What is a good medical decision? A research agenda guided by perspectives from multiple stakeholders

Accuracy of Expected Symptoms and Subsequent Quality of Life Measures Among Adults With COPD

Importance

Patients' expectations for future health guide their decisions and enable them to prepare, adapt, and cope. However, little is known about how inaccurate expectations may affect patients' illness outcomes.

Objective

To assess the association between patients' expectation inaccuracies and health-related quality of life.

Design, Setting, and Participants

This cohort study of patients with severe chronic obstructive pulmonary disease (COPD) was conducted from 2017 to 2021, which included a 24-month follow-up period. Eligible participants received outpatient primary care at pulmonary clinics of a single large US health system. Data were analyzed between 2021 and 2023.

Exposure

Expectation accuracy, measured by comparing patients' self-reported expectations of their symptom burden with their actual physical and emotional symptoms 3, 12, and 24 months in the future.

Main Outcome and Measure

Health-related quality of life, measured by the St George's Respiratory Questionnaire-COPD at 3, 12, and 24 months.

Results

A total of 207 participants were included (median age, 65.5 years [range, 42.0-86.0 years]; 120 women [58.0%]; 118 Black [57.0%], 79 White [38.2%]). The consent rate among approached patients was 80.0%. Most patients reported no or only limited discussions of future health and symptom burdens with their clinicians. Across physical and emotional symptoms and all 3 time points, patients' expectations were more optimistic than their experiences. There were no consistent patterns of measured demographic or behavioral characteristics associated with expectation accuracy. Regression models revealed that overoptimistic expectations of future burdens of dyspnea (linear regression estimate, 4.68; 95% CI, 2.68 to 6.68) and negative emotions (linear regression estimate, -3.04; 95% CI, -4.78 to 1.29) were associated with lower health-related quality of life at 3 months after adjustment for baseline health-related quality of life, forced expiratory volume over 1 second, and interval clinical events (P < .001 for both). Similar patterns were observed at 12 months (dyspnea: linear regression estimate, 2.41; 95% CI, 0.45 to 4.37) and 24 months (negative emotions: linear regression estimate, -2.39; 95% CI, -4.67 to 0.12; dyspnea: linear regression estimate, 3.21; 95% CI, 0.82 to 5.60), although there was no statistically significant association between expectation of negative emotions and quality of life at 12 months.

Conclusions and Relevance

In this cohort study of patients with COPD, we found that patients are overoptimistic in their expectations about future negative symptom burdens, and such inaccuracies were independently associated with worse well-being over time. Developing and implementing strategies to improve patients' symptom expectations may improve patient-centered outcomes.

Community-based approaches to infant safe sleep and breastfeeding promotion: a qualitative study

BACKGROUND

In the U.S., sudden unexpected infant deaths (SUID) due to accidental suffocation and strangulation in bed (ASSB) are increasing, with disparities by race/ethnicity. While breastfeeding is a protective factor against infant mortality, racial/ethnic disparities are present in its uptake, and motivations to breastfeed are also often coupled with non-recommended infant sleep practices that are associated with infant sleep deaths. Combining infant safe sleep (ISS) and breastfeeding promotion on the community level presents opportunities to address racial/ethnic disparities and associated socioeconomic, cultural, and psychosocial influences.

METHODS

We completed a descriptive qualitative hermeneutical phenomenology using thematic analysis of focus group data. We examined the phenomenon of community-level providers promoting ISS and breastfeeding in communities vulnerable to ISS and breastfeeding disparities. We asked eighteen informants participating in a national quality improvement collaborative about i.) areas requiring additional support to meet community needs around ISS and breastfeeding, and ii.) recommendations on tools to improve their work promoting ISS and breastfeeding.

RESULTS

We identified four themes: i.) education and dissemination, ii.) relationship building and social support, iii.) working with clients' personal circumstances and considerations, and iv.) tools and systems.

