Topics covered in this chapter

Three key points about values in medicine are outlined as illustrated by a GP consultation for chronic low back pain between Dr. Gulati and her patient, Roy Walker.

Other topics include:

• Ethical and other values

• Clinician and patient values

• Foreground and background values

• The network of values

• Values, decisions and actions

• NICE guidelines for low back pain.

Take-away message for practice

Values in medicine (i) include but are wider than ethics, (ii) are everywhere and (iii) are action-guiding.

Values-based practice, as we indicated in our introduction, is a new skills-based approach to working more effectively with complex and sometimes conflicting values in medicine. As such, values-based practice is like evidence-based practice: both are responses to the growing complexity of clinical decision-making. Evidence-based practice supports clinical decision-making where complex and sometimes conflicting evidence is in play. Values-based practice supports clinical decision-making where complex and sometimes conflicting values are in play.

In this chapter, we illustrate the complexities of values in medicine not with a high-profile “ethics case” but rather as they emerge from the everyday scenario of a GP consultation for chronic low back pain. Three key points will emerge from this scenario, namely that values in medicine:

• are wider than just ethics, which nonetheless are an important aspect of our values;

• are everywhere in medicine, although not always recognized for what they are;

• are important because they stand alongside evidence in guiding decisions and actions.

Introduction to Part 4

Values-based practice, as we have emphasized, is very much a partner to evidence-based practice as a support tool for clinical decision-making. The stories in earlier chapters all illustrate the close connections between values and evidence in clinical care and related areas of training and research.

So close indeed is the relationship between them that values and evidence may each in different ways sometimes come to mask or eclipse the other, with adverse consequences for practice. The three chapters in this part of the book illustrate three distinct ways in which this may happen and the importance of maintaining a balanced approach that keeps both values and evidence always equally in view:

1. • In Chapter 10, the Two-feet Principle underlines the point made in Chapter 1 that in medicine all decisions are both values and evidence driven. All decisions, then, in the terms of this principle stand on the two feet, respectively, of values and of evidence. In practice, however, where a decision is strongly evidence-based, important values may get overlooked – we may become, as this chapter will show, “values blinded by the evidence.”

2. This is what happened to Dr. Jane Hilary, the GP in this chapter, in her management of a middle-aged man, Jim Burns, with essential hypertension. So focused was Dr. Hilary on the evidence guiding her management that she failed to recognize the crucial impact of her own and Jim Burns' values.

We began with our assertion that the most likely reason why things go wrong in clinician–patient interactions is a failure of values-based practice, not a failure of evidence-based practice. In light of what you have gleaned about the processes of values-based practice from our clinical illustrations, you may like to test our claim over the coming year.

We end with another assertion. If you rehearse and practice the elements of values-based practice detailed in this book, you are likely to find your consultations more personally rewarding and your patients are likely to derive more benefit.

Don't forget you already possess many, if not most, of the skills, and if some (such as dissensus and casuistry) are new to you, you will find them relatively easy to adopt.

Topics covered in this chapter

This chapter discusses the Squeaky-wheel Principle and how it reminds us not to lose sight of the evidence when we are focusing on values.

Other topics include:

• Targets and care – are the goals the same?

• “Inappropriate” attendance and misuse of resources

• Use of interpreters and the role of family

• Intercultural medicine and varying patient expectations

• The role of third-sector organizations.

Take-away message for practice

When you are focusing on values (ethical or otherwise), never lose sight of the evidence. So, think values, think evidence too!

The Squeaky-wheel Principle as we noted in Chapter 3 reminds us that values, although always there and important, tend to get our attention particularly when they cause trouble: it is, as they say, “the squeaky wheel that gets the grease.” This is an important reminder clinically because we are always at risk of losing sight of the evidence when the values are “squeaking” and hence grabbing our attention. Just as therefore the clinical bottom line of the last chapter was to “Think evidence, think values too!” so the clinical bottom line of this chapter is that it is equally important to “Think values, think evidence too!”

