Not all patients want to participate in decision making. A national study of public preferences

The influence of age on the breast surgery decision-making process

BACKGROUND

Mastectomy rates have been assumed to be a function of physician recommendations, although they correlate with patient involvement in decision making. The influence of age on the decision-making process and treatment choice is poorly described.

METHODS

All women with ductal carcinoma in situ (DCIS) and a random sample with invasive breast cancer were identified from two Surveillance Epidemiology and End Results (SEER) program registries and surveyed 6 months postoperatively. Women older than 79 years with noninvasive or localized invasive breast cancer diagnosed in 2002 were included. Women with breast-conserving therapy (BCT) contraindications were excluded. Women were questioned about involvement in surgical decision-making, inquiring if this decision was patient-based, surgeon-based, or shared. Knowledge and concerns were assessed.

RESULTS

The response rate was 77.0%. There were 1,259 patients who met the study eligibility criteria and age data was available for 1,131. Median patient age was 59.9 years. The frequency of patient-based decisions did not vary with age (p = 0.20), but older women had less knowledge for decision making. The mastectomy rate overall was 19.7%, with no differences in mastectomy choice by age (p = 0.18). In logistic regression for the likelihood of undergoing mastectomy, patient involvement (p < 0.0001), larger tumor size (p < 0.0001), lower education (p = 0.0002), number of surgeons consulted (p = 0.0005), and nonwhite race origin (p = 0.011) were significant predictors, while age, invasion, and comorbidities were not significant.

CONCLUSION

Older women participate equally in breast cancer surgical decision making and are equally likely to select mastectomy, but use less knowledge to make the decision. The impact of education and ethnic origin on mastectomy use indicates the need for improved educational strategies for these groups.

Development of an instrument to measure seniors' patient safety health beliefs: the Seniors Empowerment and Advocacy in Patient Safety (SEAPS) survey

OBJECTIVE

To develop a survey to measure seniors' embracement of ambulatory patient safety self-advocacy behaviors, the Senior Empowerment and Advocacy in Patient Safety (SEAPS) survey.

METHODS

Content was developed by review of published recommendations combined with interviews and focus groups with community members; items were generated for subscales based on the health belief model (HBM). Psychometric characteristics were assessed by cluster and correlation analyses on a pilot test of 143 community dwelling seniors; the ability of the subscales and demographic variables to predict reported behavior was investigated by multiple regression.

RESULTS

The four subscales of the SEAPS were outcome efficacy (OE), attitudes (ATT), self-efficacy (SE) and behaviors (BEH). Cronbach alphas were 0.74 for ATT, 0.79 for BEH, and 0.91 for OE and SE. Analysis of variance showed that there were no differences in any subscale score by race, education level or frequency of doctor visits, but women were noted to have significantly higher scores (p<.01) on the ATT and SE subscales and for the total of all the scales. Multiple regressions showed that SE significantly predicted self-reported behavior (p<.001). OE was a significant predictor for whites (p<.001) but not for African-Americans (p=.24).

CONCLUSIONS

We have developed a short, 21-item self-administered survey to assess seniors' views about their participation in safety tasks.

PRACTICE IMPLICATIONS

We believe the SEAPS shows promise to be a tool for evaluating interventions and training programs aimed at improving seniors' self-advocacy skills. Effective interventions may improve the involvement of patients in their own safety in the clinical setting.

Optimizing medicines management: From compliance to concordance

Medication prescribed but not consumed represents a huge loss in drug and prescribing costs and an enormous waste of expensive medical time. In this article we discuss what is known about compliance and adherence, explore the concept of concordance and demonstrate its fundamental difference from both. Not all patients are ready or suitable for shared decision making in management of their condition, some still preferring a doctor-led decision but an increasing number want a partnership approach. By opening up and rebalancing the discussion about medication, we can expect a consultation which is more satisfying for both parties and flowing from this, more effective, focused prescribing of medication which is more likely to be adhered to by the patient. We examine the extent to which doctor and patient behaviors are currently compatible with this change of concept and practice, look at available consultation models which might be useful to the reflective practitioner and consider what actions on the part of the doctor and the healthcare system could promote medicine prescription and utilization in line with this new approach based on partnership.

The medical dialogue: disentangling differences between Hispanic and non-Hispanic whites

BACKGROUND

Patients' race and ethnicity play an important role in quality of and access to healthcare in the United States.

OBJECTIVES

To examine the influence of ethnicity--Hispanic whites vs. non-Hispanic whites--on respondents' self-reported interactions with healthcare providers. To understand, among Hispanic whites, how demographic and socioeconomic characteristics impact their interactions with healthcare providers.

DESIGN

Cross-sectional analysis of the 2002 Medical Expenditure Panel Survey, a nationally representative survey on medical care conducted by the Agency for Healthcare Research and Quality.

