L22 Decision Making

Question 1

Understand issues patients face when making health decisions

Answer 1

DECISIONS 1. TYPE OF PRIMARY TREATMENT If mastectomy = > Breast reconstruction OR not ?? If breast reconstruction
=> Immediate OR Delayed
• TYPE OF ADJUVANT(“insurance”) TREATMENT
? Chemotherapy
? Hormone therapy
• FERTILITY OPTIONS
Complementary therapy; Clinical trial

Question 2

What do patients have to weigh up with breast cancer?

Answer 2

Weighing up medical and personal concerns
Weighing up uncertain risks against uncertain side-effects (additional chemotherapy / hormone therapy)
- (Likely) loss of fertility/onset of menopausal symptoms

Question 3

Explain different consultation/medical decision-making styles

Answer 3

PATERNALISM: Clinician-centred approach
Clinician: • the Expert
• protects patient from disturbing information
• takes away the burden of decision-making
• projects confidence & care
• clinician makes the decision in patient’s best interests

INFORMED/Patient-directed: Patient as ‘the consumer’, proactive
Clinician: • tells patient all the relevant information
• is available to answer patient’s questions
• does not make a recommendation
• allows patient to reach his/her own decision

Shared Decision-Making (SDM)
Collaborative process between clinician and patient to make informed, value-sensitive decisions that both agree upon.
Patients and clinicians have different but equally valuable perspectives and roles within the medical encounter
• No one accepted “gold standard” definition of SDM
• SDM approaches often similar in their essence, but have different names / stages / focus

Question 4

• Models of SDM (Charles et al., 1997; Elwyn et al., 2012)

Answer 4

Charles et al. (1997; 1999): SDM Framework
Pioneering model of SDM
• Most widely cited model of SDM (2,040 citations)
• An encounter in which BOTH clinician and patient:
- Share information (INFORMATION EXCHANGE) Clinician: shares all relevant information about available options. Patient: provides information about their preferences, values, beliefs social context, and knowledge about the illness/treatment
- Mutually deliberate on treatment options process (DELIBERATION) Interactively expressing & discussing treatment preferences
- Choose a treatment to implement (DECISION) Both parties work towards reaching an agreement & action plan

ElwynClick et al. (2012): SDM model for clinical practice
Provides guidance about how to accomplish SDM in routine clinical practice
• 3-step model:
- CHOICE Talk: introducing choice; does not have to occur during a face-to-face consultation (email, letter, phone call)
-OPTION Talk: describing options
-DECISION Talk: helping patients explore preferences and make decisions

• Underpinned by the process of DELIBERATION
• an ongoing and progressive process; may be repeated over time
• may include use of decision support tools and discussions with others

Question 5

• Hobbs et al. (2015), US, N = 5,285 cancer patients

Answer 5

Preferences:
Family-controlled decision making: 1%
Shared decision making with family: 49%
 Some family input: Little family input: 22%
Little Family input: 28%

• Greater family involvement preference by patients who were: married, female, older, & from an ethnically diverse background (Asian, Hispanic)

Question 6

Family involvement: Decision-making STAGES

Answer 6

Family involvement: additional stages to those proposed by Charles et al. (1997; 1999)
• Informed by qualitative interviews & quantitative analysis of consultation audiotapes (Laidsaar-Powell et al., 2015; 2016)
PREconsultation preparation
Information exchange
Deliberation
Decision
POST-decision Reflection

Question 7

Balancing patient priority with family needs

Answer 7

• Family ‘influence’ appropriate/needed in certain situations => flexible approach based on patient (and family) needs
• Family involvement does not necessarily equal dominance
• Many family members see their own role as a ‘backup’ or ‘auxilliary’ to the patient, and self-censor their opinions
• Benefits of family involvement in the decision-making process: feeling more informed, thinking more about the decision, improved confidence about decision, feeling supported, shared burden.