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PubMed2001

Effects of patients' preferences on the treatment of atrial fibrillation: observational study of patient-based decision analysis.

OBJECTIVE: To investigate the effect of patients' preferences in the treatment of atrial fibrillation by using individualized decision analysis in which probability and utility assessments are combined into a decision tree. DESIGN: Observational study based on interviews with patients. SETTING: 8 general practices in Avon, England. PARTICIPANTS: 260 randomly selected patients aged 70 to 85 years with atrial fibrillation. MAIN OUTCOME MEASURES: Patients' treatment preferences regarding anticoagulation treatment (warfarin sodium) after individualized decision analysis; comparison of these preferences with treatment guidelines on the basis of comorbidity and absolute risk and compared with current prescription. RESULTS: Of 195 eligible patients, 97 participated in decision making using decision analysis. Among these 97, the decision analysis indicated that 59 (61%; 95% confidence interval, 50%-71%) would prefer anticoagulation treatment, considerably fewer than those who would be recommended treatment according to guidelines. There was marked disagreement between the decision analysis and guideline recommendations (kappa> or =0.25). Of 38 patients whose decision analysis indicated a preference for anticoagulation, 17 (45%) were being prescribed warfarin; on the other hand, 28 (47%) of 59 patients were not being prescribed warfarin, although the results of their decision analysis suggested they wanted to be. CONCLUSIONS: In the context of shared decision making, individualized decision analysis is valuable in a sizable proportion of elderly patients with atrial fibrillation. Taking account of patients' preferences would lead to fewer prescriptions for warfarin than under published recommendations. Decision analysis as a shared decision-making tool should be evaluated in a randomized controlled trial.

Aged↗
PubMed1996

A decision-making process in shared governance.

Shared governance teams require a good decision making process. After identifying the root cause of a problem, finding a solution that addresses the right issues begins. An issues flow chart and decision-making process were developed to help teams better identify and solve problems.

Decision Making, Organizational↗
PubMed1997

Partnerships with patients: the pros and cons of shared clinical decision-making.

The traditional style of medical decision-making in which doctors take sole responsibility for treatment decisions is being challenged. Attempts are being made to promote shared decision-making in which patients are given the opportunity to express their values and preferences and to participate in decisions about their care. Critics of shared decision-making argue that most patients do not want to participate in decisions; that revealing the uncertainties inherent in medical care could be harmful; that it is not feasible to provide information about the potential risks and benefits of all treatment options; and that increasing patient involvement in decision-making will lead to greater demand for unnecessary, costly or harmful procedures which could undermine the equitable allocation of health care resources. This article examines the evidence for and against these claims. There is considerable evidence that patients want more information and greater involvement, although knowledge about the circumstances in which shared decision-making should be encouraged, and the effects of doing so, is sparse. There is an urgent need for more research into patients' information needs and preferences and for the development and evaluation of decision-support mechanisms to enable patients to become informed participants in treatment decisions.

Decision Making↗
PubMed2001

[General practice adrift. Explosion of knowledge, technological development and population].

The explosion of biomedical research, and in turn, the far-reaching specialisation, which accompanies it, makes the health service field increasingly obscure and confusing. The general practitioner as gatekeeper occupies a central and much needed role in health care. Inherent this role are the professional core qualities of continuity, entirety, and a personal doctor-patient relationship, which ideally allow the GP to sort out and co-ordinate available services so that they suit the individual patient. These GP qualities also have the merit of making patients more content, they contribute to shared decision making, and they limit costs through more co-ordinated services. General practice today is faced with a dilemma. Increasing specialisation, consumerism, and liberalizsation threaten to eliminate the generalist role in health care, precisely at a time when it is most acutely needed.

Attitude to Health↗
PubMed2005

Individual differences in causal learning and decision making.

In judgment and decision making tasks, people tend to neglect the overall frequency of base-rates when they estimate the probability of an event; this is known as the base-rate fallacy. In causal learning, despite people's accuracy at judging causal strength according to one or other normative model (i.e., Power PC, DeltaP), they tend to misperceive base-rate information (e.g., the cause density effect). The present study investigates the relationship between causal learning and decision making by asking whether people weight base-rate information in the same way when estimating causal strength and when making judgments or inferences about the likelihood of an event. The results suggest that people differ according to the weight they place on base-rate information, but the way individuals do this is consistent across causal and decision making tasks. We interpret the results as reflecting a tendency to differentially weight base-rate information which generalizes to a variety of tasks. Additionally, this study provides evidence that causal learning and decision making share some component processes.

Cognition↗
PubMed2006

Understanding cardiopulmonary resuscitation decision making: perspectives of seriously ill hospitalized patients and family members.

