telephone. Access to his flat is courtesy of a neighbour who lives downstairs (if he’s at home). The key safe is empty.

This man had spent days in bed, unwell, not eating or drinking properly, before a relative alerted us to the situation. He’d been attended by the ambulance service 2 days earlier, and had declined vehemently to be taken to hospital. It was deemed safe for him to stay at home with community services input.

Rather miraculously, I found the patient alive and in bed. He was clinically stable, but his catheter was no longer draining and his abdomen was distended. He was slightly confused but had the capacity to tell me that he absolutely did not want to be admitted to hospital. I gave him a drink and arranged for his community nursing team to change his catheter that afternoon, to administer oral antibiotics for a week and to monitor the situation. The whole scenario felt fraught but we helped him stay out of hospital.

The second patient came to see me at the GP surgery a week later. He too lives on his own but is entirely independent and self-caring. He had noticed his urine had become cloudy. I sent off a specimen, gave him a prescription for broad-spectrum antibiotics and arranged for his catheter to be changed.

He returned 2 weeks later on a Friday evening, with a 4-day history of passing frequent diarrhoea and lots of mucus. He fervently wanted to be helped but wanted to avoid hospital admission if at all possible. On further questioning he told me he’d been admitted to hospital last year with what turned out to be Clostridium difficile and he’d been quarantined for a week, isolated in more ways than one.

I suspected C. difficile again as a result of the recent course of antibiotics, and I imagined the desire to avoid hospital admission would be held mutually by both patient and hospital. He too was clinically stable, and with the help of dehydration salt drinks and after some discussion about what was safe for him, he agreed that he would provide stool samples on Monday morning. He promised to contact the out-of-hours GP service over the weekend if his condition deteriorated.

As a GP I don’t often see what it’s like to be a patient in hospital – but I did recently. My partner spent a month in hospital recovering from major bowel surgery. He barely ate or slept, lost a lot of weight; one of his wounds dehisced and he was miserable. He couldn’t get out of bed without help, and he had to listen to the distress of other patients coming and going. The nights were as noisy as the days. There was no question that he needed to be there, but I found it almost unbearable to watch him unravel. I’d forgotten how easy it is to become institutionalised and even infantilised as an in-patient. With his surgical team’s blessing he was eventually discharged home. He was soon eating like a horse, the perineal cavity started to heal, and he was much happier. Weeks later he still has moments of post-traumatic stress about the whole ordeal.

We’re doing what we can to avoid the expense of admitting patients to hospital. But it’s not just about blocking beds, it’s also about maintaining morale and autonomy. I’ve witnessed at close quarters why it’s better for patients too.

Footnotes

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

  • Patient consent for publication Obtained.

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