22 Medical Decision-Making Flashcards
Explain the issues patients face when making health decisions
Weighing up medical and personal concerns
- The health and benefits in terms of survival (quantity of life) vs my ability to keep the family functioning (quality of life)
- Side-effects of treatment on the ability to have children/sexuality/body image
- Weighing up uncertain risks against uncertain side effects -> additional therapy
What effects do treatments have on decision-making?
Being able to live with uncertainty -> can no longer trust their body
What type of decisions have to be considered in terms of diagnosis?
- Type of primary treatment
- Type of adjuvant treatment
- Fertility options
- Other decisions e.g. complementary therapy
What are uncertain risks against uncertain side effects example?
Chance of relapse vs likely loss of fertility and onset of menopause
Describe Paternalism as an approach to consultation styles in medical decision making
- The clinician is the expert, protects the patient from disturbing information
- takes away the burden of decision-making
- Clinician projects confidence and care also makes the decision in the patient’s best interest
What type of approach is PATERNALISM
Clinician-centred approach
Describe the informed/autonomous approach to consultation styles in medical decision making
- Clinician tells the patient all the relevant information and is available to answer patient’s questions
- Does not make a recommendation
- Allows the patient to reach his/her own decision
- Patient preferences not really taken into account
What type of approach is the INFORMED/AUTONOMOUS
Patient-directed; patient as ‘the consumer’
Describe the shared decision-making approach to medical decision making
- Patients and clinicians have different but equally valuable perspectives and roles within the medical encounter
- SDM approaches often similar in their essence, but have different names/stages/focus
- Both are looked at as experts -> patient always has last word
What type of approach is SHARED DECISION-MAKING
The collaborative process between clinician and patient to make informed, value-sensitive decisions that both agree upon
Which medical decision-making approach is preferred?
Shared decision-making
Describe the shared decision-making framework (Charles, 1997)
Pioneering model of SDM (most widely cited SDM)
Encounter in which both clinician and patient:
- Share information (information exchange)
- Mutually deliberate on treatment options process (deliberation)
- Choose a treatment to implement (Decision)
What is the expectation of patient and professional in the SDM framework model?
Both the patient and the professional share information, deliberate and reach consensus on the treatment option and decide a plan to be implemented
Describe the shared decision-making model for clinical practice (Elwyn, 2012)
Provides guidance about how to accomplish SDM in routine clinical practice using a 3-step model
TEAM talk
- Work together, describe choices, offer support, and ask about goals
e. g. Let’s work as a team to make a decision that suits you best
OPTION talk
- Discuss alternatives using risk communication principles
e.g . Let’s compare the possible options
DECISION talk
- Get to informed preferences make preference-based decisions
e.g. Tell me what matters most to you for this decision
In the SDM model for clinical practice by Elwyn (2012) what does it mean by active listening?
Paying close attention and responding to accurately
In the SDM model for clinical practice by Elwyn (2012) what does it mean by deliberation?
Thinking carefully about options when facing a decision
When should shared decision-making (SDM) be used?
One size does NOT fit all -> patient preferences vary
Appropriate in preference-sensitive scenarios when treatment outcomes are uncertain, quality of life may be affected or patient values determine the best outcome
- consultation needs to match the patient’s preferences
What is shared decision-making demonstrated to be effective at?
- Overall satisfaction with their care
- Satisfaction with the doctor-patient relationship
- Satisfaction with the decision-making process
- Knowledge
- Quality of life
- Treatment adherence
What are some patient barriers experienced during shared decision-making?
- Conforming to social expectations of doctor/patient roles
- Emotionally vulnerable and emotional, possibly feeling powerless
- Lack a medical vocabulary
What are some clinician barriers experienced during shared decision-making?
Not an easy task for the health professional as most NOT trained in SDM (particularly in Australia)
What are some common misconceptions about clinicians?
- Patients will feel unsupported when making decisions
- It will lead to longer consultations and make patients more anxious
- “I already do this” or “Not everyone can do this”
- Not enough evidence behind SDM and it being too complex for some vulnerable patients they won’t understand
What is family involvement in decision-making stages?
Pre-consultation preparation - within and outside medical consultation
Information exchange
Deliberation
Decision
POST-decision reflection - within and outside medical consultation
Explain the effects of ATTITUDES on family involvement in decision-making
Patient as priority
- The patient has ultimate authority over a medical decision => patient wishes are paramount
- challenge: Family who comprise patient autonomy
Rights of the family to be involved
- Although patient rights emphasized, families involvement in decision-making also seen as important
Balancing patient priority with family needs
- Family ‘influence’ appropriate/needed in certain situations -> flexible approach based on patient (and family) needs
- Family involvement does not equal dominance
- Family members see their own role as ‘backup’ to the patient
What are the benefits of family involvement in the decision-making process?
Feeling more informed, thinking about the decision, improved confidence about the decision, feeling supported, shared burden
Describe the TRIO framework
(Shared triadic decision-making)
New clinician-patient-family (triadic) conceptual framework of family involvement in medical decision-making/consultations
What is involved in the TRIO framework?
- Describes and maps the possible wide-ranging family influences in medical decision-making/consultation
- Captures and explains the complexity and variability of family involvement in medical consultation and care
What does SDM involve?
SDM involves the collaboration of the clinician and patient -> each brings their respective expertise
What are the different approaches to SDM?
Two different models by Charles et al, and Elwyn et al., (2012) -> they share many similarities but differ in focus
To what extent is family care involved?
Family cares are regularly involved in consultation and the decision-making process: usually in supportive capacity but can be challenging
What are the three consultation styles in medical decision-making?
- Paternalism
- Informed/Autonomous
- Shared decision-making