CONCLUSIONS

Our findings support embedding risk-mitigation approaches in ISS education; relationship building between providers, clients, and peers; and the provision of ISS and breastfeeding supportive material resources with educational opportunities. These findings may be used to inform community-level provider approaches to ISS and breastfeeding promotion.

Developing an Educational and Decision Support Tool for Stage I Lung Cancer Using Decision Science

BACKGROUND

Guidelines recommend shared decision-making about treatment options for high-risk, operable stage I lung cancer. Patient decision aids can facilitate shared decision-making; however, their development, implementation, and evaluation in routine clinical practice presents numerous challenges and opportunities.

METHODS

The purpose of this review is to reflect on the process of tool development; identify the challenges associated with meeting the needs of patients, clinicians from multiple disciplines, and institutional workflow during implementation; and propose recommendations for future clinicians who wish to develop, refine, or implement similar tools into routine care.

RESULTS

In this review, we: (1) discuss guidelines for decision aid development; (2) describe how we applied those to create an education and decision support tool for patients with clinical stage I lung cancer deciding between radiation therapy and surgical resection; and (3) highlight challenges in implementing and evaluating the tool.

CONCLUSIONS

We provide recommendations for those seeking to develop, refine, or implement similar tools into routine care.

Associations between health literacy and information-evaluation and decision-making skills in Japanese adults

Background

Health literacy among Japanese is often low, making it difficult for them to evaluate health information and make informed decisions. However, the health literacy scales applied measure the perceived difficulty of health-related tasks; they do not directly assess the specific skills needed to perform the tasks: the skills to judge the reliability of diverse information using evaluation criteria and implement rational decision-making. Therefore, the study objectives were to investigate the following issues using a nationwide survey in Japan. (1) When obtaining information, to what extent do people apply criteria for evaluating information to confirm its reliability; when making decisions, to what extent do they seek out available options and compare pros and cons based on their own values? (2) How strongly are such skills associated with health literacy and demographic characteristics? (3) What opportunities are available to learn these skills?

Methods

We conducted an online questionnaire survey using a Japanese Internet research company; 3,914 valid responses were received. The measures comprised health literacy (European Health Literacy Survey Questionnaire), five items on information evaluation, four items on decision-making, and items on the availability and location of learning opportunities. We calculated Pearson correlations to explore the association of health literacy with information-evaluation and decision-making skills. Multivariate analyses were also conducted using these factors as dependent variables.

Results

Fewer than half (30%–50%) of respondents reported always or often evaluating information and engaging in decision-making. Health literacy was significantly and positively correlated with the specific skills of information evaluation and decision-making (r = .26 and .30, respectively) as were multivariate analyses (beta = .15 and .22, respectively).

Over 40% of respondents had never learned those skills. The most common resources for learning the skills were the Internet and television; less-used resources were schools and workplaces.

Conclusions

Both information-evaluation and decision-making skills were associated with health literacy. However, these skills are not sufficiently widespread in Japan because there are few opportunities to acquire them. More research is needed to raise awareness of the importance of such skills for improving health literacy and providing learning opportunities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13892-5.

(Re)Conceptualising 'good' proxy decision-making for research: the implications for proxy consent decision quality

People who are unable to make decisions about participating in research rely on proxies to make a decision based on their wishes and preferences. However, patients rarely discuss their preferences about research and proxies find it challenging to determine what their wishes would be. While the process of informed consent has traditionally been the focus of research to improve consent decisions, the more conceptually complex area of what constitutes 'good' proxy decision-making for research has remained unexplored. Interventions are needed to improve and support proxy decision-making for research but are hampered by a lack of understanding about what constitutes decision quality in this context. A global increase in conditions associated with cognitive impairment such as dementia has led to an urgent need for more research into these conditions. The COVID-19 pandemic and subsequent necessity to conduct research with large numbers of critically ill patients has made this need even more pressing. Much of the empirical research centres on the desire to improve decision accuracy, despite growing evidence that authenticity is more reflective of the aim of proxy decisions and concerns about the methodological flaws in authenticity-focused studies. Such studies also fail to take account of the impact of decision-making on proxies, or the considerable body of research on improving the quality of healthcare decisions. This paper reports a concept synthesis of the literature that was conducted to develop the first conceptualisation of 'good' proxy decisions about research participation. Elements of decision quality were identified across three stages of decision-making: proxy preparedness for decision-making which includes knowledge and understanding, and values clarification and preference elicitation; the role of uncertainty, decisional conflict, satisfaction and regret in the decision-making process; and preference linked outcomes and their effect. This conceptualisation provides an essential first step towards the future development of interventions to enhance the quality of proxy decision-making and ensure proxy decisions represent patients' values and preferences.

