Friday, January 20, 2017

Do we ask the patient: “What matters to you?”

Recently, I was having a conversation with a friend about the care of his elderly relative. My friend was a bit annoyed that his relative was not following all of the advice of his physicians. My friend obviously loved his family member and was really concerned about his health. He told me that he had had a frank conversation with this loved one and that if he did not follow all of the advice of the physicians, that he “was done.” By this, my friend meant that he would not be as attentive when his loved one called for help.

I asked my friend if he had asked his relative what mattered to him. My friend looked perplexed at my question. People are used to following their doctors’ recommendations, as they should be, but is following every well-intentioned recommendation really the “bottom line?” Shouldn’t we start any conversation about a plan for people with chronic disease, especially those towards the end of life, by asking “What matters to you?”

In my friend’s example, he was most annoyed by his loved ones’ dietary indiscretions. Well, the loved one was already frail and eating his favorite things was one of the few pleasures he had left. So eating what he liked, meant more to him than possibly shortening his life by a few days or hours.

Maureen Bisognano, the former president of the Institute for Healthcare Improvement (IHI), first began encouraging clinicians to change the question to the patient from “what is the matter with you?” to “what matters to you?” The ultimate decision about diagnostic tests or therapies lies with the patient, not the physician. The role of the physician, or advanced practitioner, is to lay out the choices along with the evidence as to their efficacy. Knowing matters most to the patient will help guide the dialogue between the provider and the patient and has a better chance of resulting in a plan that the patient will actually adhere to.

At GBMC we have learned a lot through our study of people who leave our hospital “against medical advice,” in other words leaving when we think they need to stay for some diagnostic procedure or therapy. We have met patients who leave rather than get fired from their job and patients who leave rather than miss a family celebration. Knowing what matters most to the patient may not change our primary recommendation, but it may get us to a common ground that ends up in a better plan.

So, let’s work to make the conversation about “What matters to you?” to be part of our standard work with people with chronic disease. What do you think about this? Please give me your thoughts.
Helpful links to IHI and “what matters to you?”

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