We illustrate the importance of “Think values, think evidence too!” with the story of a senior emergency care nurse, Matthew Cruickshank, and his problems with a non-English-speaking patient, Fatima Mahmood.

Topics covered in this chapter

The importance of diverse team values (as well as knowledge and skills) in values-based practice is illustrated by the issues of risk and safety in a child protection case.

Other topics include:

• Risk assessment and values

• Strengths and limitations of protocols and procedural guidelines

• Balanced clinical judgment

• Diverse team values and person-values-centered care

• The “extended” multidisciplinary team.

Take-away message for practice

Working in teams opens up a resource of diverse value perspectives that can support you in making balanced decisions in areas like risk assessment that require difficult judgment calls.

Like person-centered care in the last chapter, values-based practice brings an extra dimension to multidisciplinary teamwork. Teamwork is important in modern health care in part because no single profession, let alone individual, can hope to encompass all the diverse knowledge and skills required for effective evidence-based practice in the increasingly complex environment of modern health care. But the complexity of modern health care, as we saw in Part 1, is a complexity as much of the values-base of practice as of its evidence-base. Correspondingly, teamwork is important in values-based practice as much for the diverse values that different team members bring to the decision-making process as for their diverse knowledge and skills.

In this chapter, we illustrate the importance of the diverse value perspectives of team members through the story of how a GP, Dr. Lee Chew, manages the child protection issues raised when a young mother, Jade Spence, arrives in an “Extras” clinic on a Friday evening concerned that her four-month-old baby, Brit, has become sore “down below.”

Topics covered in this chapter

The role of reasoning in values-based practice is illustrated by the use of case-based reasoning (casuistry) in the management of a case of teenage acne.

Other topics include:

• Evidence-based medicine and management of teenage acne

• Cosmetic and medical treatments

• Values and communication skills

• Principles reasoning

• Other methods of ethical reasoning (utilitarianism and deontology).

Take-away message for practice

You can use case-based and other ways of reasoning about values to explore your own and other's values as they as they impact on practice.

Where awareness of values as the first skills element of the process of values-based practice provides a wake-up call to values, reasoning about values as the second element is about expanding our values horizons. Reasoning skills in values-based practice are not used to derive particular moral or other evaluative conclusions (to “prove” what is right or wrong). In values-based practice, reasoning skills are used rather to explore and come to understand better our own and other's values as these bear on and influence a given situation.

Expanding our values horizons with case-based reasoning (casuistry)

The importance of expanding our values horizons in this way is illustrated in this chapter by following a consultation between a GP, Dr. Charles Mangate, and his patient Jane Brewer, a 17-year-old aspiring model with mild acne.

With Part 2, we come to the first and foundational group of process elements of values-based practice: the four key areas of clinical skills.

• Chapter 4 introduces awareness. Without awareness of values and of the often-surprising diversity of values, none of the other process elements of values-based practice can get any purchase. In this chapter, the story of how a young woman, Sally Coombs, reaches a turning point towards recovery from schizophrenia illustrates the importance of raised awareness of values as the basis of effective clinical care. Later chapters will illustrate the importance also of developing tools for self-awareness.

• Chapter 5 describes reasoning. In Chapter 2, Dr. Gulati applied “top-down” principles reasoning in trying to work out what to do about Roy Walker's demand for an off-work certificate. This chapter shows how “bottom-up” case-based reasoning (sometimes called casuistry) helped a different GP, Dr. Charles Mangate, in managing a case of teenage acne.

• Chapter 6 discusses knowledge. This chapter focuses the narrative primarily on knowledge of values for training and research. It shows, through the story of a nurse practitioner, Trish Butler, and her patient, Sandy Fraser, with chronic obstructive pulmonary disease, what we can learn but also what we cannot learn about values by searching electronic databases.