'I Don't Like Uncertainty, I Like to Know': How and why uveal melanoma patients consent to life expectancy prognostication

BACKGROUND

Technological advances have led to cancer prognostication that is increasingly accurate but often unalterable. However, a reliable prognosis of limited life expectancy can cause psychological distress. People should carefully consider offers of prognostication, but little is known about how and why they decide on prognostication. Using uveal melanoma (UM) patients, we aimed to identify (i) how and why do people with UM decide to accept prognostication and (ii) alignment and divergence of their decision-making from conceptualizations of a 'well-considered' decision.

METHODS

UM provides a paradigm to elucidate clinical and ethical perspectives on prognostication, because prognostication is reliable but prognoses are largely nonameliorable. We used qualitative methods to examine how and why 20 UM people with UM chose prognostication. We compared findings to a template of 'well-considered' decision-making, where 'well-considered' decisions involve consideration of all likely outcomes.

RESULTS

Participants wanted prognostication to reduce future worry about uncertain life expectancy. They spontaneously spoke of hoping for a good prognosis when making their decisions, but largely did not consider the 50% possibility of a poor prognosis. When pressed, they argued that a poor outcome at least brings certainty.

CONCLUSIONS

While respecting decisions as valid expressions of participants' wishes, we are concerned that they did not explicitly consider the realistic possibility of a poor outcome and how this would affect them. Thus, it is difficult to see their decisions as 'well-considered'. We propose that nondirective preference exploration techniques could help people to consider the possibility of a poor outcome.

PATIENT OR PUBLIC CONTRIBUTION

This paper is a direct response to a patient-identified and defined problem that arose in therapeutic and conversational discourse. The research was informed by the responses of patient participants, as we used the material from interviews to dynamically shape the interview guide. Thus, participants' ideas drove the analysis and shaped the interviews to come.

A Framework for Clinicians to Improve the Decision-Making Process in Return to Sport

Return-to-sport (RTS) decisions are critical to clinical sports medicine and are often characterised by uncertainties, such as re-injury risk, time pressure induced by competition schedule and social stress from coaches, families and supporters. RTS decisions have implications not only for the health and performance of an athlete, but also the sports organisation. RTS decision-making is a complex process, which relies on evaluating multiple biopsychosocial factors, and is influenced by contextual factors. In this narrative review, we outline how RTS decision-making of clinicians could be evaluated from a decision analysis perspective. To begin with, the RTS decision could be explained as a sequence of steps, with a decision basis as the core component. We first elucidate the methodological considerations in gathering information from RTS tests. Second, we identify how decision-making frameworks have evolved and adapt decision-making theories to the RTS context. Third, we discuss the preferences and perspectives of the athlete, performance coach and manager. We conclude by proposing a framework for clinicians to improve the quality of RTS decisions and make recommendations for daily practice and research.

Unexpected Outcomes of Measuring Decision Regret: Using a Breast Cancer Decision-Making Case Example

Shared decision making can help patients feel supported and empowered when deciding between healthcare options. Decision regret can be a meaningful measure of the quality of that encounter. However, in a patient-engaged research study examining shared decision making for breast cancer surgery, decision regret was a difficult construct to assess, and asking questions about decision regret caused the patient to experience that emotion upon reflection. In this article, we consider the complexity of decision regret, and discuss the difficulty of measuring that emotion through existing instruments. We call for clarity in definitions of decision regret and offer suggestions for developing a set of questions that can capture regret in a more meaningful way.

