Physician as partner or salesman? Shared decision-making in real-time encounters

When Decisions Should Be Shared

Background. Shared decision making (SDM) is often advocated as an ideal for making medical decisions. Until now, however, opinions regarding which treatment situations warrant SDM have not been systematically investigated. The purpose of this study was to examine social norms regarding medical decision making, using a factorial survey design. Methods. The factorial survey applied in this study consisted of 7 situational factors (e.g., the reason for consultation), each with 2 to 3 levels (e.g., prevention and severe disease). These factors were turned into various descriptions of treatment situations. A total of 101 physicians, 115 patients, and 113 members of self-help groups participated in the study. Each participant assessed 10 vignettes using a 5-point scale to indicate who they thought should make the decision in each specific situation. Results. Most assessments across the 3 groups called for a shared decision (39%). Ordered logistic regression analysis demonstrated that, according to study participants, all 7 situational factors (reason for consultation, time frame of negative outcomes, time pressure, number of therapeutic options, side effects, scientific evidence of efficacy, and desire to participate) significantly affected how decisions regarding treatment should be made. The strongest factor was the patient’s desire to participate in decision making (odds ratio = 1.84; P ≤ 0.001), followed by the reason for consultation (odds ratio = 0.69; P ≤ 0.001). Conclusions. This study reveals that there is a general desire for SDM in a variety of treatment situations. Furthermore, based on the responses of our participants, our findings also lay the framework in determining which treatment situations warrant SDM.

Partnership-based practice with young people: relational dimensions of partnership in a therapeutic setting

The recent literature concerning partnership between professionals and young people reveals important developments regarding the nature of partnership: from short-term partnerships with young people's parents intended to improve decision-making in the context of critical life decisions, to a growing interest in direct partnership between professionals and young people as a core principle of long-term relationships. Although it is widely acknowledged among health and social service professionals that partnerships can have positive outcomes for young people, the concept and implementation of partnership remain vague. This article examines the meanings of partnership for people involved in a community youth centre for marginalised youth. Data were collected during the year 2011 using multiple-methods including focus groups (with eight youth workers), participant observations (in assembly meetings and 'partnership meetings') and semi-structured interviews (with 10 principal stakeholders, including youth, youth workers and the Center's founders). Data were analysed using principles of grounded theory to articulate partnership as an ongoing experience, combining both structural-technical and content-experiential components. Our findings present partnership as existing simultaneously in the practice of decision-making and in the realm of self-experience and interpersonal relationships, and explore the relationship between both spheres. The findings also shed light on the importance of the specific characteristics of shared decision-making (atmosphere, content and duration) in the creation of partnership. We discuss our findings in the light of possibilities for partnership-based practice with marginalised youth.

Use of implicit persuasion in decision making about adjuvant cancer treatment: A potential barrier to shared decision making

BACKGROUND

Shared decision making (SDM) is widely advocated, especially for preference-sensitive decisions like those on adjuvant treatment for early-stage cancer. Here, decision making involves a subjective trade-off between benefits and side-effects, and therefore, patients' informed preferences should be taken into account. If clinicians consciously or unconsciously steer patients towards the option they think is in their patients' best interest (i.e. implicit persuasion), they may be unwittingly subverting their own efforts to implement SDM. We assessed the frequency of use of implicit persuasion during consultations and whether the use of implicit persuasion was associated with expected treatment benefit and/or decision making.

METHODS

Observational study design in which consecutive consultations about adjuvant systemic therapy with stage I-II breast cancer patients treated at oncology outpatient clinics of general teaching hospitals and university medical centres were audiotaped, transcribed and coded by two researchers independently.

RESULTS

In total, 105 patients (median age = 59; range: 35-87 years) were included. A median of five (range: 2-10) implicitly persuasive behaviours were employed per consultation. The number of behaviours used did not differ by disease stage (P = 0.07), but did differ by treatment option presented (P = 0.002) and nodal status (P = 0.01). About 50% of patients with stage I or node-negative disease were steered towards undergoing chemotherapy, whereas 96% of patients were steered towards undergoing endocrine therapy, irrespective of expected treatment benefit. Decisions were less often postponed if more implicit persuasion was used (P = 0.03).

INTERPRETATION

Oncologists frequently use implicit persuasion, steering patients towards the treatment option that they think is in their patients' best interest. Expected treatment benefit does not always seem to be the driving force behind implicit persuasion. Awareness of one's use of these steering behaviours during decision making is a first step to help overcome the performance gap between advocating and implementing SDM.

"It's Not Like You Need to Live 10 or 20 Years": Challenges to Patient-Centered Care in Gynecologic Oncologist-Patient Interactions

The literature suggests that the patient-perspective approach (i.e., eliciting and responding to patients' perspectives, including beliefs, preferences, values, and attitudes) to patient-centered care (PCC) is not a reliable predictor of positive outcomes; however, little is known about why the patient-perspective approach does not necessarily lead to positive outcomes. By using discourse analysis to examine 44 segments of oncologist-patient interactions, we found that providers' use of patient-perspective contextualization can affect the quality of care through (a) constructing the meanings of patient conditions, (b) controlling interpreting frames for patient conditions, and (c) manipulating patient preferences through strategic information sharing. We concluded that providers' use of patient-perspective contextualization is an insufficient indicator of PCC because these discursive strategies can be used to control and manipulate patient preferences and perspectives. At times, providers' patient-perspective contextualization can silence patients' voice and appear discriminatory.

Does sharing the electronic health record in the consultation enhance patient involvement? A mixed-methods study using multichannel video recording and in-depth interviews in primary care

BACKGROUND

Sharing the electronic health-care record (EHR) during consultations has the potential to facilitate patient involvement in their health care, but research about this practice is limited.

METHODS

We used multichannel video recordings to identify examples and examine the practice of screen-sharing within 114 primary care consultations. A subset of 16 consultations was viewed by the general practitioner and/or patient in 26 reflexive interviews. Screen-sharing emerged as a significant theme and was explored further in seven additional patient interviews. Final analysis involved refining themes from interviews and observation of videos to understand how screen-sharing occurred, and its significance to patients and professionals.