PARTICIPANTS

Civilian, noninstitutionalized U.S. population aged > or = 18 years who reported visiting a healthcare provider within the past 12 months prior to data collection.

RESULTS

After controlling for several demographic and socioeconomic covariates, compared to non-Hispanic whites (reference group), Hispanic whites who had visited a doctor's office or clinic in the past 12 months were more likely to report that their healthcare provider "always" listened to them [odds ratio (OR) = 1.36, 95% confidence interval (CI) 1.21-1.53], explained things so that they understood (OR = 1.25, 95% CI 1.10-1.41), showed respect for what they had to say (OR = 1.52, 95% CI 1.35-1.72), and spent enough time with them (OR = 1.22, 95% CI 1.08-1.38). However, Hispanics were less likely to indicate that their health care provider "always" gave them control over treatment options (OR = 0.83, 95% CI 0.72-0.95) as compared to non-Hispanics. Within the Hispanic population exclusively, age, place of residence, census region, health insurance status, and presence of a usual source of care influenced self-reported interactions with healthcare providers.

CONCLUSION

Hispanic white respondents were more likely to report that some aspects of provider-patient interactions were indicative of high quality, whereas those related to decision-making autonomy were not. These somewhat paradoxical results should be examined more fully in future research.

Perceptions of healthcare providers' communication skills: do they differ between urban and non-urban residents?

We examined the association of place of residence--urban versus non-urban--with patients' perceptions regarding communication and interactions with healthcare providers. Respondents' perceptions of their healthcare providers' communication skills were assessed by responses to six items from the 2002 Medical Expenditure Panel Survey, a nationally representative survey of the civilian, non-institutionalized US population. After controlling for several covariates, respondents in urban areas reported poorer communication by their healthcare providers than non-urban respondents. Differences in perceived quality of communication could contribute to reduce use of preventive healthcare and indicates a need to improve healthcare provider-patient communication in the urban setting.

Elderly patients' preferences and experiences with providers in managing their drug costs

OBJECTIVES

To determine whether elderly patients with high drug expenditures want and receive providers' help in managing drug costs.

DESIGN

Cross-sectional survey.

SETTING

A Medicare managed care plan (>400,000 members) in one state in 2002.

PARTICIPANTS

One thousand one hundred six seniors (62% response rate) sampled so that half exceeded caps on their drug benefits the previous year, and all had total drug expenditures in the top quartile of members in their cap level.

MEASUREMENTS

Participants' preferences and experiences with providers discussing costs and participation in choosing medications.

RESULTS

Two-thirds reported difficulty paying for medications, and one-fourth decreased medication use because of cost. Most wanted providers to ask about medication affordability (81%), consider cost (86%), offer choices (70%), and to persuade them or decide for them which medication to use (88%), but few said providers asked about affordability (17%), usually or always discussed prices (19%), or offered choices (45%), although nearly all said providers chose their medications (93%). Sixty-two percent had asked providers for help with drug costs, although 34% who used less medication because of cost or had difficulty paying for medications had not asked for help.

CONCLUSION

Providers should be aware that elderly patients want their help in managing drug costs but do not always receive it or ask for help when they need it. Providers could improve communication by initiating conversations about cost and by asking patients about preferences when prescribing.

Does participatory decision making improve hypertension self-care behaviors and outcomes?

This study examined patients' perceptions of their providers' participatory decision making (PDM) style and hypertension self-care behaviors and outcomes. Five hundred fifty-four veterans with hypertension enrolled in the Veterans' Study to Improve the Control of Hypertension rated providers' PDM styles using a validated 3-item instrument. Behaviors assessed included presence of a home blood pressure monitor, monitoring frequency, and self-reported antihypertensive medication adherence. Overall, veterans with hypertension rated providers as highly participatory. In adjusted analyses, a lower PDM score was associated with decreased odds of having a home monitor (odds ratio, 0.90 per 10-point decrement in PDM score; 95% confidence interval, 0.83-0.98) but not with monitoring frequency, adherence, or blood pressure control. Providers' involvement of patients in decision making, reflected in ratings of PDM style, may be important to securing patients' participation in their own care, but alone this factor seems insufficient. No relationship between PDM score and blood pressure control was observed.

Minding the shop: The case of obstetrics conferences

We estimate the impact of annual obstetricians and gynecologists' conferences on births in Australia and the United States. In both countries, the number of births drops by 2-4 percent during the days on which these conferences are held. Since it is unlikely that parents take these conferences into account when conceiving their child, this suggests that medical professions are timing births to suit their conference schedule. We argue that for this reason professional obstetrics societies should reconsider the timing of their annual conferences to accommodate the lowest natural birth rate in the year.

