Making health choices

Sometimes it’s very clear that treatment is needed, fast.

• George

  George is walking down the street when he is suddenly run over by a car. He is knocked unconscious and is bleeding heavily. An ambulance is called and paramedics immediately start treating him with fluids into his veins and drugs to support his heart and lungs.

But sometimes it is much less clear - and more difficult to decide.

• Helen and Susan

  Helen and Susan have had their blood pressure checked and been told it is high. They are each recommended medication to lower their blood pressure. They are each on five other tablets already, and don't really want to take another one. Helen and Susan also know that having a high blood pressure increases the risk of a heart attack or stroke. Helen and Susan wonder what to do.

In many situations there are pros and cons which have to be weighed up. These depend on the circumstances and wishes of the person.

For example:

• Helen

  Helen has lung cancer which has spread. She knows that she is not likely to live for more than a year or two. She has decided that she wants a good quality of life and wants to avoid the change of side effects from treatment. Since the blood pressure tablets are designed to work to reduce the risk of heart attacks and strokes over years, she decides not to take them.

• Susan

  Susan’s parents had heart attacks. She has a type of arthritis which she knows increases her risk of a heart attack or stroke. She is very keen to try and reduce her risk as much as she can. She is already eating healthily, has stopped smoking, and exercises regularly. She decides that taking another tablet is worth it.

• Naz

  Naz has a chesty cough but is otherwise well. He wants to know if he really needs antibiotics. Guidelines from the National Institute of Health and Care Excellence (NICE) say that antibiotics are not needed if the person is otherwise well. He is just as likely to get better without them. Naz is right - he doesn’t need antibiotics. However - if he had taken them, he would get still have got better. That could make us think the antibiotics helped - when they didn’t.

People are different and can make different, but equally good, choices about their health

It’s usually a good idea to take some time to think about your options.

Your options will often include doing nothing - sometimes the treatment can be worse than the condition you have. Some people find thinking about their choices with a checklist helps, like this one 

There is also help available for some choices at NHS Right Care. Many people want to make sure that their healthcare professionals know about their choices. This can be done with a care plan.

You might be offered one or you can ask for one.

You might also be interested in guardianship or powers of attorney.

These are legal documents designed for people who are not able to make choices about their healthcare, either because of disability or illness. They try to make sure that healthcare staff know about your wishes.

Powers of attorney are created when you are well and able to say what you would like if you can’t make your own choices in the future. It’s better to have one and not need it rather than need one and not have it!

It’s never too early for adults to consider making a power of attorney.

• Further information

  Guardianship

  • Scotland - If you are in Scotland, information is available on the Office of the Public Guardian website.

  • England - The Department of Health and Social Care has produced a fact sheet on Guardianship.

  • Wales - NHS Wales has produced a patient information leaflet on Guardianship

  Powers of attorney

  • England - Make, register or end a lasting power of attorney

  • Scotland - Setting up power of attorney

  • Wales - Lasting Power of Attorney

  • Northern Ireland

  • Managing your affairs and enduring power of attorney

  • Information on Enduring Powers of Attorney

Steve is 70 and is taking several medications for gout, hip arthritis, and chronic bronchitis. The pharmacy offered to check his blood pressure when he last went for his prescriptions. It was high and they have told him to see his doctor. He agreed to start medication for it - but he felt dizzy with the tablets and this is stopping him getting out for walks. He goes back to see his doctor. 
 
Steve wants to know if he really needs the tablets? His doctor tells him that they are recommended by guidelines. Steve asks his doctor how likely they are to help him, and wants to know if there are any alternatives?

• Balancing risks

  Making choices about treatment is often hard. People have to balance the potential for risks, harms, benefits, and side effects. We know that lowering blood pressure can help to avoid a heart attack or stroke. But it does not help everyone who takes it.

  • But not everyone who has high blood pressure will have a heart attack or a stroke

  • But some people who have high blood pressure will have a heart attack or a stroke

  • Taking medication can reduce the risk of having a heart attack or stroke

  • But not everyone who takes medication for their blood pressure will stop a heart attack or stroke from happening

  • It isn’t possible to predict which individual people with high blood pressure are going to have a heart attack or stroke

  • It isn’t possible to know which individual people taking blood pressure medication prevent a heart attack or stroke by taking the tablets

  • There are other tablets to treat blood pressure which might be better for Steve and could be tried

  • Blood pressure can also be lowered by exercise or a low salt diet

  And of course, maybe Steve's blood pressure is fine at home and he just gets high blood pressure when meeting health professionals (white coat syndrome).

Making good choices often means juggling many possibilities

There is a similar problem with tests - like blood tests or X-rays or CT scans.

Often the result is clear.

However, the result is often not clear - the blood test result may be slightly abnormal. Or a scan shows a small lump somewhere unexpected - and it’s not clear whether it is something worrying or not. As we get older we get more small abnormalities in our bodies - like cysts or warty skin growths - and the majority are benign - not cancer, and will not do us any serious harm.