RESULTS

Eighteen (16%) of 114 videoed consultations involved instances of screen-sharing. Screen-sharing occurred in six of the subset of 16 consultations with interviews and was a significant theme in 19 of 26 interviews. The screen was shared in three ways: 'convincing' the patient of a diagnosis or treatment; 'translating' between medical and lay understandings of disease/medication; and by patients 'verifying' the accuracy of the EHR. However, patients and most GPs perceived the screen as the doctor's domain, not to be routinely viewed by the patient.

CONCLUSIONS

Screen-sharing can facilitate patient involvement in the consultation, depending on the way in which sharing comes about, but the perception that the record belongs to the doctor is a barrier. To exploit the potential of sharing the screen to promote patient involvement, there is a need to reconceptualise and redesign the EHR.

Challenges, solutions and future directions in the evaluation of service innovations in health care and public health

Evaluating service innovations in health care and public health requires flexibility, collaboration and pragmatism; this collection identifies robust, innovative and mixed methods to inform such evaluations.

Shared Decision-Making in Oncology - A Qualitative Analysis of Healthcare Providers' Views on Current Practice

BACKGROUND

Despite an increased awareness of shared decision-making (SDM) and its prominent position on the health policy agenda, its implementation in routine care remains a challenge in Germany. In order to overcome this challenge, it is important to understand healthcare providers' views regarding SDM and to take their perspectives and opinions into account in the development of an implementation program. The present study aimed at exploring a) the attitudes of different healthcare providers regarding SDM in oncology and b) their experiences with treatment decisions in daily practice.

MATERIAL AND METHODS

A qualitative study was conducted using focus groups and individual interviews with different healthcare providers at the University Cancer Center Hamburg, Germany. Focus groups and interviews were audio-recorded, transcribed and analyzed using conventional content analysis and descriptive statistics.

RESULTS

N = 4 focus groups with a total of N = 25 participants and N = 17 individual interviews were conducted. Attitudes regarding SDM varied greatly between the different participants, especially concerning the definition of SDM, the attitude towards the degree of patient involvement in decision-making and assumptions about when SDM should take place. Experiences on how treatment decisions are currently made varied. Negative experiences included time and structural constraints, and a lack of (multidisciplinary) communication. Positive experiences comprised informed patients, involvement of relatives and a good physician-patient relationship.

CONCLUSION

The results show that German healthcare providers in oncology have a range of attitudes that currently function as barriers towards the implementation of SDM. Also, their experiences on how decision-making is currently done reveal difficulties in actively involving patients in decision-making processes. It will be crucial to take these attitudes and experiences seriously and to subsequently disentangle existing misconceptions in future implementation programs.

Advice, authority and autonomy in shared decision-making in antenatal screening: the importance of context

Shared decision-making (SDM) has been widely advocated across many branches of healthcare, yet there is considerable debate over both its practical application and how it should be examined or assessed. More recent discussions of SDM have highlighted the important of context, both internal and external to the consultation, with a recognition that decisions cannot be understood in isolation. This paper uses conversation analysis (CA) to examine how decision-making is enacted in the context of antenatal screening consultations in Hong Kong. Building on previous CA work (Collins et al. , Toerien et al. 2013), we show that, whilst previously identified formats are used here to present the need for a decision, the overriding basis professionals suggest for actually making a decision in this context is the level of worry or concern a pregnant woman holds about potential foetal abnormality. Professionals take an unknowing 'epistemic stance' (Heritage ) towards this worry, and hence step back from involvement in decision-making. We argue that this is linked to the non-directive ethos that prevails in antenatal screening services, and suggest that more research is needed to understand how the enactment of SDM is affected by wider professional contexts and parameters.

Using Option Grids: steps toward shared decision-making for neonatal circumcision

OBJECTIVES

To assess the impact, acceptability and feasibility of a short encounter tool designed to enhance the process of shared decision-making and parental engagement.

METHODS

We analyzed video-recordings of clinical encounters, half undertaken before and half after a brief intervention that trained four clinicians how to use Option Grids, using an observer-based measure of shared decision-making. We also analyzed semi-structured interviews conducted with the clinicians four weeks after their exposure to the intervention.

RESULTS

Observer OPTION(5) scores were higher at post-intervention, with a mean of 33.9 (SD=23.5) compared to a mean of 16.1 (SD=7.1) for pre-intervention, a significant difference of 17.8 (95% CI: 2.4, 33.2). Prior to using the intervention, clinicians used a consent document to frame circumcision as a default practice. Encounters with the Option Grid conferred agency to both parents and clinicians, and facilitated shared decision-making. Clinician reported recognizing the tool's positive effect on their communication process.

CONCLUSIONS

Tools such as Option Grids have the potential to make it easier for clinicians to achieve shared decision-making.

PRACTICE IMPLICATIONS

Encounter tools have the potential to change practice. More research is needed to test their feasibility in routine practice.

Clinical decision making and outcome in the routine care of people with severe mental illness across Europe (CEDAR)

AIMS

Shared decision making has been advocated as a means to improve patient-orientation and quality of health care. There is a lack of knowledge on clinical decision making and its relation to outcome in the routine treatment of people with severe mental illness. This study examined preferred and experienced clinical decision making from the perspectives of patients and staff, and how these affect treatment outcome.

METHODS

"Clinical Decision Making and Outcome in Routine Care for People with Severe Mental Illness" (CEDAR; ISRCTN75841675) is a naturalistic prospective observational study with bimonthly assessments during a 12-month observation period. Between November 2009 and December 2010, adults with severe mental illness were consecutively recruited from caseloads of community mental health services at the six study sites (Ulm, Germany; London, UK; Naples, Italy; Debrecen, Hungary; Aalborg, Denmark; and Zurich, Switzerland). Clinical decision making was assessed using two instruments which both have parallel patient and staff versions: (a) The Clinical Decision Making Style Scale (CDMS) measured preferences for decision making at baseline; and (b) the Clinical Decision Making Involvement and Satisfaction Scale (CDIS) measured involvement and satisfaction with a specific decision at all time points. Primary outcome was patient-rated unmet needs measured with the Camberwell Assessment of Need Short Appraisal Schedule (CANSAS). Mixed-effects multinomial regression was used to examine differences and course over time in involvement in and satisfaction with actual decision making. The effect of clinical decision making on the primary outcome was examined using hierarchical linear modelling controlling for covariates (study centre, patient age, duration of illness, and diagnosis). Analysis were also controlled for nesting of patients within staff.