Impact of the bidirectional relationship between communication and cognitive efficacy on orthopedic patient adherence behavior

Background

There is growing interest in patient autonomy, and communication between physicians and patients has become the essential cornerstone for improving the quality of healthcare services. Previous research has concentrated on the direct effect of physician-patient communication on service outcomes. In the present study, we examined the influence among constructs in the service process and the impact on healthcare outcomes. The present study used behavioral theory to expand the process aspect of the Donabedian healthcare service quality structure-process-outcome model to examine the impact of cognitive changes and communication feedback on patients’ adherence behavior. In addition, the moderating effect of hospital facility levels is examined.

Methods

A conceptual model was developed and tested using a questionnaire administered to patients in eight hospitals. A total of 397 respondents returned usable surveys, with a response rate of 92.11%. Structural equation modeling was used to analyze the data in two steps that involved a measurement model and a structural model. The former was applied to estimate the Cronbach’s alphas, intercorrelations of factors, and descriptive statistics; the latter was used to test the hypothesized relationships of the constructs.

Results

The results identified three mediators of the healthcare process within the healthcare services framework: physician-patient communication, cognitive efficacy, and adherence behavior. Physician-patient communication influenced cognitive efficacy (β = 0.16, p < 0.001), and cognitive efficacy influenced physician-patient communication (β = 0.18, p < 0.001). The effect of this bidirectional relationship on adherence behavior was positive (β = 0.38, p < 0.001). The healthcare structure influenced healthcare outcomes via these three healthcare process constructs. The adherence behavior of patients who were treated in the medical center has greater influences by the structure and physician-patient communication than it was treated in the regional hospitals.

Conclusions

This study revealed a complex pattern in relationships among process constructs for healthcare services. The findings of this study acknowledge the important potential interrelationships among the healthcare service constructs to improve the quality of healthcare outcomes.

Trial registration

CRREC104107. Date: 22/01/2016. Prospectively Registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07575-5.

Are We Improving? Update and Critical Appraisal of the Reporting of Decision Process and Quality Measures in Trials Evaluating Patient Decision Aids

Background

In 2014, a systematic review found large gaps in the quality of reporting of measures used in 86 published trials evaluating the effectiveness of patient decision aids (PtDAs). The purpose of this study was to update that review.

Methods

We examined measures of decision making used in 49 randomized controlled trials included in the 2014 and 2017 Cochrane Collaboration systematic review of PtDAs. Data on development of the measures, reliability, validity, responsiveness, precision, interpretability, feasibility, and acceptability were independently abstracted by 2 paired reviewers.

Results

Information from 273 measures was abstracted, and 109 of these covered the core domains of decision processes (n = 55) and decision quality including informed choice/knowledge (n = 48) and values-choice concordance (n = 12). Very few studies reported data on the performance and clinical sensibility of measures, with reliability (23%) and validity (6%) being the most common. Studies using new measures were less likely to include information about their psychometric performance compared with previously published measures.

Limitations

The review was limited to reporting of measures in studies included in the Cochrane review and did not consult prior publications.

Conclusion

There continues to be very little reported about the development or performance of measures used to evaluate the effectiveness of PtDAs in published trials. Minimum reporting standards have been published, and efforts to require investigators to use them are needed.

Shared decision-making for infant feeding and care during the coronavirus disease 2019 pandemic

Despite decades of research establishing the importance of breastfeeding, skin-to-skin contact and mother-infant closeness, the response to the coronavirus disease 2019 (COVID-19) pandemic has underscored the hidden assumption that these practices can be dispensed with no consequences to mother or child. This article aims to support shared decision-making process for infant feeding and care with parents and health care providers during the unprecedented times of the pandemic. It proposes a structure and rationale to guide the process that includes (1) discussing with parents evidence-based information and the different options to feed and care for an infant and young child in the context of the pandemic as well as their potential benefits, risks and scientific uncertainties; (2) helping parents to recognize the sensitive nature of the decisions and to clarify the value they place on the different options to feed and care for their infant or young child; and (3) providing guidance and support needed to make and implement their decisions. A shared decision-making process will help parents navigate complex feeding and care decisions for their child as we face the different stages of the COVID-19 pandemic.