This is one of the reasons why it’s important to carefully consider when to do tests, and when not to.

It can be hard to work out which are worrying abnormalities, and which are 'normal' abnormalities. This often means people have further tests or scans to see if they are worse or better. Rather than reassuring people, these further tests can cause more anxiety, or pain, or infection. Tests can end up doing more harm than good. If you are interested, there is more about that on the Conversation website. 

This is why doctors are taught to think before testing. People need reliable information before deciding to be tested too.

For example, coughing is a common symptom of lung cancer.

• Lung cancer

  But most people with coughs will not have lung cancer... they will have colds, or flu, or allergies. Very few people with a cough will have lung cancer. Millions of us have a cough during the year.
  
  If everyone with a cough was sent for a chest x ray, it would do more harm than good - through overdiagnosis (finding small abnormalities that won’t do any damage, but can lead to further tests with side effects) radiation (chest x rays are low in radiation, but coughing is so common that would mean hundreds of thousands more x rays) or cost (spending more money on unnecessary X-rays will leave less money for nurses salaries, or operations.)
  
  This is why time is often used to help sort out which symptoms need further tests. Coughing which doesn’t stop over several weeks may need X-rays or other testing - and even then, most people won’t have lung cancer as a cause of their cough.

• More on tests

  Earlier in the course we talked about screening tests - tests in people who feel well. Screening tests which sound good often don’t work well in real life. This is one of the reasons why it is important to consider carefully what tests to do.  
  
  Take a group of people whose risk of having a disease is 10 in 1,000 (1%). 90% of the time, if the person has the disease, the test will diagnose the disease correctly. However, 10% of the time, the person will not have the disease, but will have a positive test result.  
  
  If you have a positive test, how likely are you to have the disease?

  Think of a group of 10,000 people. 100 of them will have the disease (1%). The test is 90% accurate, so will pick up 90/100 people who do have the disease. 
  
  The test is also wrong in people who don’t have the disease, 10% of the time. This means, for the 9900 people (i.e.99% of the group) who do not have the disease, 990 (10%) test positive for the disease - even though they don’t have it. 
  
  That means that a total of 990+90 people test positive for the disease (1080). But we know that only 90 of these people really have the disease. So that means, if you have a positive test result, the chance of you really having the disease is 90/1080 - a just over 8% chance.

  

  Let’s take another situation. This time let’s say the risk of having a disease is 100 in 1,000 (10%) The test is the same. It will give a positive result for 90% of people who have the disease. It will also give a positive result 10% of the time in people who do not have the disease. 
  Take the group of 10,000 people. This time, 1000 of them will have the disease. The test will pick up 90% of this group (900 people). The test is still wrong for 10% of the people who don’t have the disease. That means, for the 9000 who don’t have the disease, 900 people test positive.
  So, a total of 900+900 people test positive for the disease (1800). However only 900 really do have the disease, so the test now gives correct results half the time.

  

  This is just an example. All tests vary in how accurate they are - and how common disease is.

Decision aids can help some people. This is one has been made the National Institute for Health and Care Excellence (NICE) about whether or not to take statins to lower cholesterol. It might be useful to read before you see your GP. Statins are used to reduce the risk of heart attacks and strokes. They can be used in people who have already had a heart attack or stroke (secondary prevention) or to try to prevent them in the first place (primary prevention).

When they are used for primary prevention (people who have never had a heart attack or stroke) your risk is worked out. This depends on things like age, family history, smoking, or diabetes.

If you are at 35% risk of having a heart attack or stroke over the next 10 years (35 in 100 people like you will have a heart attack stroke in the next 10 years) you can see how taking statins for 10 years will change that risk. This a way of looking at this risk (35 in 100) using a graph. The faces in green represent people who don’t have a heart attack or stroke, and the red faces represent people who do have a heart attack or stroke.

 Here you can see the difference if the same group of 100 people take statins for 10 years.

22 will have a heart attack or stroke (red faces) even though they took statins. 13 will avoid a heart attack or stroke because they took statins (yellow faces). However, 22 people still had a heart attack even though they took statins, and 65 people took statins when they weren’t going to have a heart attack or stroke anyway (green faces).

All medicines have some sort of side effect.

This graph shows that the risk of developing type 2 diabetes is increased by taking a statin (in this case, atorvostatin) for 10 years. Without statins, six in 100 people will develop diabetes over the next 10 years. With statins, nine people in 100 will develop diabetes. Some people will decide this is worth it because there is a bigger chance of stopping a heart attack or stroke.

You can see more about the pros and cons of statins in the NICE decision aid, or by using the Qintervention website. 

Other decision aids are available for different conditions on NHS Shared Decision Making and The Absolute CVD Risk/Benefit Calculator.