RESULTS

Of 708 individuals approached, 588 adults with severe mental illness (52% female, mean age = 41.7) gave informed consent. Paired staff participants (N = 213) were 61.8% female and 46.0 years old on average. Shared decision making was preferred by patients (χ 2 = 135.08; p < 0.001) and staff (χ 2 = 368.17; p < 0.001). Decision making style of staff significantly affected unmet needs over time, with unmet needs decreasing more in patients whose clinicians preferred active to passive (-0.406 unmet needs per two months, p = 0.007) or shared (-0.303 unmet needs per two months, p = 0.015) decision making.

CONCLUSIONS

Decision making style of staff is a prime candidate for the development of targeted intervention. If proven effective in future trials, this would pave the ground for a shift from shared to active involvement of patients including changes to professional socialization through training in principles of active decision making.

Outcome-Relevant Effects of Shared Decision Making

BACKGROUND

Shared decision making (SDM) is considered a gold standard for the cooperation of doctor and patient. SDM improves patients' overall satisfaction and their confidence in decisions that have been taken. The extent to which it might also positively affect patient-relevant, disease-related endpoints is a matter of debate.

METHODS

We systematically searched the PubMed database and the Cochrane Library for publications on controlled intervention studies of SDM. The quality of the intervention and the risk of bias in each publication were assessed on the basis of pre-defined inclusion and exclusion criteria. The effects of SDM on patient-relevant, disease-related endpoints were compared, and effect sizes were calculated.

RESULTS

We identified 22 trials that differed widely regarding the patient populations studied, the types of intervention performed, and the mode of implementation of SDM. In ten articles, 57% of the endpoints that were considered relevant were significantly improved by the SDM intervention compared to the control group. The median effect size (Cohen's d) was 0.53 (0.14-1.49). In 12 trials, outcomes did not differ between the two groups. In all 22 studies identified, 39% of the relevant outcomes were significantly improved compared with the control groups.

CONCLUSION

The trials performed to date to addressing the effect of SDM on patient-relevant, disease-related endpoints are insufficient in both quantity and quality. Although just under half of the trials reviewed here indicated a positive effect, no final conclusion can be drawn. A consensus-based standardization of both SDM-promoting measures and appropriate clinical studies are needed.

Shared decision making: Concepts, evidence, and practice

OBJECTIVE

Shared decision-making (SDM) is advocated as the model for decision-making in preference-sensitive decisions. In this paper we sketch the history of the concept of SDM, evidence on the occurrence of the steps in daily practice, and provide a clinical audience with communication strategies to support the steps involved. Finally, we discuss ways to improve the implementation of SDM.

RESULTS

The plea for SDM originated almost simultaneously in medical ethics and health services research. Four steps can be distinguished: (1) the professional informs the patient that a decision is to be made and that the patient's opinion is important; (2) the professional explains the options and their pros and cons; (3) the professional and the patient discuss the patient's preferences and the professional supports the patient in deliberation; (4) the professional and patient discuss the patient's wish to make the decision, they make or defer the decision, and discuss follow-up. In practice these steps are seen to occur to a limited extent.

DISCUSSION

Knowledge and awareness among both professionals and patients as well as tools and skills training are needed for SDM to become widely implemented.

PRACTICE IMPLICATIONS

Professionals may use the steps and accompanying communication strategies to implement SDM.

Challenges of implementing collaborative models of decision making with trans-identified patients

BACKGROUND

Factors health providers face during the doctor-patient encounter both impede and assist the development of collaborative models of treatment.

OBJECTIVE

I investigated decision making among medical and therapeutic professionals who work with trans-identified patients to understand factors that might impede or facilitate the adoption of the collaborative decision-making model in their clinical work.

DESIGN

Following a grounded theory approach, I collected and analysed data from semi-structured interviews with 10 U.S. physicians and 10 U.S. mental health professionals.

RESULTS

Doctors and therapists often desire collaboration with their patients but experience dilemmas in treating the trans-identified patients. Dilemmas include lack of formal education, little to no institutional support and inconsistent understanding and application of the main documents used by professionals treating trans-patients.

CONCLUSIONS

Providers face considerable risk in providing unconventional treatments due to the lack of institutional and academic support relating to the treatment for trans-people, and the varied interpretation and application of the diagnostic and treatment documents used in treating trans-people. To address this risk, the relationship with the patient becomes crucial. However, trust, a component required for collaboration, is thwarted when the patients feel obliged to present in ways aligned with these documents in order to receive desired treatments. When trust cannot be established, medical and mental health providers can and do delay or deny treatments, resulting in the imbalance of power between patient and provider. The documents created to assist in treatment actually thwart professional desire to work collaboratively with patients.

Probabilities of benefit and harms of preoperative radiotherapy for rectal cancer: What do radiation oncologists tell and what do patients understand?

OBJECTIVE

Probabilities of benefits and harms of treatment may help patients when making a treatment decision. This study aimed to examine (1) whether and how radiation oncologists convey probabilities to rectal cancer patients, and (2) patients' estimates of probabilities of major outcomes of rectal cancer treatment.

METHODS

First consultations of oncologists and patients eligible for preoperative radiotherapy (PRT) (N=90) were audio taped. Tapes were transcribed verbatim and coded to identify probabilistic information presented. Patients (N=56) filled in a post-consultation questionnaire on their estimates of probabilities.