Understanding of the benefits of coronary revascularization procedures among patients who are offered such procedures

BACKGROUND

To participate meaningfully in decisions regarding invasive procedure use, patients should understand the benefits and risks. Previous work has focused on risks; we assessed patient understanding of the benefits of coronary revascularization procedures.

METHODS

We interviewed 1650 patients and their treating physicians after elective coronary angiography performed at 3 Veterans Health Administration hospitals and 1 university hospital. We excluded patients for whom the decision to undergo revascularization was made before admission. This report focuses on 633 patients who had been offered coronary artery bypass surgery (CABG, n = 324) or percutaneous coronary interventions (PCIs) and responded to questions about expected benefits. Both patient and physician were asked to report the benefits they expected from revascularization. Forty-nine physicians reported on 490 patients.

RESULTS

Most patients were older (mean age 63.8 years), white (89.4%), and male (77.6%). Most patients expected improved symptoms (83%) and survival (83%). Physician-patient agreement regarding whether survival would improve was no better than chance (kappa = 0.02 for CABG, kappa = -0.01 for PCI, both P > .10). There was also poor agreement regarding whether symptoms were expected to improve, but this was better than chance (kappa = 0.09, P = .01 for CABG; kappa = 0.19, P = .02 for PCI). Physician-patient agreement was poor regardless of patient characteristics.

CONCLUSIONS

Patients have more optimistic expectations about benefits of coronary revascularization than the cardiologist offering the procedure. Further research should confirm this finding and clarify how physician-patient disagreement regarding the benefits of coronary revascularization affects patient participation in decision making.

Osteoporosis medication profile preference: results from the PREFER-US study

Objective  To assess patient preferences for two osteoporosis medications.

Design  Women aged 50+ were surveyed via the Internet to assess preferences for two osteoporosis medication profiles. Drug A and Drug B, consistent with ibandronate and alendronate, respectively, differed by: time on market (recently vs. 10 years), dosing frequency (monthly vs. weekly), effectiveness (not proven vs. proven to reduce non‐spine or hip fracture after 3 years) and dosing procedure (60 vs. 30 min wait before eating/drinking). Each profile had the same out‐of‐pocket costs, side‐effects, potential for drug interaction and spine fracture efficacy. Patients force ranked and rated the importance of each attribute. Subgroup comparisons included diagnosed vs. at‐risk respondents and treated vs. untreated respondents.

Results  Among the 999 respondents, Drug B was preferred by 96%. Effectiveness was ranked as the most important determinant of preference (79% ranked it #1) compared with time on market (14%), dosing procedure (4%) and dosing frequency (3%). Effectiveness had the highest mean importance rating on a scale of 1 (extremely unimportant) to 7 (extremely important): mean (SD) = 6.1 (1.8), followed by time on market: 4.7 (1.7), dosing procedure: 4.6 (1.4) and dosing frequency: 4.5 (1.4). No significant differences in profile choice were found across study subgroups.

Conclusions  The drug profile showing reductions in non‐vertebral and hip fracture risk was chosen by almost all respondents. Drug effectiveness was the most important determinant of preference, while dosing frequency was the least important determinant. Incorporation of patient preferences in the medication decision‐making process could enhance patient compliance and clinical outcomes.

Communicating the uncertainty of harms and benefits of medical interventions

BACKGROUND

There is growing interest in shared medical decision making among patients, physicians, and policy makers. This requires patients to interpret increasing amounts of medical information, much of which is uncertain. Little is known about the optimal approaches to or outcomes of communicating uncertainty about the risks and benefits of treatments.

METHODS

The authors reviewed the literature on various issues related to uncertainty in decision making: conceptualizing uncertainty, identifying its potential sources, assessing uncertainty, potential methods of communicating uncertainty, potential outcomes of communicating uncertainty, and current practices and recommendations by expert groups on communicating uncertainty.

RESULTS

There are multiple sources of uncertainty in most medical decisions. There are conceptual differences in how researchers define uncertainty and its sources, as well as in its measurement. The few studies that have assessed alternate means of communicating uncertainty dealt mostly with presenting uncertainty about probabilities. Both patients' and physicians' interpretation of and responses to uncertainty may depend on their personal characteristics and values and may be affected by the manner in which uncertainty is communicated.

CONCLUSIONS

Research has not yet identified best practices for communicating uncertainty to patients about harms and benefits of treatment. More conceptual, qualitative, and quantitative studies are needed to explore fundamental questions about how people process, interpret, and respond to various types of uncertainty inherent in clinical decisions.

