Who Decides?(Thanks for all the comments on my “Priorities” post last week. Sounds like I hit a nerve…)Today, the New York Times features a commentary about current debates on the health care needs of an aging population. The author, Dr. Pauline Chen, makes the point that most debates focus on the looming shortage of doctors, and discussions about how to change medical care delivery focus on this group as well.What’s missing, Dr. Chen points out, is the involvement of nurses in policy discussions. Nurses not only provide an in-depth knowledge of the care challenges patients face, but they also could be part of innovative care solutions that focus on medical teams, rather than simply recruiting medical doctors.Dr. Chen reminds us of something that hit me a while ago when I wrote my book on dementia. I now routinely ask my audiences to consider this question: “Who decides when a person with dementia gets a psychotropic drug for their distress–the medical staff or the nursing staff?” To most, the obvious answer is the doctor; she/he is the one who writes the order, after all.But there’s a less obvious answer too. With all the people living with dementia that we care for in hospitals and nursing homes, who is it that decides when to bring the doctor in to consult on one person, while caring for a similar person next door without recruiting the doctor and his/her pills? It’s the nurse who does the “triage” and decides who gets the doc’s attention.The only thing a doctor has that a nurse doesn’t is a license to prescribe. So a call to a doctor for behavioral symptoms is basically a request for medication, because if it were anything else, the care staff could take care of it themselves.There’s a powerful message here: the nurses absolutely control who gets medications for behavioral distress. That is why, even though I wanted a broad audience to read my book, I chose nurses as the core readership: I knew that if we can empower this group of talented individuals to find successful non-drug solutions, the doctors will follow suit.