BACKGROUND: To improve communication and decision making related to cardiopulmonary resuscitation (CPR), a greater understanding of the perspectives of hospitalized patients with advanced diseases and their family members are needed. METHODS: In five Canadian hospitals, we administered a face-to-face questionnaire to older inpatients with end-stage cancer and advanced medical diseases and, where possible, to one of their family members, regarding information needs, the deliberation process, and their preferred decisional role. FINDINGS: A total of 440 of 569 patients (78%) and 160 of 176 available caregivers (91%) agreed to participate. Most patients (61%) had thought about what treatment they wanted if their heart stopped, few patients (11.3%) could describe more than two components of CPR, and only 2.7% of patients thought that the success rate of CPR was < 10%. A minority of patients (34%) had discussed CPR with their physician; 37% did not want to discuss their preferences with their doctor. Patients who felt that end-of-life issues were relevant to them were 5.5 times more likely to want a discussion with the physician regarding resuscitation (odds ratio, 5.5; 95% confidence interval, 2.5 to 12.0). The preferred role in decision making was variable, but most patients (59.7%) and family members (81.6%) preferred some degree of shared decision making that included the family member. There were no significant differences between cancer and medical patients in their preferred decisional role. INTERPRETATION: Seriously ill hospitalized patients have poor knowledge about CPR, and variable preferences for deliberation and their role in the decision-making process regarding their treatment. Strategies that improve understanding of CPR and foster discussions that involve patients, family members, and physicians in the decision-making process may improve the quantity and quality of communication and decision making about CPR.

Aged↗
PubMed2026

How do we counsel patients on short- and long-term complications after hypospadias repair? - A survey study.

INTRODUCTION: Hypospadias correction remains one of the most performed pediatric urologic procedures, affecting up to 1/150 males born in the United States. Current studies suggest that surgical counseling has a significant impact on shared decision making, decisional regret, and long-term follow-up. However, no set paradigm currently exists for long-term follow-up or counseling. We sought to obtain consensus from established pediatric urologists the optimal content and potential short, intermediate, and long-term complications to be considered when counseling patients and parents of patients with hypospadias. METHODS: We conducted an IRB-approved survey study, which sampled the responses of Pediatric Urologists from National and International listservs. A google scholar search was performed using key words including "hypospadias" and "long-term complications." Descriptions of pertinent short, intermediate and long-term complications were identified and compiled from existing patient handouts. Survey items were then developed asking respondents to rate proposed descriptions, provide potential edits, and describe their overall approach to counseling. RESULTS: A total of 290 surgeons were contacted with 120 (41 %) responding. In total, 89 respondents (74 %) identified as male and 105 (88 %) had undergone a pediatric urology fellowship. Most surgeons described a reliance on verbal counseling (95 %) with the assistance of hand-drawn diagrams (75 %) to explain long-term care, rather than electronic or audiovisual materials (3-12 %). Of note, fewer surgeons endorsed routine discussion of long-term complications (Range 29.2 %-50.8 %) than shorter-term complications (56.7 %-89.2 %). On a Likert scale, physicians reported that they were mostly satisfied (72 %) with their current approaches to counseling. DISCUSSION: Perioperative counseling has an important yet often overlooked role in surgical care. The aim of this study was to better understand current counseling practices in pediatric hypospadias to identify gaps in urologic care and areas for improvement as one of the most common conditions treated by pediatric urologists. Our results suggest that surgeons who perform hypospadias repairs have potential to include more comprehensive discussion during post-operative follow-up. We proposed a preliminary counselling guide for these concerns which incorporates language from the most commonly selected complication description by survey respondents. Future studies will involve expert consensus and patient input to confirm the adequacy of the content, the method of delivery, content appearance, and accommodations for health literacy. Limitations of the study include small sample size and response bias. The results are reflective of the summed responses of participants and are not reflective of individual providers or practices. Importantly, this study omits the input of other advanced practice providers (nurse practitioners, physician assistants, etc.), nurses, and ancillary staff who are also crucial to hypospadias care. The proposed counseling guide represents a first attempt at creating standardization of hypospadias counseling. CONCLUSION: Surgeons who perform hypospadias repair do not routinely discuss long-term complications after repair, though are overall satisfied with their counseling practices. Better tools, such as improved multimodal counseling guides, could be used to deliver this counseling efficiently and accurately to ensure patients receive optimal long-term care. Future studies will focus on developing educational materials for short, intermediate, and long-term counseling on complications after hypospadias repair with input from patients and clinicians.

Humans↗
PubMed2002

"Choice" in end-of-life decision making: researching fact or fiction?