RESULTS

Probabilities were mentioned in 99% (local recurrence), 75% (incontinence), 72% and 40% (sexual dysfunction in males and females, respectively) of cases. Most patients (89%) correctly estimated that PRT decreases the probability of local recurrence, and 10% and 38%/54% that it increases the probability of incontinence and sexual dysfunction in males/females, respectively. Patients tended to underestimate the probabilities of harms of treatment.

CONCLUSION

Our results show that oncologists almost always mention probabilities of benefit of PRT. In contrast, probabilities of harms often go unmentioned. The effect of PRT on adverse events is often underestimated.

PRACTICE IMPLICATIONS

Oncologists should stay alert to patients' possible misunderstanding of probabilistic information and should check patients' perceptions of probabilities.

Evolution of Pediatric Chronic Disease Treatment Decisions: A Qualitative, Longitudinal View of Parents' Decision-Making Process

BACKGROUND

In the context of pediatric chronic conditions, patients and families are called upon repeatedly to make treatment decisions. However, little is known about how their decision making evolves over time. The objective was to understand parents' processes for treatment decision making in pediatric chronic conditions.

METHODS

We conducted a qualitative, prospective longitudinal study using recorded clinic visits and individual interviews. After consent was obtained from health care providers, parents, and patients, clinic visits during which treatment decisions were expected to be discussed were video-recorded. Parents then participated in sequential telephone interviews about their decision-making experience. Data were coded by 2 people and analyzed using framework analysis with sequential, time-ordered matrices.

RESULTS

21 families, including 29 parents, participated in video-recording and interviews. We found 3 dominant patterns of decision evolution. Each consisted of a series of decision events, including conversations, disease flares, and researching of treatment options. Within all 3 patterns there were both constant and evolving elements of decision making, such as role perceptions and treatment expectations, respectively. After parents made a treatment decision, they immediately turned to the next decision related to the chronic condition, creating an iterative cycle.

CONCLUSION

In this study, decision making was an iterative process occurring in 3 distinct patterns. Understanding these patterns and the varying elements of parents' decision processes is an essential step toward developing interventions that are appropriate to the setting and that capitalize on the skills families may develop as they gain experience with a chronic condition. Future research should also consider the role of children and adolescents in this decision process.

Delivering patient choice in clinical practice: a conversation analytic study of communication practices used in neurology clinics to involve patients in decision-making

Background

The NHS is committed to offering patients more choice. Yet even within the NHS, the meaning of patient choice ranges from legal ‘rights to choose’ to the ambition of establishing clinical practice as a ‘partnership’ between doctor and patient. In the absence of detailed guidance, we focused on preciselyhowto engage patients in decision-making.

Objectives

To contribute to the evidence-base about whether or not, and how, patient choice is implemented to identify the most effective communication practices for facilitating patient choice.

Design

We used conversation analysis to examine practices whereby neurologists offer choice. The main data set consists of audio- and video-recorded consultations. Patients completed pre- and post-consultation questionnaires and neurologists completed the latter.

Setting and participants

The study was conducted in neurology outpatient clinics in Glasgow and Sheffield. Fourteen neurologists, 223 patients and 120 accompanying others took part.

Results

Patients and clinicians agreed that choice had featured in 53.6% of consultations and that choice was absent in 14.3%. After 32.1% of consultations,eitherpatientorneurologist thought choice was offered. The presence or absence of choice was not satisfactorily explained by quantitatively explored clinical or demographic variables. For our qualitative analysis, the corpus was divided into four subsets: (1) patient and clinician agree that choice was present; (2) patient and clinician agree that choice was absent; (3) patient ‘yes’, clinician ‘no’; and (4) patient ‘no’, clinician ‘yes’. Comparison of all subsets showed that ‘option-listing’ was the only practice for offering choice that was presentonly(with one exception, which, as we show, proves the rule) in those consultations for which participantsagreed there was a choice. We show how option-listing can be used to engage patients in decision-making, but also how very small changes in the machinery of option-listing [for instance the replacement or displacement of the final component of this practice, the patient view elicitor (PVE)] can significantly alter the slot for patient participation. In fact, a slightly modified form of option-listing can be used to curtail choice. Finally, we describe two forms of PVE that can be used to hand a single-option decision to the patient, but which, we show, can raise difficulties for patient choice.

Conclusions

Choice features in the majority of recorded consultations. If doctors want to ensure a patient knows she or he has a choice, option-listing is likely to be best understood by patients as an invitation to choose. However, an important lesson from this study is that simply asking doctors to adopt a practice (like option-listing) will not automatically lead to a patient-centred approach. Our study shows that preciselyhowa practice is implemented is crucial.

Future research

Future research should investigate (1) links between the practices identified here and relevant outcome measures (like adherence); (2) whether being given a choice is better or worse for patients than receiving a doctor’s recommendation, taking account of clinical and demographic factors; and (3) how our approach could be fruitfully applied in other settings.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Ethics and shared decision-making in paediatric occupational therapy practice

BACKGROUND

Sharing information and decisions with children and their parents is critical in pediatric rehabilitation. Although the ethical significance and clinical benefits of sharing decisions are established, approaches for implementing shared decision-making in clinical practice are still developing.

AIM

To explore the ethical challenges of sharing information and decisions with one family in pediatric occupational therapy.

METHOD

We used a single qualitative in-depth interview with an occupational therapist to examine the ethical dimensions of sharing decisions.

RESULTS

We found that asking what was ethically at stake in the information-sharing process, highlighted how timing and style of information sharing impacts on understanding and collaboration within the therapeutic relationship. Using ethics-based questions assisted in drawing out the complexity of implementing the ideals of sharing information and decisions in pediatric practice.

CONCLUSION

Reflecting on ethical dimensions of communication with families assists to identify approaches to shared decision-making in clinical practice.

The development and evaluation of a five-language multi-perspective standardised measure: clinical decision-making involvement and satisfaction (CDIS)

BACKGROUND

The aim of this study was to develop and evaluate a brief quantitative five-language measure of involvement and satisfaction in clinical decision-making (CDIS) - with versions for patients (CDIS-P) and staff (CDIS-S) - for use in mental health services.

