22 Medical Decision-Making

Question 1

Explain the issues patients face when making health decisions

Answer 1

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

Question 2

What effects do treatments have on decision-making?

Answer 2

Being able to live with uncertainty -> can no longer trust their body

Question 3

What type of decisions have to be considered in terms of diagnosis?

Answer 3

• Type of primary treatment
• Type of adjuvant treatment
• Fertility options
• Other decisions e.g. complementary therapy

Question 4

What are uncertain risks against uncertain side effects example?

Answer 4

Chance of relapse vs likely loss of fertility and onset of menopause

Question 5

Describe Paternalism as an approach to consultation styles in medical decision making

Answer 5

• 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

Question 6

What type of approach is PATERNALISM

Answer 6

Clinician-centred approach

Question 7

Describe the informed/autonomous approach to consultation styles in medical decision making

Answer 7

• 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

Question 8

What type of approach is the INFORMED/AUTONOMOUS

Answer 8

Patient-directed; patient as ‘the consumer’

Question 9

Describe the shared decision-making approach to medical decision making

Answer 9

• 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

Question 10

What type of approach is SHARED DECISION-MAKING

Answer 10

The collaborative process between clinician and patient to make informed, value-sensitive decisions that both agree upon

Question 11

Which medical decision-making approach is preferred?

Answer 11

Shared decision-making

Question 12

Describe the shared decision-making framework (Charles, 1997)

Answer 12

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)

Question 13

What is the expectation of patient and professional in the SDM framework model?

Answer 13

Both the patient and the professional share information, deliberate and reach consensus on the treatment option and decide a plan to be implemented

Question 14

Describe the shared decision-making model for clinical practice (Elwyn, 2012)

Answer 14

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

Question 15

In the SDM model for clinical practice by Elwyn (2012) what does it mean by active listening?

Answer 15

Paying close attention and responding to accurately

Question 16

In the SDM model for clinical practice by Elwyn (2012) what does it mean by deliberation?

Answer 16

Thinking carefully about options when facing a decision

Question 17

When should shared decision-making (SDM) be used?

Answer 17

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

Question 18

What is shared decision-making demonstrated to be effective at?

Answer 18

• Overall satisfaction with their care
• Satisfaction with the doctor-patient relationship
• Satisfaction with the decision-making process
• Knowledge
• Quality of life
• Treatment adherence

Question 19

What are some patient barriers experienced during shared decision-making?

Answer 19

• Conforming to social expectations of doctor/patient roles
• Emotionally vulnerable and emotional, possibly feeling powerless
• Lack a medical vocabulary

Question 20

What are some clinician barriers experienced during shared decision-making?

Answer 20

Not an easy task for the health professional as most NOT trained in SDM (particularly in Australia)

Question 21

What are some common misconceptions about clinicians?

Answer 21

• 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

Question 22

What is family involvement in decision-making stages?

Answer 22

Pre-consultation preparation - within and outside medical consultation
Information exchange
Deliberation
Decision
POST-decision reflection - within and outside medical consultation

Question 23

Explain the effects of ATTITUDES on family involvement in decision-making

Answer 23

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

Question 24

What are the benefits of family involvement in the decision-making process?

Answer 24

Feeling more informed, thinking about the decision, improved confidence about the decision, feeling supported, shared burden

Question 25

Describe the TRIO framework

Answer 25

(Shared triadic decision-making)

New clinician-patient-family (triadic) conceptual framework of family involvement in medical decision-making/consultations

Question 26

What is involved in the TRIO framework?

Answer 26

• 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

Question 27

What does SDM involve?

Answer 27

SDM involves the collaboration of the clinician and patient -> each brings their respective expertise

Question 28

What are the different approaches to SDM?

Answer 28

Two different models by Charles et al, and Elwyn et al., (2012) -> they share many similarities but differ in focus

Question 29

To what extent is family care involved?

Answer 29

Family cares are regularly involved in consultation and the decision-making process: usually in supportive capacity but can be challenging

Question 30

What are the three consultation styles in medical decision-making?

Answer 30

1. Paternalism
2. Informed/Autonomous
3. Shared decision-making