Mike's Cheeky Blog: I ordered the fish, and they brought me the chicken !

I went to a restaurant last week. I studied the menu, and ordered fish and a pot of tea. Ten minutes later, the waiter appeared with chicken and a cup of coffee.

I pointed out that I had not ordered that: he said "I discussed your order with the chef, and we decided you should have ordered the chicken and coffee, sir".

So I walked out of the restaurant.

Obviously, I made that up - a restaurant couldn't get away with such behaviour.

This blog piece 'is somewhat cryptic' - readers will need to figure out for themselves, 'what Mike is getting at'.

I posed a question in a couple of places recently:

'Imagine a wife who is suffering from advanced dementia, and who is clearly not mentally-capable to decide whether she should start taking a tablet every morning. The GP, her husband and the wife are discussing this. If the wife is to actually take this tablet every morning, it would have to be given to her by her husband. The wife might dislike taking tablets, without understanding any possible medical benefit: whoever is 'the best-interests decision-maker' has to consider that dislike, which is challenging - but who is making a best-interests decision here ? Is this two different best-interests decisions ? Do both the GP, who would prescribe the tablet, and the husband who would be the person administering the tablet, have a best-interests decision to make: and is that the same decision, or are they considering two different questions ?'

Recently I have been looking at the Coordinate My Care website: CMC is an online database which contains information about end-of-life patients. There are some documents you can download from the website, including 'The Devil is in the Decisions' which is a 'round-table' discussion, about 'shared decision-making'. It describes the problems encountered during end-of-life quite well, but there is not any 'shared decision-making' during EoL: they should be talking about Supported Decision-Making if the patient is mentally capable, or about the process of best-interests decision-making if the patient is mentally-incapable. Some clinicians have understood this point - some recent guidance from the Royal College of Surgeons about the legal requirements of consent to operations, does not contain the word 'shared' even once [according to Acrobat] but the word supported appears 30 times: and the title of the guidance is 'Consent: Supported Decision-Making'.

Another paper you can download from the CMC website, is by the GP Dr Naz Jivani, titled 'How sharing urgent care plans helps vulnerable patients get the care they want'. It contains this:

'The second challenge is about trust. Each clinician in a GP practice, a hospital a hospice or in the community can add to the virtual CMC urgent care plan. The key challenge is trusting colleagues.'

And I'll close with something which appeared in a recent e-mail from someone I discuss the Mental Capacity Act with:

EMAIL TO ME:

'So I think the efforts of us 'toilers in the vineyard', or worker ants, or however we can conceptualise what we are doing, are bearing a little fruit (or helping the lives of the more vulnerable ants.... I think this analogy is showing major flaws but am leaving it in case it amuses you or you can think of a better one.)'

REPLY FROM ME:

'I'm interested - is there a queen ant (and who is that) ?

And is the colony intelligence, 'fuzzy as opposed to hierarchical' ?

I ask the second question, because I'm strongly in favour of 'asking everyone who could reasonably consider a best-interests decision, to consider it and express an answer - then, if everyone came up with the same answer, 'just take that as the best-available best-interests decision and do NOT suggest that any specific individual 'made the decision''.'

REPLY TO MY QUESTION:

'I knew my analogy was not a good one so refuse to be drawn about queen ants!'