METHODS

An English CDIS was developed by reviewing existing measures, focus groups, semistructured interviews and piloting. Translations into Danish, German, Hungarian and Italian followed the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Task Force principles of good practice for translation and cultural adaptation. Psychometricevaluation involved testing the measure in secondary mental health services in Aalborg, Debrecen, London, Naples, Ulm and Zurich.

RESULTS

After appraising 14 measures, the Control Preference Scale and Satisfaction With Decision-making English-language scales were modified and evaluated in interviews (n = 9), focus groups (n = 22) and piloting (n = 16). Translations were validated through focus groups (n = 38) and piloting (n = 61). A total of 443 service users and 403 paired staff completed CDIS. The Satisfaction sub-scale had internal consistency of 0.89 (0.86-0.89 after item-level deletion) for staff and 0.90 (0.87-0.90) for service users, both continuous and categorical (utility) versions were associated with symptomatology and both staff-rated and service userrated therapeutic alliance (showing convergent validity), and not with social disability (showing divergent validity), and satisfaction predicted staff-rated (OR 2.43, 95%CI 1.54- 3.83 continuous, OR 5.77, 95%CI 1.90-17.53 utility) and service user-rated (OR 2.21, 95%CI 1.51-3.23 continuous, OR 3.13, 95%CI 1.10-8.94 utility) decision implementation two months later. The Involvement sub-scale had appropriate distribution and no floor or ceiling effects, was associated with stage of recovery, functioning and quality of life (staff only) (showing convergent validity), and not with symptomatology or social disability (showing divergent validity), and staff-rated passive involvement by the service user predicted implementation (OR 3.55, 95%CI 1.53-8.24). Relationships remained after adjusting for clustering by staff.

CONCLUSIONS

CDIS demonstrates adequate internal consistency, no evidence of item redundancy, appropriate distribution, and face, content, convergent, divergent and predictive validity. It can be recommended for research and clinical use. CDIS-P and CDIS-S in all 3 five languages can be downloaded at http://www.cedar-net.eu/instruments.

TRIAL REGISTRATION

ISRCTN75841675.

The role of medical schools in promoting social accountability through shared decision-making

Reducing health inequalities and enhancing the social accountability of medical students and physicians is a challenge acknowledged by medical educators and professionals. It is usually perceived as a macro-level, community type intervention. This commentary suggests a different approach, an interpersonal way to decrease inequality and asymmetry in power relations to improve medical decisions and care. Shared decision-making practices are suggested as a model that requires building partnership, bi-directional sharing of information, empowering patients and enhancing tailored health care decisions. To increase the implementation of shared decision-making practices in Israel, an official policy needs to be established to encourage the investment of resources towards helping educators, researchers, and practitioners translate and integrate it into daily practice. Special efforts should be invested in medical education initiatives to train medical students and residents in SDM practices.

Shared decision-making in medical encounters regarding breast cancer treatment: the contribution of methodological triangulation

The aim of this study on shared decision-making in the doctor-patient encounter about surgical treatment for early-stage breast cancer, conducted in a regional cancer centre in France, was to further the understanding of patient perceptions on shared decision-making. The study used methodological triangulation to collect data (both quantitative and qualitative) about patient preferences in the context of a clinical consultation in which surgeons followed a shared decision-making protocol. Data were analysed from a multi-disciplinary research perspective (social psychology and health economics). The triangulated data collection methods were questionnaires (n = 132), longitudinal interviews (n = 47) and observations of consultations (n = 26). Methodological triangulation revealed levels of divergence and complementarity between qualitative and quantitative results that suggest new perspectives on the three inter-related notions of decision-making, participation and information. Patients' responses revealed important differences between shared decision-making and participation per se. The authors note that subjecting patients to a normative behavioural model of shared decision-making in an era when paradigms of medical authority are shifting may undermine the patient's quest for what he or she believes is a more important right: a guarantee of the best care available.

Real life clinic visits do not match the ideals of shared decision making

OBJECTIVE

To use observation to understand how decisions about higher-risk treatments, such as biologics, are made in pediatric chronic conditions.

METHODS

Gastroenterology and rheumatology providers who prescribe biologics were recruited. Families were recruited when they had an outpatient appointment in which treatment with biologics was likely to be discussed. Consent/assent was obtained to video the visit. Audio of the visits in which a discussion of biologics took place were transcribed and analyzed. Our coding structure was based on prior research, shared decision making (SDM) concepts, and the initial recorded visits. Coded data were analyzed using content analysis and comparison with an existing model of SDM.

RESULTS

We recorded 21 visits that included discussions of biologics. In most visits, providers initiated the decision-making discussion. Detailed information was typically given about the provider's preferred option with less information about other options. There was minimal elicitation of preferences, treatment goals, or prior knowledge. Few parents or patients spontaneously stated their preferences or concerns. An implicit or explicit treatment recommendation was given in nearly all visits, although rarely requested. In approximately one-third of the visits, the treatment decision was never made explicit, yet steps were taken to implement the provider's preferred treatment.

CONCLUSIONS

We observed limited use of SDM, despite previous research indicating that parents wish to collaborate in decision making. To better achieve SDM in chronic conditions, providers and families need to strive for bidirectional sharing of information and an explicit family role in decision making.

Preoperative risk information and patient involvement in surgical treatment for rectal and sigmoid cancer

AIM

Surgery for rectal and sigmoid cancer is a model setting for investigating preoperative information provision and shared decision making (SDM), as the decision consists of a trade-off between the pros and cons of different treatment options. The aim of this study was to explore surgeons' opinion on the preoperative information that should be given to rectal and sigmoid cancer patients and to evaluate what is actually communicated. In addition, we assessed surgeons' attitudes towards SDM and compared these with patient involvement.

METHOD

A questionnaire was sent to Dutch surgeons with an interest in gastroenterology. Preoperative consultations were recorded. A checklist was used to code the information that surgeons communicated to the patients. The OPTION-scale was used to measure patient involvement.