• Chapter 7 describes communication skills. Where Chapter 6 focused on training and research, this chapter brings us back to the challenges of clinical work. Through the story of a teenager, Vicky Bartlett, with type I diabetes, it illustrates the importance of communication skills, particularly for eliciting values and in conflict resolution.

Topics covered in this chapter

A story from palliative care illustrates the role of dissensus (alongside consensus) in bringing together the elements of values-based practice to support partnership in decision-making.

Other topics include:

• Multidisciplinary cancer care

• The National Confidential Enquiry into Patient Outcomes and Death (NCEPOD)

• Transition from (surgical) cure to (palliative) care

• Spiritual and religious beliefs

• Advance care planning (ACP) in end-of-life care

• Consensus (in evidence-based practice) and dissensus (in values-based practice)

• Reminders of process elements of values-based practice (VBP flashbacks).

Take-away message for practice

Dissensual decision-making can help usx to build genuine partnerships in working with other team members and with patients and their families.

Partnership between stakeholders in decision-making, although coming tenth in the list of process elements of values-based practice, is last but definitely not least in importance. We will see in this chapter that, as the tenth element, partnership draws together and underpins the process of values-based practice as a whole.

The importance of partnership in values-based decision-making is illustrated in this chapter through the story of a 69-year-old man, Joe Monaghan, after he is found to have disseminated bowel cancer following an emergency admission with acute abdominal symptoms. There has been much talk in such situations of a “good death.” But the surgical team and Joe Monaghan's various family members, as we will see, had very different perspectives on what a “good death” would mean, with Joe Monaghan himself, as is so often the case, at risk of becoming caught between their conflicting best intentions.

Topics covered in this chapter

The Science-driven Principle – that advances in medical science and technology drive the need equally for values-based as for evidence-based practice – is illustrated by the experience of a couple seeking treatment for infertility.

Other topics include:

• Patients' experiences of infertility treatment

• Clinicians' experiences of infertility treatment

• NICE guidelines

• Spiritual direction

• Importance of the extended multidisciplinary team.

Take-away message for practic

It is above all in a high-tech area of medicine (like IVF) that it is important to adopt a balanced “values plus evidence” approach. So, “think high-tech, think values and evidence!”

Organ transplants, prosthetic limbs, laser surgery, in vitro fertilization – these are just some of the growing list of new high-tech resources now available in everyday clinical practice driven by the unprecedented advances in medical science and technology in recent decades. Nor is there any sign of the rate of advance slowing. Gene therapy, it is true, heralded over 20 years ago as the next big thing, is only just beginning to get under way, but getting underway it is.

Two high-tech challenges

Advances in high-tech medicine clearly hold out the promise of great benefits for patients. But these same advances raise many challenges for practitioners, both scientific and ethical. On the science side, there is the challenge of keeping up to date with the evidence: here the resources of evidence-based practice guidelines are helpful. Whatever the limitations of locally or nationally agreed guidelines, they at least set mutual limits on our options.

Topics covered in this chapter

Continuing the story of Dr. Gulati and Roy Walker, this chapter takes us to the starting point for values-based practice in the complex values involved in individual clinical decision-making.

Other topics include:

• Codes of ethics

• Principles reasoning

• How values and ethics fit together

• Decision analysis

• How values and evidence fit together

• Clinical judgment.

Take-away message for practice

All current tools need the application of individual clinical judgment and up until now there has been little to guide clinicians on processes to find the best solutions for individual cases.

In this chapter, we take the story of Roy Walker and Dr. Gulati a stage further. The doctor turns for help to a number of tools in medicine's values toolbox: first, codes of practice and ethics, then decision analysis and finally evidence-based practice. These all prove helpful but only up to a point, for when applied to the particular circumstances of the patient, each of them raises but fails to resolve a number of complex values issues.

It is these and similar complex values issues raised by clinical decision-making between individual patients and individual clinicians that take us to the starting point for values-based practice.

What to do?