Effect of shared decision making on mode of delivery and decisional conflict and regret in pregnant women with previous cesarean section: a randomized clinical trial

BACKGROUND

The promotion of vaginal birth after cesarean section (VBAC) is the best method for the reduction of repeated cesarean sections. Nonetheless, the decisional conflict which often results from inadequate patient involvement in decision making, may lead to delayed decision making and regret about the choices that were made. The present study aimed to determine the effect of shared decision making on the mode of delivery and decisional conflict and regret in pregnant women with previous cesarean section.

METHODS

This randomized clinical trial was conducted on 78 pregnant women with a previous cesarean section referring to community health centers in Torbat-e Jam, Iran, in 2019. They were randomly assigned to two groups of intervention and control. During weeks 24-30 of pregnancy, the Decisional Conflict Scale (DCS) was completed by pregnant mothers. Apart from the routine care, the experimental group received a counseling session which was held based on the three-talk model of shared decision making. This session was moderated by a midwife; moreover, a complementary counseling session was administered by a gynecologist. During weeks 35-37 of pregnancy, DCS was completed, and the Decision Regret Scale (DRS) was filled out for both groups at the 8th weeks postpartum and they were asked about the mode of delivery. Data were analyzed in SPSS software (version 19) using the Mann-Whitney, Chi-squared and Fisher's exact tests. p-value less than 0.05 was considered statistically significant.

RESULTS

After the intervention, the decisional conflict score was significantly lower in the shared decision making (SDM) group, compared to that in the control group (14.90 ± 9.65 vs. 25.41 ± 13.38; P < 0.001). Moreover, in the SDM group, the rate of vaginal birth was significantly higher than that in the control group (P < 0.001). Two month after the delivery, the mean score of decision regret was lower in the SDM group, in comparison to that in the control group (15.67 ± 23.37 vs. 27. 30± 26.75; P = 0.007).

CONCLUSIONS

Based on the results of the study, shared counseling can be effective in the reduction of decisional conflict and regret, as well as rate enhancement of VBAC. Therefore, it can be concluded that this counseling method can be used in prenatal care to reduce the rate of repeated cesarean section.

TRIAL REGISTRATION

IRCT20190506043499N1; Name of the registry: Iranian Registry of Clinical Trials; Registered 10. August 2019. URL of registry: https://en.irct.ir/trial/39538. Date of enrolment of the first participant to the trial: August 2019.

Discussing measurement-based care with patients: An analysis of clinician-patient dyads

Abstract Measurement-based care (MBC) refers to the use of three integrated strategies to improve effectiveness of behavioral health care: routine outcomes monitoring using symptom measures; regularly sharing these data with patients; and using these data to inform treatment decisions. This study examined how clinicians discuss MBC data with patients, including identifying what aspects of these discussions contribute to clinician-patient agreement on the value of MBC, and how clinicians use MBC data to inform treatment decisions. Twenty-six clinician-patient dyads participated in semi-structured interviews and provided a treatment session recording in which MBC data were discussed. Qualitative data analyses revealed four subtypes of dyads: clinician and patient both valued MBC; clinician valued MBC, patient passively participated in MBC; clinician valued MBC, patient had mixed perceptions of MBC; clinician and patient reported moderate or low value for MBC. In dyads for whom both the clinician and patient valued MBC, the clinician provided clear and repeated rationale for MBC, discussed data with patients at every administration, and connected observed scores to patient skills or strategies. Emerging best practices for discussing MBC include providing a strong rationale, discussing results frequently, actively engaging patients in discussions, and using graphs to visualize progress.

Enhancing shared and surrogate decision making for people living with dementia: A systematic review of the effectiveness of interventions

BACKGROUND

Dementia can have a profound impact on decision making. People living with dementia (PLwD) often need to make decisions about health care, and, as dementia progresses, decisions may need to be made on their behalf. Specific interventions may support this process.