RESULTS

Questionnaires were sent to 240 surgeons, and 103 (43%) responded. They stated that information on anastomotic leakage and its consequences, the benefits and risks of a defunctioning stoma and the impact of a stoma on quality of life were necessary preoperative information. In practice, patients were inconsistently informed of these items. Most participants agreed to using SDM in their consultations. However, in practice, most patients were offered only one treatment option and little SDM was seen. The mean OPTION-score was low (7/100).

CONCLUSION

Insufficient information is given to patients with rectal and sigmoid cancer to guide them on their preferred surgical option. Information should be given on all treatment options, together with their complications and outcome, before any decision is made.

Shared decision making in palliative cancer care: a literature review

Background

Patients require information to make informed decisions and consent to medical treatment. Shared decision making (SDM) is a methodology that promotes a patient-centred approach to informed consent and demonstrates respect for autonomy

Purpose

The purpose of this paper is to critically review the legal and ethical issues relevant to Canadian and UK informed consent and SDM practices and how these processes relate to current palliative care practices, with a particular emphasis on radiation therapy.

Methodology

A review of the English literature from 2003 to 2013 was performed using the databases PubMed (NML), OVID Medline and Google Scholar.

Results and Conclusions

The literature identifies that palliative cancer patients desire the opportunity to be involved with decision-making discussions, which has shown to increase knowledge and result in better health-related outcomes. However, ethical and legal issues regarding the practicality of including this patient population in SDM discussions raises questions about validity of consent. For SDM to be considered a valid methodology to obtain informed consent, open and honest communication between the patient and multidisciplinary team is essential. Treatment options for palliative cancer patients are often complex and SDM allows healthcare professionals and patients to exchange information and negotiate feasible treatment options based on medical expertise and patient preferences.

Legal frameworks have defined current standards of practice for various healthcare professions, including radiation therapy. Radiation therapists, as members of the multidisciplinary team, are currently key contributors in providing information to patients regarding the radiotherapy process. Individuals working within advanced practice roles have the ability to develop skills once considered to be within medical domains and have begun to incorporate the delegated act of obtaining informed consent into practice which has shown to increase professional autonomy, accountability and improves patient-centred care.

Models of physician-patient relationships in pharmaceutical direct-to-consumer advertising and consumer interviews

The rise of direct-to-consumer advertising (DTCA) has mirrored, if not facilitated, the shift toward more active health care consumers. We used content analysis to identify models of physician-patient interaction in DTCA from the 1997 to 2006 issues of a broad sample of women's, men's, and common readership magazines. We also conducted 36 in-depth interviews to examine the ways consumers receive and regard advertising messages, and to explore their preferences for clinical communication and decision making. We identified four models of physician-patient relationships that vary in their locus of control (physician, patient, or shared) and the form of support sought or obtained in the relationship (emotional or instrumental). Whereas consumer interviews reflected references to all four models of interaction, only two appeared in DTCA. The limited range of interactions seen in these advertisements creates a lack of congruity between interaction styles found in advertisements vs. styles reported by actual consumers.

How healthcare provider talk with parents of children following severe traumatic brain injury is perceived in early acute care

Healthcare provider talk with parents in early acute care following children's severe traumatic brain injury (TBI) affects parents' orientations to these locales, but this connection has been minimally studied. This lack of attention to this topic in previous research may reflect providers' and researchers' views that these locales are generally neutral or supportive to parents' subsequent needs. This secondary analysis used data from a larger descriptive phenomenological study (2005-2007) with parents of children following moderate to severe TBI recruited from across the United States. Parents of children with severe TBI consistently had strong negative responses to the early acute care talk processes they experienced with providers, while parents of children with moderate TBI did not. Transcript data were independently coded using discourse analysis in the framework of ethnography of speaking. The purpose was to understand the linguistic and paralinguistic talk factors parents used in their meta-communications that could give a preliminary understanding of their cultural expectations for early acute care talk in these settings. Final participants included 27 parents of children with severe TBI from 23 families. We found the human constructed talk factors that parents reacted to were: a) access to the child, which is where information was; b) regular discussions with key personnel; c) updated information that is explained; d) differing expectations for talk in this context; and, e) perceived parental involvement in decisions. We found that the organization and nature of providers' talk with parents was perceived by parents to positively or negatively shape their early acute care identities in these locales, which influenced how they viewed these locales as places that either supported them and decreased their workload or discounted them and increased their workload for getting what they needed.

Readability and content of patient education material related to implantable cardioverter defibrillators

BACKGROUND

Implantable cardioverter defibrillators (ICDs) are increasingly offered to patients for primary prevention of sudden cardiac death. Candidates for ICD receive ICD-related patient education material when they make decisions to consent or decline a primary prevention ICD. Printed patient education material directed at ICD candidates has not been the focus of direct appraisal.

OBJECTIVE

We evaluated the readability and content of ICD-related print education materials made available to patients who were enrolled in a study involving patient decision making for ICD from 3 ICD sites in southern Ontario, Canada.

METHODS

All ICD print materials referred to during interviews and/or that were available in ICD site waiting rooms were collected for analysis. Readability testing was conducted using the "simple measurement of gobbledygook" and Fry methods. The material was evaluated according to selected plain-language criteria, thematic content analysis, and rhetoric analysis.

RESULTS

Twenty-one print materials were identified and analyzed. Documents were authored by device manufacturers, tertiary care hospitals, and cardiac support organizations. Although many documents adhered to plain-language recommendations, text-reading levels were higher than recommended. Twelve major content themes were identified. Content focused heavily on the positive aspects of living with the device to the exclusion of other possible information that could be relevant to the decisions that patients made.

CONCLUSIONS

Print-based patient education materials for ICD candidates are geared to a highly literate population. The focus on positive information to the exclusion of potentially negative aspects of the ICD, or alternatives to accepting 1, could influence and/or confuse patients about the purpose and implications of this medical device. Development of print materials is indicated that includes information about possible problems and that would be relevant for the multicultural and debilitated population who may require ICDs. The findings are highly relevant for nurses who care for primary prevention ICD candidates.

