Thursday, 15 January 2015

Person-centred care: "What matters most to you today?" by Al May

What's this all about?

I read about an interesting concept via twitter the other day.  My understanding was that a hospital ward somewhere was displaying the message "What matters most to me today:" on whiteboards next to patients. The patients would be asked the question and the answer would be displayed for all to see.

It immediately struck me as a simple but potentially powerful way of putting the patient at the forefront of people’s minds.  As an anaesthetist, I don’t have a ward but I do see a lot of patients pre- and post-operatively.  What would happen if I put this question into my pre-operative conversations with patients?  Before I did it, I tried to consider the potential effects.

What were the possible effects of doing this?
On the positive side it might:
  • Unearth some useful information
    • Although I always ask if the patient has any questions, closing with this particular phrase is a slightly more structured way of asking and also a second chance for the patient.

    • Prioritise what matters
      • For example, if a patient answers that the most important thing is not feeling sick, I can then consider and explore with the patient whether a regional technique with opiate sparing would be feasible even when this wasn’t my initial plan based on risk-benefit.  Asking "What matters most to you?" could potentially add another piece of information into the risk-benefit discussion.

    • Let the patient know that you're doing your best
      • I am always trying to do my best for the patient.  However, following the ethos of Fred Lee, author of IfDisney Ran Your Hospital (previously a book of the month) making these aspects visible and letting the patient know can improve the overall experience.

    On the negative side it might:
    • Be misinterpreted
      • The patient could interpret the question as restrictive in that they can only have one thing.  This is however probably dependant on the way the question is phrased and the specific situation.  For example: “Im going to look after you and do everything that I normally do, but what matters the most to you today?”  Also, there may need to be an acknowledgement of the patient's specific situation, for example in cancer surgery, “I know this is a really big day for you and we are going get you through this but what matters the most to you today?”

    What happened when I tried it?

    I started with trepidation but also interest in whether this would be a worthwhile addition to my usual routine.  I was worried about it coming across as an insincere service industry type “Have a nice day”  and was very careful in the delivery to try and avoid this.  I deliberately asked whether the patients had any questions before I asked them the "what matters" question.  The first patient replied that he hadn’t thought about that before and that he was “here and just wanting to get it done”.  I wondered whether I had rushed the patient and he hadn’t had a chance to think about the question and simply said what first came to mind.  I was a little disheartened initially as it didn’t seem to have utlility but I was determined to continue trying it.  

    I did the same with the second patient and got a completely different repsonse, he said “Well, it’s a bit embarrassing and I’m not sure whether it matters but I’ve been reading about this thing of being awake with muscle relaxant during the surgery and it’s making me really anxious, I didn’t sleep well last night with worry”.  This led into a discussion with him about anaesthetic awareness and the fact that for the surgical procedure and anaesthetic technique he was going to have, the risk was in fact probably less than 1 in 100 000.  Bear in mind that I had already asked whether the patient had any questions and he had said no.

    With such a productive conversation with the second patient, I reflected back on the discussion with the first patient to really consider in context what he had told me.  What I think he was telling me was that he had taken time off work and arranged for someone to be at home with him postoperatively and therefore simply having the procedure was the most improtant thing.  I wasn’t sure whether that would come into any of the decision making but if there was the requirement for a cancellation of one of the patients due to time for example, this could be considered along with clinical need.  


    I think that using this closing question can potentially add to the patient experience in a positive way.  I plan to use it carefully for a few weeks and gauge the response and utility.  This concept has already spread to two other anaesthetists in my department!

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