Participation in Medical Decision Making: The Patients' Perspective

Purpose. Variability in reports of patients' preferences to participate in decision making may be due in part to a lack of understanding about how patients conceptualize their participation. The authors sought to learn more about how patients view their involvement in decisions related to their health care. Methods. The authors conducted individual interviews to allow patients to frame the decision-making process from their own perspective. The constant comparative-method approach to analysis was employed to ensure that the analysts defined the codes in a consistent manner. Results. Twenty-six persons were interviewed. The main themes discussed by the participants reflecting how they viewed their involvement in medical decision making are the following: 1) decision making is often an ongoing process in which patient participation may change over time, 2) decision making is performed within an extended social context, 3) the decisions patients report being involved in are often distinct from those traditionally studied (choice of treatment or screening strategies), 4) patient involvement in decision making occurs in response to physicians' recommendations, and 5) patients make choices in the context of their specific illness perceptions. Conclusions. Participants in this study view their participation in decision making as including ideas distinct from those traditionally discussed by researchers. These findings suggest that the variability in patient participation noted in previous studies may be due in part to limitations in study design.

Older people's preferences for involvement in their own care: a qualitative study in primary health care in 11 European countries

OBJECTIVE

The aim of the study was to explore the views of people aged over 70 years on involvement in their primary health care in 11 different European countries.

METHODS

Older patients were asked about their views on patient involvement in a face-to-face interview. All interviews were audio-recorded, transcribed and analysed in accordance with the principles of 'qualitative content analysis'. An international code list was used.

RESULTS

Four hundred and six primary care patients aged between 70 and 96 years were interviewed. Their views could be categorized into four major groups: doctor-patient interaction, GP related topics, patient related issues and contextual factors.

CONCLUSION

People over 70 do want to be involved in their care but their definition of involvement is more focussed on the 'caring relationship', 'person-centred approach' and 'receiving information' than on 'active participation in decision making'.

PRACTICE IMPLICATIONS

The desire for involvement in decision making is highly heterogeneous so an individual approach for each patient in the ageing population is needed. Future research and medical education should focus on methods and training to elicit older patients' preferences. The similar views in 11 countries suggest that methods for enhancing patient involvement in older people could be internationally developed and exchanged.

Do people want to be autonomous patients? Preferred roles in treatment decision-making in several patient populations

BACKGROUND

What role do people want to play in treatment decision-making (DM)?

OBJECTIVE

Examine the role patients indicate they would prefer in making treatment decisions across multiple clinical settings in Ontario, Canada.

DESIGN

Secondary analysis of a series of survey/interview-based studies measuring preferred role, conducted in 12 different populations.

SETTING AND PARTICIPANTS

Respondents were outpatients, largely but not entirely attending outpatient clinics in large teaching hospitals in urban settings in the Province of Ontario, Canada. The subgroups and sample sizes were: breast cancer (202), prostate disease (202), fractures (202), continence (46), orthopaedic (111), rheumatology (56), multiple sclerosis (22), HIV/AIDS (431), infertility (454), benign prostatic hyperplasia (678) and cardiac disease (300), plus 50 healthy nursing students (for scale validation).

MEASUREMENTS

All studies categorized preferred role using the Problem-Solving Decision-Making (PSDM) scale with one or both of the Current Health condition and Chest Pain vignettes.

RESULTS

Few respondents preferred an autonomous role (1.2% for the current health condition vignette and 0.7% for the chest pain vignette); most preferred shared DM (77.8% current health condition; 65.1% chest pain) or a passive role (20.3% current health condition; 34.1% chest pain). Familiarity with a clinical condition increases desire for a shared (as opposed to passive) role. Preferences for passive vs. shared roles varied across settings; older and less educated individuals were most likely to prefer passive roles.

CONCLUSIONS

Despite consumerist rhetoric among some bioethicists, very few respondents wish an autonomous role. Most wish to share DM with their providers.

Patient and physician attitudes in the health care context: attitudinal symmetry predicts patient satisfaction and adherence

BACKGROUND

There is increasing interest in the role that patient and physician health-related attitudes may play in predicting patient outcomes.

PURPOSE

This study examined the similarity of the attitudes held by patients and their physicians about the patient role in health care delivery and its relationship to patient outcomes.

METHODS

Participants were 16 primary care physicians from a single academic medical center and 146 patients who had been seen by their respective physician at least twice during the prior 6 months. Physicians and patients completed two measures reflecting healthcare-related attitudes: the Multidimensional Health Locus of Control questionnaire and the Patient-Practitioner Orientation Scale (PPOS). Patients also completed measures of satisfaction and adherence.

RESULTS

Analyses were conducted using hierarchical linear modeling with patients clustered within physicians. Degree of symmetry on internal health locus of control was positively associated with both patient adherence, F(2, 131) = 3.75, p = .03, and satisfaction, F(2, 133) = 7.16, p = .01. Degree of similarity on the Information/Power Sharing subscale of the PPOS was not positively associated with adherence or satisfaction.