We start this chapter with a suggested reflection aimed at helping us to get away from general ethical theorizing about what Dr. Gulati ought to do and to focus rather on what she could do in the particular circumstances in which she found herself on a Monday morning at the start of a busy clinic.

In this appendix, we summarize the essential features of values-based practice and give brief definitions of some of the key terms used in this book.

NOTE: Terms in bold correspond to terms highlighted in blue in the index, which in turn is supported by an index spreadsheet (on the VBP web site) showing what is covered by each of the highlighted index references.

Values-based practice

Values-based practice is a new approach to working with complex and conflicting values in healthcare that is:

• Complementary to other approaches to working with values such as ethics (medicine's values tool box) in focusing on individual values

• A partner to evidence-based practice in supporting clinical judgment in individual cases.

Values-based practice thus links science with the unique values of the particular people involved (clinicians, patients, carers and others) in a given clinical decision.

Values-based practice builds on a premise of mutual respect to support balanced decision-making through a ten-part process covering clinical skills, professional relationships, links with evidence-based practice and partnership.

Values

Values are anything positively or negatively weighted as a guide to action (for example, needs, wishes and preferences).

Values-based practice is a process that supports healthcare decision-making where complex and conflicting values are in play.

• Complex values are values that mean different things to different people (for example, ‘best interests’)

• Conflicting values are values that are in conflict one with another (for example, there are often tensions in healthcare decision-making between ‘best interests’ and ‘freedom of patient choice’).

The stories in this book have illustrated some of the ways in which the skills and other process elements of values-based practice support balanced decision-making in medicine and health care where complex and conflicting values are in play.

As a response to complexity, values-based practice, as we have emphasized throughout, is a partner to evidence-based practice. Decisions – all decisions, whether clinical or otherwise – stand, as we put it in Chapter 1, on two feet, a values foot and an evidence foot. The process of evidence-based practice has been developed as a response to the growing complexity of the evidence base of clinical decision-making. The process of values-based practice has been developed as a response to the growing complexity of the values base of clinical decision-making.

Linking science with people

The complementary relationship between evidence-based practice and values-based practice can be understood in part in terms of the relationship between the sciences and the humanities.

There are overlaps, of course. The founders of evidence-based practice, as we saw from David Sackett's work in Part 1, although focusing on the technical processes required for establishing generalizable conclusions about best scientific evidence, set this in context with the need to link best evidence with clinical experience and patients' values. Values-based practice similarly, although derived primarily from work in analytic and other areas of philosophy, includes knowledge of values (including as we described in Chapter 6, research-based knowledge) as one of its four key skills areas; and the process elements of values-based practice include three specific principles (covered in Part 4) directly linking evidence and values.

Topics covered in this chapter

This chapter describes how to bring together the elements of values-based practice within a framework of shared values to support balanced decision-making in clinical practice.

Other topics include:

• Management of chronic low back pain

• Chronicity and compliance

• Protected learning time

• Efficiency and effectiveness

• Practice policies

• Values-based commissioning

Take-away message for practice

A framework of shared values, built up between clinicians, patients, carers and managers, provides a basis for balanced decision-making on contested issues.

In this chapter, we return to the story of Dr. Gulati from Part 1 to see how the elements of values-based practice, as set out separately in the preceding chapters, came together to support her in resolving her dilemma about how to manage the demand of her patient, Roy Walker, for an off-work certificate.

The buck stops here

Dr. Gulati's reflection had helped to clarify her dilemma. There were important ancillary issues: her personal and professional obligations to Dr. Austin, and her concerns for Roy Walker's family. But the essence of her dilemma was that she was caught between two important conflicting aspects of good practice. On the one hand, she wanted to support autonomy of patient choice as an aspect of person-centered practice, while on the other hand, she had not only her societal responsibility for certification but also her responsibility to Roy Walker to act in his clinical best interests as indicated by established evidence on chronicity and low back pain.