REVIEW QUESTION

What interventions are effective in improving shared decision making or surrogate decision making on the health care of PLwD?

METHODS

A narrative systematic review of existing literature was conducted. Seven databases, grey literature and key journals were searched. After exclusion by title, abstracts then full texts were reviewed collaboratively to manage any disagreements.

RESULTS

Eight studies met the inclusion criteria. Two articles, including one RCT, evaluated decision aids regarding the use of enteral feeding in advanced dementia. Six further articles, including five RCTs, were found which evaluated the effectiveness of interventions supporting patients or carers with advance care planning.

CONCLUSION

Decision-making interventions typically consist of multiple components which aim to establish preferences for future health care. Advance care planning interventions supported aspects of the decision-making processes but their impact on decision quality was rarely evaluated. Interventions did not increase the concordance of decisions with a person's values. The decision-specific interventions are unlikely to produce benefit in other decision contexts.

PATIENT INVOLVEMENT

Two caregivers, a public stakeholder group and a carer group were consulted in the design of the wider study to which this review relates. Six PLwD refined the research questions addressed in this paper.

Conceptualizations of clinical decision-making: a scoping review in geriatric emergency medicine

BACKGROUND

Clinical decision-making (CDM) is an important competency for young doctors especially under complex and uncertain conditions in geriatric emergency medicine (GEM). However, research in this field is characterized by vague conceptualizations of CDM. To evolve and evaluate evidence-based knowledge of CDM, it is important to identify different definitions and their operationalizations in studies on GEM.

OBJECTIVE

A scoping review of empirical articles was conducted to provide an overview of the documented evidence of findings and conceptualizations of CDM in GEM.

METHODS

A detailed search for empirical studies focusing on CDM in a GEM setting was conducted in PubMed, ProQuest, Scopus, EMBASE and Web of Science. In total, 52 publications were included in the analysis, utilizing a data extraction sheet, following the PRISMA guidelines. Reported outcomes were summarized.

RESULTS

Four themes of operationalization of CDM emerged: CDM as dispositional decisions, CDM as cognition, CDM as a model, and CDM as clinical judgement. Study results and conclusions naturally differed according to how CDM was conceptualized. Thus, frailty-heuristics lead to biases in treatment of geriatric patients and the complexity of this patient group was seen as a challenge for young physicians engaging in CDM.

CONCLUSIONS

This scoping review summarizes how different studies in GEM use the term CDM. It provides an analysis of findings in GEM and call for more stringent definitions of CDM in future research, so that it might lead to better clinical practice.

Discussions about contralateral prophylactic mastectomy among surgical oncology providers and women with sporadic breast cancer: a content analysis

Rates of contralateral prophylactic mastectomy (CPM) have risen substantially, yet little is known about how and to what extent CPM is discussed within surgical oncology visits at the time of treatment decision-making. We examined CPM discussions in naturally occurring interactions between sporadic breast cancer patients and their surgical oncology providers. Women with early-stage unilateral disease were recruited before their first surgical visit and completed brief questionnaires to determine study eligibility and interest in treatment options. After their visits, enrolled patients and their providers completed questionnaires assessing discussion of and interest in CPM. Audio-recorded visits from 36 unique patients were randomly selected, transcribed, and analyzed. A CPM discussion was present in 28 transcripts. Approximately half of CPM discussions were initiated by the patient or the oncology provider. The topic of CPM was most frequently introduced while reviewing available treatment options. Patients were most interested in pursuing CPM to reduce the risk of future breast cancer. Providers most frequently responded by offering information (e.g., about risk of contralateral disease). A high level of agreement was found among patient, provider, and observer ratings of whether or not CPM was discussed. CPM discussions were consistently present within our sample. Results can be used to build providers' skills and bring provider-patient communication more in line with best practices and recommendations from leading professional medical societies.