CONCLUSIONS

These data suggest that patients who are more similar in attitude to their physicians as indicated by internal health locus of control scores (but not PPOS scores) are more satisfied with their medical care and more adherent with treatment recommendations than patients who are less internally focused than their physicians.

Can patients' preferences for involvement in decision-making regarding the use of medicines be predicted?

OBJECTIVE

The current study aimed to develop a model of patients' preferences for involvement in decision-making concerning the use of medicines for chronic conditions in the UK and test it in a large representative sample of patients with one of two clinical conditions.

METHODS

Following a structured literature review, an instrument was developed which measured the variables that had been identified as predictors of patients' preferences for involvement in decision making in previous research. Five hundred and sixteen patients with rheumatoid arthritis or type 2 diabetes were recruited from outpatient and primary care clinics and asked to complete the instrument.

RESULTS

Multivariate analysis revealed that age, social class and clinical condition were associated with preferences for involvement in decision-making concerning the use of medicines for chronic illness but gender, ethnic group, concerns about medicines, beliefs about necessity of medicines, health status, quality of life and time since diagnosis were not. In total, the fitted model explained only 14% of the variance.

CONCLUSION

This study has demonstrated that current research does not provide a basis for predicting patients' preferences for involvement in decision-making.

PRACTICE IMPLICATIONS

Building concordant relationships may depend on practitioners developing strategies to establish individuals' preferences for involvement in decision-making as part of the ongoing prescriber-patient relationship.

Fears and beliefs of patients regarding cardiac catheterization

The fears and beliefs patients hold about invasive medical interventions may affect their perceptions about risk and subsequent decisions to undergo those procedures. Little is known about fears and beliefs in patients undergoing invasive cardiac procedures and their relationship to perceptions of risks. Using a grounded theory approach, 10 men and 10 women referred for their first cardiac catheterization (CATH) from referral centers in Ontario, Canada were interviewed to identify fears and beliefs related to the procedure. Overall, women expressed more fears than men. Fears for both groups arose from: (1) lack of control about (i) physical aspects and (ii) psychosocial aspects of the CATH; (2) an unknown future; and (3) possible medical complications. Beliefs related to health personnel involved in the CATH, the technology used during the CATH and personal coping mechanisms. Men were more inclined to believe in technology, which overrode concerns about the procedure. Participants viewed CATH as a routine and necessary step in determining their future. Patients imputed previously held fears and beliefs and formulated new ones regarding the CATH during the process of anticipating the procedure. They viewed themselves as passive participants and not as actively consenting to the CATH. This paper offers previously undocumented insights from patients regarding CATH and provides the basis for developing future investigations.

[Determinants of severely injured patients' trust in their hospital physicians]

BACKGROUND

Several studies have shown negative effects of insufficient physician-patient interaction leading to a lack of compliance, worse subjective and objective evaluation of treatment outcome, increased consumption of pain medication, and decreased patient satisfaction. The aim of the present study was to identify patient-, physician-, and/or hospital-specific determinants which have a significant influence on the trust of severely injured patients in their physicians.

METHODS

A written questionnaire was sent to 121 severely injured patients hurt predominantly in traffic accidents and treated between July 1996 and July 2001 in two departments of surgery in the German state of Northrhine-Westfalia. Applying the Total Design Method, a response rate of 74.4% (n=90) could be achieved.

RESULTS

Using univariate analysis as a preselection tool, we developed a logistic regression model which identified four significant predictors of patients' trust in their physicians: (1) patient evaluation of information, (2) patient evaluation of their physician's decision policy, (3) patient evaluation of treatment success, and (4) patient age.

CONCLUSIONS

Besides age of patient and subjective evaluation of treatment success, it is psychosocial aspects of interaction which influence trust in a physician. The results of this analysis confirm the importance of physician-patient communication for medical education, also for surgeons.

What are the essential elements to enable patient participation in medical decision making?

BACKGROUND

Patient participation in shared decision making (SDM) results in increased patient knowledge, adherence, and improved outcomes. Despite the benefits of the SDM model, many patients do not attain the level of participation they desire.

OBJECTIVE

To gain a more complete understanding of the essential elements, or the prerequisites, critical to active patient participation in medical decision making from the patient's perspective.

DESIGN

Qualitative study.

SETTING

Individual, in-depth patient interviews were conducted until thematic saturation was reached. Two analysts independently read the transcripts and jointly developed a list of codes.

PATIENTS

Twenty-six consecutive subjects drawn from community dwelling subjects undergoing bone density measurements.

MEASUREMENTS

Respondents' experiences and beliefs related to patient participation in SDM.

