Clinical decisions at risk
Decision making in the general medical process is, in a certain sense, a critical point of events. A doctor's decision, then implemented as an intervention, has a significant impact on the whole further course of the clinical process.
When making a clinical decision, one always has to take into account the probability of threatening events associated with medical intervention. The risk of an unfavorable outcome may be associated with possible complications from the prescribed treatment (for example, serious side effects of pharmacotherapy), the failure of the intervention itself (say, a risky surgical operation), actions under high uncertainty (a rapidly developing pathological condition with an unconfirmed diagnosis) and other circumstances .
Obligations of the doctor in the context of taking a risky decision
The main duties of a doctor in the context of taking a risky decision are:
1) a thorough assessment of the situation;
2) adequate interaction with the patient.
In this case, the doctor, of course, must take into account the fullness of circumstances for choosing the right course of action (urgency of the situation, the patient's condition, concomitant pathology, etc.).
In the situation of choice of medical intervention, when the attending physician must take a complex clinical decision, he first of all must analyze the problem of his patient and as fully as possible take into account all possible risks of the proposed intervention.
In the decision making process, the most obvious and secondary risks, the possible consequences of the intervention, the features of the individual patient history should be taken into account. In some cases, the risk does not mean a single perceived threat, but some family of threats, for which a probability distribution is typical (often only very roughly estimated by the clinician). Decision making must weigh possible clinical outcomes and assess their probabilities.
According to modern ideas, for a rational analysis of the situation the physician must have scientific knowledge of the degree of risk, for which it is necessary to get acquainted with the scientific literature on the problem (or type of problems), including available scientific data on quantitative risk assessments.
If necessary, it is necessary to attract specialists who will be able to help in developing sound tactics.
The attending physician is obliged, if necessary, to invite colleagues (convening a consultation, referring to a more experienced doctor). Unfortunately, many tragic consequences arise because of frequent violations of this rule, when simply because of presumption or personal ambitions, the doctor does not use additional opportunities to assess the situation and make a better clinical decision.
Based on the circumstances, it should also be determined who will participate in the decision. If emergency care is required, the patient's condition does not allow him to express his will, and there are no legal representatives (for special categories of patients), the decision is taken by the consultation; If it is not possible to collect a consultation - the decision is made by the attending physician (on duty). At the same time, all the norms of the law (proper registration in medical records, subsequent notification of proper persons) must be observed.
In cases when the usual model of informed voluntary consent (ie when the situation is not urgent, the patient is able to express his will and make competent decisions), the patient should be fully informed of the complexity of the current clinical situation and the risks associated with the alleged intervention. After receiving the information, the patient should consider the information provided to him and consent to or decline the intervention.
When considering, the patient, of course, has the right to use all the support and assistance he needs. After all, the risk of intervention is directed directly at him. The patient has the right to consult with close people whom he trusts, to receive the so-called second opinion, i.e. the judgment of an independent doctor (for example, from another medical institution), to re-contact your doctor for additional explanations.
On the part of the attending physician, his participation in the process of considering his decision by the patient should in no case be reduced to a purely formal provision to the patient of the necessary information. Medical ethics require that the doctor be open to dialogue with the patient. The doctor has no right to leave the patient without support in the difficult situation of choosing the solution. In these cases, a joint discussion of all circumstances is required, a doctor's advice is needed so that the patient can better understand the situation and can rationally weigh everything "for" and against .
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