Values clarification and parental decision making about newborn genomic sequencing

OBJECTIVE

Using an online decision aid developed to support parental decision making about newborn genomic sequencing, we tested whether adding a values clarification exercise to educational content would improve decision making outcomes and influence intention to pursue genomic sequencing. We also examined whether the effect of values clarification varied depending on one's health literacy level.

METHOD

In an online experiment, women and men aged 18 to 44 who were either pregnant or had a pregnant partner, were currently trying to get pregnant, or were preparing for a pregnancy within the next 2 years were randomly assigned to complete either a decision aid with educational information about newborn genomic sequencing or a decision aid with the same educational information and a values clarification exercise.

RESULTS

Of the 1,000 participants who completed the decision aid, those who completed the values clarification exercise reported less decision regret, F(1, 995) = 6.19, p = .01, and were clearer about their personal values, F(1, 995) = 6.39, p = .01. Moderation analyses revealed that the benefit of values clarification on decisional conflict was particularly evident among participants with lower health literacy, B = -3.94, SE = 1.67, t = -2.36, p = .018. There was not a significant moderation effect of health literacy and decision aid condition on decision regret.

CONCLUSIONS

Adding a values clarification exercise to decision aids for parents making decisions about genomic sequencing may improve the decision-making experience and provide some benefit to individuals with lower health literacy. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Value discrepancies between nurses and patients: A survey study

Background

Patient-centeredness, respect for patient autonomy, and shared decision-making have now made it to center stage in discussions on quality of care. Knowing what actually counts in care and how it should be accomplished from the patients’ and nurses’ perspective seems crucial.

Aim

To explore how patients and their nurses perceive the importance and enactment of values in their healthcare.

Research design

An observational, cross-sectional study using a self-developed questionnaire, consisting of 15 items related to seven values (e.g. uniqueness, autonomy, professionalism, compassion, responsiveness, partnership, and empowerment) as described in the taxonomy of Bastemeijer et al.

Participants and research context

The survey was completed by 384 patients and 81 nurses. Participants were recruited on eight internal medicine wards of a 1000-bed university hospital in Belgium.

Ethical considerations

This study was approved by the ethical committee of the Ghent University Hospital (B670201836799).

Findings

(1) Patients and nurses prioritize values of care differently; (2) nurses report not being able to enact the values they prioritize in actual practice as much as one would like to; and (3) there is a gap in experienced delivery of a comprehensible explanation of all treatment options, a conversation based on equality, making shared decisions, and being non-judgmental between nurses and patients.

Discussion

Our findings challenge nurses’ overemphasis on professional compassion and uniqueness while arguing for increased attention on authentic shared decision-making and empowerment. The first step to a patient-centered culture truly involving patients in their healthcare is communication and information provision, rather than focusing on tangible and normative constructs.

Conclusion

Our findings revealed differences in prioritization and actual enactment of values in care between patients and nurses. This was especially so for values related to communication, provision of complete unbiased information, and shared decision-making. Nurses should prioritize providing comprehensible information and using conversations based on equality to make decision together with patients.

The Policies of Provision of Assistive and Welfare Technology—A Literature Review

Background: Due to the increasing ageing population worldwide, humanity is facing global demographic challenges. For many people, their later years are often lived with changed functioning and the need for support in daily living activities. Assistive technology and welfare technology (AT/WT) constitute a partial solution to the demographic challenges. Objectives: The purpose of this literature review is to identify the policy features, such as decision models and guidance for the provision of AT/WT as reported in the current scientific literature. Methods: A literature review with a deductive approach using the structure of the Global Cooperation on Assistive Technology (GATE) model was conducted. The data were searched from the databases: PubMed, Cinahl Plus, and the Web of Science, resulting in nine included articles. Results: The findings are presented according to the structure of the eight domains from the GATE model— policy, assessment, procurement, technology, environment, usability, sustainability and rights— which are further grouped into categories exploring the variations in every domain. Conclusion: The review reveals a nascent and growing interest in the area; however, evidence-based decision models and other guidance on AT/WT are lacking. Recent scholarships and policy reforms can form the basis of stronger guidance to organise complex AT/WT systems, but further and future research is needed.