RESULTS

Five elements were repeatedly described by respondents as being essential to enable patient participation in medical decision making: (1) patient knowledge, (2) explicit encouragement of patient participation by physicians, (3) appreciation of the patient's responsibility/rights to play an active role in decision making, (4) awareness of choice, and (5) time.

LIMITATIONS

The generalizability of the results is limited by the homogeneity of the study sample.

CONCLUSIONS

Our findings have important clinical implications and suggest that several needs must be met before patients can become active participants in decisions related to their health care. These needs include ensuring that patients (1) appreciate that there is uncertainty in medicine and "buy in" to the importance of active patient participation in decisions related to their health care, (2) understand the trade-offs related to available options, and (3) have the opportunity to discuss these options with their physician to arrive at a decision concordant with their values.

Medical information and surrogate designation: results of a prospective study in elderly hospitalised patients

OBJECTIVES

To determine the preferences of French elderly inpatients concerning medical information and surrogate designation in life-threatening situations.

METHODS

Intention-to-act questionnaire was completed by two geriatricians during a patient interview in the week following admission in three geriatric units in France. The participants were elderly patients (> or =70 years) with adequate cognitive performance for decision making as assessed by the Mini Mental State Examination. The impact of socio-demographic factors, level of confidence in medical care, cognitive or physical disability on surrogate designation and amount of medical information expected were measured.

MEASUREMENTS

Impact of socio-demographic factors, level of confidence in medical care, cognitive or physical disability on surrogate designation and amount of medical information expected.

RESULTS

426 consecutive elderly patients were recruited. 32.6% wanted to receive complete information about their care and 77% declared they would want to be informed if they were in a life-threatening situation. 4.5% reported they would not want any medical information. A family member was designated as surrogate by 73% of the patients. In 28%, a second surrogate was also designated, usually the family physician (22%) or a member of the hospital medical staff (10%). Polytomous logistic regression analysis was used to assess determinants of the amount of information expected and social and medical parameters. MMSE score, the presence of physical disability, a low level of confidence in medicine and the presence of children were identified as independent determinants of a high level of information expectation.

CONCLUSION

Elderly hospitalised patients expressed a strong desire to receive extensive information and were willing to designate a surrogate in a life-threatening situation. The surrogate was usually a family member alone or with another person, usually a practitioner.

Informed consent in clinical medicine

Over the past third of a century, there has been a revolution in the way that health-care providers and patients make most medical decisions. Paternalism has slowly gone the way of the long-play record, and in its place has emerged a consent process in which the patient is a more fully informed and active participant. This process takes time however, and for the busy health-care provider there is often the temptation to hand the patient a consent form to sign. It is important to realize that signing a consent form does not constitute informed consent. True informed consent is a process, and, as such, it requires that the health-care provider enter into a discussion that ultimately leads to the patient understanding of their options, and the risks and benefits of the alternative courses of action. The purpose of this article was to describe, in some detail, the consent process in practical clinical terms, and to note when and how it should be obtained.

Factors associated with patient involvement in surgical treatment decision making for breast cancer

OBJECTIVE

To evaluate factors associated with women's reported level of involvement in breast cancer surgical treatment decision making, and the factors associated with the match between actual and preferred involvement in this decision.

METHODS

Survey data from breast cancer patients in Detroit and Los Angeles was merged with surgeon data for an analytic dataset of 1101 patients and 277 surgeons. Decisional involvement and the match between actual and preferred amount of involvement were analyzed as three-level dependent variables using multinomial logistic regression controlling for clustering within surgeons. Independent variables included patient demographic and clinical factors, surgeon demographic and practice factors, cancer program designation, and two measures of patient-surgeon communication.

RESULTS

We found variation in women's actual decisional involvement and match between actual and preferred involvement. Women with a surgeon-based or patient-based (versus shared) decision were significantly (p < or = 0.05) younger. Women who had too little decisional involvement (versus the right amount) were younger, while women with too much involvement had less education. Patient-surgeon communication variables were significantly associated with both involvement and match, and higher surgeon volume as associated with too little involvement.

CONCLUSION

Patient factors and patient-surgeon communication influence women's perception of their involvement in breast cancer surgical treatment decision making.

PRACTICE IMPLICATIONS

Decision tools are needed across surgeons and practice settings to elicit patients' preferences for involvement in treatment decisions for breast cancer.

Clinical decision-making: Patients' preferences and experiences

OBJECTIVE

To determine the congruence between patients' preferred style of clinical decision-making and the style they usually experienced and whether this congruence was associated with socio-economic status and/or the perceived quality of care provided by the respondent's regular doctor.

METHODS

Cross-sectional survey of the American public using computer-assisted telephone interviewing.

