Clinical Judgment in Patient Care

Doctor at the bedside

There is a lot to be said for evidence-based medicine, but in many cases, there are no randomized controlled trials (RCTs) to answer many of the questions that we face on a daily basis. And every time a question is answered by a well-conducted RCT, there are usually several more questions left still to be answered. I don’t think we will ever be able to say that we know it all.

That’s why good clinical judgment will always be required for appropriate patient care.

If an 80 year-old female has less than 6 months to live because of a malignancy, it doesn’t make much sense to make sure she takes her bisphosphonate to treat her osteoporosis, despite what the evidence says.

Some situations may not be so obvious. Consider the following scenarios...

A 75 year-old male with a 3 month-old coronary stent requiring clopidogrel to prevent restenosis now presenting with recurrent GI bleeding due to diffuse angiodysplasia of the colon.

A 70 year old female with dementia and congestive heart failure who has developed end stage renal failure. Should she be started on dialysis?

A 68 year-old male with severe hypercarbic COPD who has just had surgery for a hip fracture. How much analgesic should he receive?

Clinical judgment and sometimes ethical judgment enter into these decisions where there are often no right or wrong answers and where there are no textbooks or RCTs that tell us what to do. Experience, discussions with the patient and family members, consultation with specialists and sometimes just common sense enter into the equation and many times it is quite complicated. There are situations where you may be on the fence and you just have to make a decision one way or the other. If always helps to have the support of the patient and family, but sometimes there is disagreement among them. Often you just have to go with what “feels right” for the patient’s welfare, and that decision may have more to do with quality of life than quantity.

Many of these decisions represent a battle between compassion and science. Some would say societal concerns should enter into these considerations as well. Should we, at the bedside, be asking ourselves questions like, “How much is this going to cost the taxpayers to put this 85 year-old patient with end-stage COPD on a ventilator for the next 10 days to extend her life maybe another six months in a nursing home environment assuming she survives this acute illness?”? My answer to this would be “No, but we should be thinking about the misery both she and the family are going through now for such minimal benefit later.” This may not be the correct answer in the minds of some, but I think it is the more compassionate answer, which is the one that I like to go by.

This page was last updated on March 3, 2011.

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