By Claudio López Bruzual MD
The classic approach of traditional medicine (preventing death and treating disease), which has been so decisive to improve life expectancy rates, and for the treatment of acute and infectious diseases, is now insufficient.
This has become more evident when we enter a scenario like the one we are facing in the XXI century, characterized by a sustained increase, both, in the number of patients with chronic diseases, and in the number of those who present multiple comorbidities of the same kind. This trend has become the paradigm for the current generation to change.
As the life expectancy of populations has increased, so has the burden of chronic diseases. These, by definition, are those that we are not able to heal, so they require the sustained action of health systems for a long time, and, in addition, a huge consumption of resources.
Therefore, we are talking about the multiple nuances between death and health, and, sometimes, of states that might be considered worse than death itself. So, there are questions that need an answer, such as: what does it mean to be healthy? Who determines when such a condition is present? Since health is what allows us to immerse ourselves in our lives and in the world, it must be defined and experienced within our own existence.
While we, physicians, have adopted the right to make those decisions, the patient is the primary producer and defining element of what it is to be healthy. Although caregiving can help him gain some control over his life, not being related to that vital control can even contribute to suffocating him. He is the agent capable of producing and enjoying health.
The role of the patient
As long as we continue to think that we are the ones called to define what health is to, then, provide it to patients through our care, we lose focus on the individual as the source of his own health.
With the above statement I do not want to say that the best path for a patient-centered health means overlooking the benefits of counseling and medical treatment, but it is necessary to outline some points that can help us guide the prevention and management of chronic diseases. Here are three aspects worth exploring:
1. We cannot assume that the most important aims of care are death and illness. That is why we cannot continue grading our clinical success with the lives saved because not all deaths in older people are premature or rejected by patients. We have to face much greater fear, such as inappropriate prolongation of lives or allowing individuals to fall into states of deterioration worse than death.
2. We must be able to deepen the perspectives of our patients in order to clearly define the nature of the problem we are facing, and the criteria for the success of our management. The objective is not to limit the physician to share information about the disease and its treatment alternatives, so the patient makes an informed decision based on their own values. It is about opening a space in the therapeutic relationship to incorporate decision-making process that can only be provided by the patient, such as symptoms, functionality, and quality of life. Since almost all care related to chronic disease is a patient affair, it is necessary to consider him in decision-making.
3. The aim of our work is to always privilege the increase of the patient's ability to take care of himself and restore in him a significant vital action. In these cases, the criterion of therapeutic success should stop being related to the disappearance of the pathological process, or even of the symptoms, to focus on helping him to gain control over his life. The extent to which we should control the symptoms in such cases is not a predetermined fact.
In short, it is not only a question of incorporating the patient's personal dimension into decision-making, but also of promoting his autonomy.