RESULTS

Three thousand two hundred and nine interviews were completed (completion rate 72%). Sixty-two percent of respondents preferred shared decision-making, 28% preferred consumerism and 9% preferred paternalism. Seventy percent experienced their preferred style of clinical decision-making. Experiencing the preferred style was associated with high income (OR, 1.59; 95% CI, 1.16-2.16) and having a regular doctor who was perceived as providing excellent or very good care (OR, 2.39; 95% CI, 1.83-3.11).

CONCLUSION

Both socio-economic status and having a regular doctor whom the respondent rated highly are independently associated with patients experiencing their preferred style of clinical decision-making.

PRACTICE IMPLICATIONS

Systems which promote continuity of care and the development of an on-going doctor-patient relationship may promote equity in health care, by helping patients experience their preferred style of clinical decision-making.

End-of-Life Communication in Veterinary Medicine: Delivering Bad News and Euthanasia Decision Making

Given the expectations of clients and the resultant impact of end-of-life conversations on pet owners and the veterinary team, compassionate end-of-life communication is considered to be an ethical obligation, a core clinical skill, and integral to the success of a veterinary team. End-of-life communication is related to significant clinical outcomes, including enduring veterinarian-client-patient relationships and veterinarian and client satisfaction. Effective techniques for end-of-life communication can be taught and are a series of learned skills. The purpose of this article is to present best practices for delivering bad news and euthanasia decision-making discussions. In this article, the SPIKES six-step model (setting, perception, invitation, knowledge, empathize, and summarize) currently employed in medical curricula is utilized to structure end-of-life conversations in veterinary medicine.

Client-Veterinarian Communication: Skills for Client Centered Dialogue and Shared Decision Making

This article reviews three decision-making models for veterinary-client and physician-patient interactions and proposes adaptation of the 4E communication model from human medicine for application in veterinary-client interactions. These models incorporate specific communication skills for achieving the four components fo a client interview: engagement, empathy, education, and enlistment.

Relationship between English language use and preferences for involvement in medical care among Hispanic women

OBJECTIVE

To assess how English language use by Hispanic women affects their preferences for participating in decision making and information seeking regarding medical care.

METHODS

The study included 235 Hispanic women aged 35-61 years participating in a larger multicenter study, the Ethnicity, Needs, and Decisions of Women (ENDOW) Project. Participants were recruited from community settings and primary care public health clinics. Bilingual (English and Spanish speaking) interviewers asked participants questions about demographic characteristics, health status, reproductive history, menopausal status, access to healthcare, experience with hormone replacement therapy (HRT) and hysterectomy, outcome expectations about HRT and hysterectomy, medical decision making, and social support. Using univariate and multivariate analyses, we assessed the relationships between the participants' preferences for participating in decision making and information seeking, their language use, and other covariates of interest.

RESULTS

Overall, the participants expressed a strong desire for information about and participating in medical decisions. However, they expressed a lower preference for participating in decisions related to use of HRT compared with the desire for engaging in decision involving invasive medical procedures (hysterectomy and cholecystectomy) and high blood pressure management. Increased use of English language was significantly associated with preferences for participating in medical care decision making, in general (p < 0.001), and with information seeking (p = 0.044). Decreased use of English language was associated with a lower desire for participating in medical care decision making.

CONCLUSIONS

Increased use of English language may influence Hispanic women's preferences for participating in medical decisions and their information-seeking behavior.

Goal setting as a shared decision making strategy among clinicians and their older patients

OBJECTIVE

Older adults are less likely than other age groups to participate in clinical decision-making. To enhance participation, we sought to understand how older adults consider and discuss their life and health goals during the clinical encounter.

METHODS

We conducted six focus groups: four with community-dwelling older persons (n=42), one with geriatricians and internists (n=6), and one with rehabilitation nurses (n=5). Participants were asked to discuss: patients' life and health goals; communication about goals, and perception of agreement about health goals. Group interactions were tape-recorded, transcribed, and analyzed using content analysis.

RESULTS

All participants were willing to discuss goals, but varied in the degree to which they did so. Reasons for non-discussion included that goal setting was not a priority given limited time, visits focused on symptoms, mutual perception of disinterest, and the presumption that all patients' goals were the same.

CONCLUSION

Interventions to enhance goal setting need to address key barriers to promoting goals discussions. Participants recognized the benefits of goal setting, however, training and instruments are needed to integrate goal setting into medicine.

PRACTICE IMPLICATIONS

Setting goals initially and reviewing them periodically may be a comprehensive, time-efficient way of integrating patients' goals into their care plans.

Views of older adults on patient participation in medication-related decision making

BACKGROUND

Medication decision making is complex, particularly for older patients with multiple conditions for whom benefits may be uncertain and health priorities may be variable. While patient input would seem important in the face of this uncertainty and variability, little is known about older patients' views of involvement in medication decision making.