Patients, providers, and systems need to acquire a specific set of competencies to achieve truly patient-centered care

Studies show that patients want to be more involved in their own health care. Yet insufficient attention has been paid to the specific competencies of both patients and providers that are needed to optimize such patient engagement and shared decision making. In this article we address the knowledge, skills, and attitudes that patients, physicians, and health care systems require to effectively engage patients in their health care. For example, many patient-physician interactions still follow the traditional office visit format, in which the patient is passive, trusting, and compliant. We recommend imaginative models for redesigned office care, restructured reimbursement schemes, and increased support services for patients and professionals. We present three clinical scenarios to illustrate how these competencies must work together. We conclude that effective shared decision making takes time to deliver proficiently and that among other measures, policy makers must change payment models to focus on value and support education and discussion of competencies for a modern health care system.

Exploring ethical aspects of elective surgery patients' decision-making experiences

The practice of respecting patients' autonomy is rooted in the healthcare professionals' empathy for patients' situations, without which appropriate supports to the patients during the informed consent process may be remarkably moderated. The purpose of this study was to explore elective surgery patients' experiences during their decision-making process. This research was conducted using a phenomenological approach, and the data analysis was guided by Colaizzi's method. A total of 17 participants were recruited from a hospital in southern Taiwan. Two major themes emerged from the analyses: (a) a voluntary yet necessary alternative--to undergo a surgery and (b) alternatives compelled by the unalterable decision--the surgery. It was concluded that unless healthcare professionals can empathize with the distressed situation of their patients who are facing elective surgery, the practice of informed consent may become merely a routine. Nurses can be the best advocates for patients and facilitators to enhance communication between patients and healthcare personnel.

Using Argumentation Theory to Identify the Challenges of Shared Decision-Making when the Doctor and the Patient have a Difference of Opinion

This paper aims to identify the challenges in the implementation of shared decision-making (SDM) when the doctor and the patient have a difference of opinion. It analyses the preconditions of the resolution of this difference of opinion by using an analytical and normative framework known in the field of argumentation theory as the ideal model of critical discussion. This analysis highlights the communication skills and attitudes that both doctors and patients must apply in a dispute resolution-oriented communication. Questions arise over the methods of empowerment of doctors and patients in these skills and attitudes as the preconditions of SDM. Overall, the paper highlights aspects in which research is needed to design appropriate programmes of training, education and support in order to equip doctors and patients with the means to successfully engage in shared decision-making.

Shared decision-making in Israel: status, barriers, and recommendations

Shared decision making (SDM) - involving patients in decisions relevant to their health - has been increasingly influential in medical thought and practice around the world. This paper reviews the current status of SDM in Israel, including efforts to promote SDM in the legislation and healthcare system, its influence in medical training and the national health plans, and funding for SDM-related research. Published studies of SDM in Israel are also reviewed. Although informed consent and patients' right to information are regulated by Israeli law, little provision is made for SDM. Further, there are few organized programs to promote SDM among medical professionals or the public, and governmental support of SDM-related research is minimal. Nonetheless, patients have begun to influence litigation in both formal and informal capacities, medical schools have begun to incorporate courses for improving physician-patient communication into their curricula, and the largest national health plan has initiated a plan to increase public awareness. A review of the limited research literature suggests that although patients and physicians express a desire for greater patient involvement, they often have reservations about its implementation. Research also suggests that despite the positive effects of SDM, such an approach may only infrequently be applied in actual clinical practice. In conclusion, though not actively promoting SDM at present, Israel's universal coverage and small number of health plans make rapid, widespread advances in SDM feasible. Israeli policymakers should thus be encouraged to nurture burgeoning initiatives and set plausible milestones. Comparing the status of SDM in Israel with that in other countries may stimulate further advancement.

How pressure is applied in shared decisions about antipsychotic medication: a conversation analytic study of psychiatric outpatient consultations

The professional identity of psychiatry depends on it being regarded as one amongst many medical specialties and sharing ideals of good practice with other specialties, an important marker of which is the achievement of shared decision-making and avoiding a reputation for being purely agents of social control. Yet the interactions involved in trying to achieve shared decision-making are relatively unexplored in psychiatry. This study analyses audiotapes of 92 outpatient consultations involving nine consultant psychiatrists focusing on how pressure is applied in shared decisions about antipsychotic medication. Detailed conversation analysis reveals that some shared decisions are considerably more pressured than others. At one end of a spectrum of pressure are pressured shared decisions, characterised by an escalating cycle of pressure and resistance from which it is difficult to exit without someone losing face. In the middle are directed decisions, where the patient cooperates with being diplomatically steered by the psychiatrist. At the other extreme are open decisions where the patient is allowed to decide, with the psychiatrist exerting little or no pressure. Directed and open decisions occurred most frequently; pressured decisions were rarer. Patient risk did not appear to influence the degree of pressure applied in these outpatient consultations.

Shared decision making or paternalism in nursing consultations? A qualitative study of primary care asthma nurses' views on sharing decisions with patients regarding inhaler device selection

BACKGROUND

Although patients with asthma would like more involvement in the decision-making process, and UK government policy concerning chronic conditions supports shared decision making, it is not widely used in practice.

OBJECTIVE

To investigate how nurses approach decision making in relation to inhaler choice and long-term inhaler use within a routine asthma consultation and to better understand the barriers and facilitators to shared decision making in practice.

SETTING AND PARTICIPANTS

Semi-structured interviews were conducted with post-registration, qualified nurses who routinely undertook asthma consultations and were registered on a respiratory course. Interviews were recorded, transcribed and analysed using the Framework approach.

RESULTS

Twenty participants were interviewed. Despite holding positive views about shared decision making, limited shared decision making was reported. Opportunities for patients to share decisions were only offered in relation to inhaler device, which were based on the nurse's pre-selected recommendations. Giving patients this 'choice' was seen as key to improving adherence.