Shared Decision-Making in Growth Hormone Therapy-Implications for Patient Care

Several studies have shown that adherence to growth hormone therapy (GHT) is not optimal. There are several reasons why patients may not fully adhere to their treatment regimen and this may have implications on treatment success, patient outcomes and healthcare spending and resourcing. A change in healthcare practices, from a physician paternalistic to a more patient autonomous approach to healthcare, has encouraged a greater onus on a shared decision-making (SDM) process whereby patients are actively encouraged to participate in their own healthcare decisions. There is growing evidence to suggest that SDM may facilitate patient adherence to GHT. Improved adherence to therapy in this way may consequently positively impact treatment outcomes for patients. Whilst SDM is widely regarded as a healthcare imperative, there is little guidance on how it should be best implemented. Despite this, there are many opportunities for the implementation of SDM during the treatment journey of a patient with a GH-related disorder. Barriers to the successful practice of SDM within the clinic may include poor patient education surrounding their condition and treatment options, limited healthcare professional time, lack of support from clinics to use SDM, and healthcare resourcing restrictions. Here we discuss the opportunities for the implementation of SDM and the barriers that challenge its effective use within the clinic. We also review some of the potential solutions to overcome these challenges that may prove key to effective patient participation in treatment decisions. Encouraging a sense of empowerment for patients will ultimately enhance treatment adherence and improve clinical outcomes in GHT.

Decisional conflict and regret: shared decision-making about pregnancy affected by β-thalassemia major in Southeast of Iran

To study the effect of shared decision-making (SDM) on decisional conflict (DC) scores immediately after consultation and to assess the decisional regret (DR) scores in the first 3 months following women's decision regarding termination of pregnancy. This quasi-experimental study was conducted during August 3rd-February 20th, 2016. We included 80 women whose fetuses were diagnosed with β-thalassemia major (β-TM) through chorionic villi sampling and were referred to the only prenatal diagnosis center at Ali-Asghar Hospital, Zahedan, Iran. While the control group went through the routine procedures, the intervention group received a 90-min counseling session based on SDM. The demographic characteristics form and DC scale were filled out immediately after the consultation session. After 3 months, the women were contacted via telephone call to collect data on their level of DR. The mean DC score was significantly (P = < 0.0025) lower in the intervention group (8.47 ± 4.63) compared with the control group (44.10 ± 14.5). Moreover, the mean score of DR was significantly (P = 0.004) lower in the intervention group (9.37 ± 15.44) compared with the control group (24.37 ± 23.42). SDM consultation can help women experience significantly lower levels of DC and DR.

Spontaneous mental associations with the words "side effect": Implications for informed and shared decision making

OBJECTIVE

To gain insight into patients' medical decisions by exploring the content of laypeople's spontaneous mental associations with the term "side effect."

METHODS

An online cross-sectional survey asked 144 women aged 40-74, "What are the first three things you think of when you hear the words 'side effect?"' Data were analyzed using content analysis, chi-square, and Fisher's exact tests.

RESULTS

17 codes emerged and were grouped into 4 themes and a Miscellaneous category: Health Problems (70.8% of participants), Decision-Relevant Evaluations (52.8%), Negative Affect (30.6%), Practical Considerations (18.1%) and Miscellaneous (9.7%). The 4 most frequently identified codes were: Risk (36.1%), Health Problems-Specific Symptoms (35.4%), Health Problems-General Terms (32.6%), and Negative Affect-Strong (19.4%). Code and theme frequencies were generally similar across demographic groups (ps>0.05).

CONCLUSION

The term "side effect" spontaneously elicited comments related to identifying health problems and expressing negative emotions. This might explain why the mere possibility of side effects triggers negative affect for people making medical decisions. Some respondents also mentioned decision-relevant evaluations and practical considerations in response to side effects.

PRACTICE IMPLICATIONS

Addressing commonly-held associations and acknowledging negative affects provoked by side effects are first steps healthcare providers can take towards improving informed and shared patient decision making.