OBJECTIVE

To explore the views of older adults regarding participation in medication decision making.

DESIGN

Qualitative study.

PARTICIPANTS

Fifty-one persons at least 65 years old who consumed at least one medication were recruited from 3 senior centers and 4 physicians' offices.

APPROACH

One-on-one interviews were conducted to uncover participants' perceptions of medication-related decision making through semistructured, open-ended questions. Themes were compared according to the constant comparative method of analysis.

RESULTS

The predominant theme that emerged was the variability in perceptions concerning whether it was possible or desirable for patients to participate in prescribing decisions. For some participants, involvement was limited to sharing information. Physician and system factors that were felt to facilitate or impede patient participation included communication skills, the expanding number of medications available, multiple physicians prescribing for the same patient, and a focus on treating numbers. Perceived lack of knowledge, low self-efficacy, and fear were the patient factors mentioned. Both the presence and absence of trust in the prescribing physician were seen as alternatively impeding and enhancing patient participation. Only 1 participant explicitly mentioned patient preference, a cornerstone of shared decision making.

CONCLUSIONS

While evolution to greater patient involvement in medication decision making may be possible, and desirable to some older patients, findings suggest that the transition will be challenging.

Testing a model of symptoms, communication, uncertainty, and well-being, in older breast cancer survivors

Among older, long-term breast cancer survivors, symptoms from previous treatment can generate uncertainty about whether they represent co-morbid conditions, recurrence, or normal aging. This uncertainty can result in emotional distress and thoughts of recurrence. Communication with health care providers may help women reduce uncertainty and improve both emotional and cognitive well-being. To assess the influence of symptoms, uncertainty, and communication with providers on well-being, data from 203 Caucasian and African American survivors, 5-9 years post treatment, were tested using structural equation modeling. Symptoms, age, and uncertainty had the strongest influence on well-being, regardless of race. There was an unexpected positive association between patient-provider communication and thoughts of recurrence. Descriptive analysis revealed that 52% of women were unable to achieve their desired decision-making role with health care providers.

Rethinking informed consent: the case for shared medical decision-making

In law, with rare exception such as legislative action, change is evolutionary and methodical. Unlike biomedical science where a breakthrough can quickly lead to dramatic changes in medical practice, legal precedent is more adherent and must evolve either through the legislative process or on a court by court basis in case law. Nevertheless, compelling evidence will pave the road to change within the law. Health care research conducted over the last three decades has produced a body of empirical evidence that suggests an overhaul of our current legal standards of informed consent is overdue.

This article uses health services research to examine the fundamental assumptions of our current informed consent laws and propose legal reform. Much has been written on how to bring the law to bear on medical practice in order to improve patient rights and protect physicians, but far less has been done to bring the practice of medicine to inform our legal standards. Prior legal scholarship on informed consent has made arguments regarding reform from both ethical and legal perspectives; however, only a small few have incorporated clinical and health services research as well as ethical and legal principles to analyze informed consent.

How do elderly patients decide where to go for major surgery? Telephone interview survey

OBJECTIVE

To learn how patients in Medicare, the US medical insurance programme that covers elderly patients, made decisions about where to undergo major surgery and how they would make future decisions.

DESIGN

National telephone interview study.

SETTING

United States.

PARTICIPANTS

510 randomly selected Medicare beneficiaries who had undergone an elective, high risk procedure about 3 years earlier--abdominal aneurysm repair (n = 103), heart valve replacement surgery (n = 96), or resection of the bladder (n = 119), lung (n = 128), or stomach (n = 64) for cancer. Response rates were 48% among eligible survivors and 68% among those able to participate.

RESULTS

Although all participants could choose where to have surgery, only 55% said there was an alternative hospital in their area where they could have gone. Overall, only 10% of respondents seriously considered going elsewhere for surgery. Few respondents (11%) looked for information to compare hospitals. Almost all respondents thought their hospital and surgeon had good reputations (94% and 88%, respectively), beliefs mostly determined by what their referring doctors said. When asked how much various factors would influence their advice to a friend about choosing where to go for major surgery, surgeon reputation was the most influential (78% said it would influence their advice "a lot"), followed by the hospital having "nationally recognised" surgeons (63%), and then various performance data (surgeon volume (58%), nurse:patient ratios (49%), number of operations carried out by the hospital (48%), and hospital operative mortality (45%)). Forty per cent said they would act on mortality data, indicating that they would switch from their initial choice of hospital to a different one if its mortality was a percentage point lower (that is, 3% v 4%).

CONCLUSION

Some respondents claimed they would switch hospital for elective surgery on the basis of mortality data. Since most respondents relied on their referring physician's opinion to decide where to have surgery, surgical performance data ought to be accessible to referring physicians.