DISCUSSION

There is a discrepancy between nurses' understanding of shared decision making and the depictions of shared decision making presented in the academic literature and NHS policy. In this study, shared decision making was used as a tool to support the nurses' agenda, rather than as a natural expression of equality between the nurse and patient.

CONCLUSION

There is a misalignment between the goals of practice nurses and the rhetoric regarding patient empowerment. Shared decision making may therefore only be embraced if it improves patient outcomes. This study indicates attitudinal shifts and improvements in knowledge of 'shared decision-making' are needed if policy dictates are to be realised.

Sharing qualitative research findings with participants: study experiences of methodological and ethical dilemmas

OBJECTIVE

Sharing qualitative research findings with participants, namely member-check, is perceived as a procedure designed to enhance study credibility and participant involvement. It is rarely used, however, and its methodological usefulness and ethical problems have been questioned. This article explores benefits and risks in applying member-check when studying healthcare topics, questioning the way it should be performed.

METHODS

We discuss researchers' experiences in applying member-check, using four examples from three different studies: healthcare-providers' experiences of working with sexual-abuse survivors; adolescents' exposure to domestic-violence, and delivering and receiving bad news.

RESULTS

Methodological and ethical difficulties can arise when performing member-check, challenging the day-to-day researcher-participant experience, and potentially, the physician-patient relationship.

CONCLUSION

Applying member-check in healthcare settings is complex. Although this strategy has good intentions, it is not necessarily the best method for achieving credibility. Harm can be caused to participants, researchers and the doctor-patient relationship, risking researchers' commitment to ethical principles.

PRACTICE IMPLICATIONS

Because participants' experience regarding member-check is difficult to predict, such a procedure should be undertaken cautiously. Prior to initiating member-check, researchers should ask themselves whether such a procedure is potentially risky for participants; and if anonymity cannot be guaranteed, use alternative procedures when needed.

Offering patients choices: a pilot study of interactions in the seizure clinic

Using conversation analysis (CA), we studied conversations between one United Kingdom-based epilepsy specialist and 13 patients with seizures in whom there was uncertainty about the diagnosis and for whom different treatment and investigational options were being considered. In line with recent communication guidance, the specialist offered some form of choice to all patients: in eight cases, a course of action was proposed, to be accepted or rejected, and in the remaining five, a "menu" of options was offered. Even when presenting a menu, the specialist sometimes conveyed his own preferences in how he described the options, and in some cases the menu was used for reasons other than offering choice (e.g., to address patient resistance). Close linguistic and interactional analysis of clinical encounters can show why doctors may feel they are offering choices when patients report that the decision was clinician dominated.

Inverting compliance, increasing concerns: aging, mental health, and caring for a trustful patient

Why, after 40 years of intensive research, is adherence to treatment still an issue? This paper suggests a possible solution to an apparently unsolvable problem: reconceptualizing adherence. To understand how adherence can affect key personnel in any western health system, this study focuses on community nurses working with older mental health patients in Quebec. When they spoke about adherence, nurses presented an idealized image of the nurse-patient relationship, namely, the caring nurse and the trustful patient. However, this idealization cannot be reduced only to questions of power and paternalism. By reconceptualizing adherence as a 'matter of concern', health professionals and researchers alike might come to understand individual care situations within a broader notion of conflicts in patient care.

Developing a framework to support shared decision making for youth mental health medication treatment

Medical shared decision making has demonstrated success in increasing collaboration between clients and practitioners for various health decisions. As the importance of a shared decision making approach becomes increasingly valued in the adult mental health arena, transfer of these ideals to youth and families of youth in the mental health system is a logical next step. A review of the literature and preliminary, formative feedback from families and staff at a Midwestern urban community mental health center guided the development of a framework for youth shared decision making. The framework includes three functional areas (1) setting the stage for youth shared decision making, (2) facilitating youth shared decision making, and (3) supporting youth shared decision making. While still in the formative stages, the value of a specific framework for a youth model in support of moving from a client-practitioner value system to a systematic, intentional process is evident.

The ethics of responsibility and ownership in decision-making about treatment for breast cancer: triangulation of consultation with patient and surgeon perspectives

Doctors are widely encouraged to share decision-making with patients. However, the assumption that responsibility for decisions is an objective quantity that can be apportioned between doctors and patients is problematic. We studied treatment decisions from three perspectives simultaneously - observing consultations and exploring patients' and doctors' perspectives on these - to understand how decision-making that we observed related to participants' subjective experience of responsibility. We audio-recorded post-operative consultations in which 20 patients who had undergone initial surgery for breast cancer discussed further treatment with one of eight surgeons in a general hospital serving a socioeconomically diverse urban population in England. We separately interviewed each patient and their surgeon within seven days of consultation to explore their perspectives on decisions that had been made. Qualitative analysis distinguished procedurally different types of decision-making and explored surgeons' and patients' perspectives on each. Surgeons made most decisions for patients, and only explicitly offered choices where treatment options were clinically equivocal. Procedurally, therefore, shared decision-making was absent and surgeons might be regarded as having neglected patients' autonomy. Nevertheless, patients generally felt ownership of decisions that surgeons made for them because surgeons provided justifying reasons and because patients knew that they could refuse. Conversely, faced with choice, patients generally lacked trust in their own decisions and usually sought surgeons' guidance. Therefore, from the perspective of ethical frameworks that conceptualise patient autonomy as relational and subjective, the surgeons were protecting patient autonomy. Studying subjective as well as procedural elements of decision-making can provide a broader perspective from which to evaluate practitioners' decision-making behaviour.

Pushing the envelope: shared decision making in mental health

TOPIC

This article reviews the literature on shared decision making in health and mental health and discusses tools in general health that are proposed for adaptation and use in mental health.

PURPOSE

To offer findings from literature and a product development process to help inform/guide those who wish to create or implement materials for shared decision making in mental health.

SOURCES USED

Published literature and research on issues related to shared decision making in health and mental health, focus groups, and product testing.

CONCLUSIONS

Structured shared decision making in mental health shows promise in supporting service user involvement in critical decision making and provides a process to open all treatment and service decisions to informed and respectful dialogue.