PURPOSE: The contribution of bioethics to clinical care at the end of life (EOL) deserves critical scrutiny. We argue that researchers have rarely questioned the normative power of autonomy-based bioethics practices. Research on the ethical dimensions of EOL decision making has focused on an idealized discourse of patient "choice" that requires patients to embrace their dying to receive excellent palliative care. DESIGN AND METHODS: Our critique is based on a comprehensive review of empirical research exploring bioethics practices at the EOL. In addition we will provide a brief review of our own ethnographic, longitudinal study of the decision-making experience of dying patients, their families, and their health care providers. RESULTS: There is little or no empirical evidence to support the autonomy paradigm of patient "choice" in EOL decision making. What we found is that (a). prognostication at the EOL is problematic and resisted; (b). shared decision making is illusory, patients often resist advance care planning and hold other values more important than autonomy, and system characteristics are more determinative of EOL care than patient preferences; and (c). the incommensurability of medical and lay knowledge and values and the multifaceted and processual nature of patient and family decision making are at odds with the current EOL approach toward advance care planning. IMPLICATIONS: It is exceedingly difficult to identify, study, and critique normative assumptions without creating them, reproducing them, or obliterating them in the process. However, a fuller account of the morally significant domains of end-of-life care is needed. Researchers and policy makers should heed what we have learned from empirical research on EOL care to develop more sensitive and supportive programs for care of the dying.

Acquired Immunodeficiency Syndrome↗
PubMed2005

Promoting informed choice: evaluating a decision-making tool for family planning clients and providers in Mexico.

CONTEXT: The World Health Organization (WHO) has developed a decision-making tool to be used by providers and clients during family planning visits to improve the quality of services. It is important to examine the tool's usability and its impact on counseling and decision-making processes during family planning consultations. METHODS: Thirteen providers in Mexico City were videotaped with family planning clients three months before and one month after attending a training session on the WHO decision-making tool. The videotapes were coded for client-provider communication and eye contact, and decision-making behaviors were rated. In-depth interviews and focus group discussions explored clients' and providers' opinions of the tool. RESULTS: After providers began using the decision-making tool, they gave clients more information on family planning, tailored that information more closely to clients' situations and more often discussed HIV/AIDS prevention, dual protection and condom use. Client involvement in the decision-making process and client active communication increased, contributing to a shift from provider-dominated to shared decision making. Clients reported that the tool helped them understand the provider's explanations and made them feel more comfortable talking and asking questions during consultations. After one month of practice with the decision-making tool, most providers felt comfortable with it and found it useful; however, they recommended some changes to the tool to help engage clients in the decision-making process. CONCLUSIONS: The decision-making tool was useful both as a job aid for providers and as a decision aid for clients.

Adolescent↗
PubMed1994

Physicians in health care management: 8. The patient-physician partnership: decision making, problem solving and the desire to participate.

How reasonable are expectations that patients will participate in care decisions? The previous article in this series reviewed models of the patient-physician relationship and views on the extent to which patients want to be informed; it also described one information tool--the interactive videodisc. This article reviews literature on the extent to which patients wish to be involved in making decisions about their care. Neither "sensitive paternalism" nor "informed consent" appears to be ideal. The author suggests a distinction between two elements of choice: problem solving and decision making. This distinction helps in identifying appropriate roles for patient and provider, thereby leading to genuine shared decision making.

Decision Making↗
PubMed2004

Involving patients in decision making and communicating risk: a longitudinal evaluation of doctors' attitudes and confidence during a randomized trial.

BACKGROUND: Important barriers to the wider implementation of shared decision making (SDM) and risk communication in practice remain. The attitudes of professionals undergoing training in these approaches may inform how to overcome these barriers, but there are few such data yet available. AIM: To identify the attitudes of professionals during participation in a large practice-based intervention study with substantial individual exposure to SDM and risk communication, and to assess their confidence with these approaches and reported frequency of implementing them. SETTING AND PARTICIPANTS: Twenty general practitioners (GPs) who had been in practice between 1 and 10 years, and participated in an explanatory trial lasting 6 months. The trial interventions comprised training in SDM skills and the use of risk communication materials. The doctors consulted with up to 48 patients each (mean = 40, half of them audio-taped) for the study. METHODS: Questionnaire assessments before and after each training stage. RESULTS: The GPs indicated positive attitudes towards involving patients and towards the training interventions. They indicated that the risk information packs were applicable but had used them only occasionally with patients outside the trial. No statistically significant changes were associated with the specific interventions in terms of doctors' confidence in discussing risk information after the risk communication intervention, or attitudes to patient involvement after the SDM intervention. Most attitudes and confidence ratings showed positive changes during the course of the trial as a cohort effect. Such positive changes were associated with female doctors more than male doctors, but not with MRCGP (postgraduate vocational) qualification. Time constraints remained important throughout the study in not implementing the approach more frequently. CONCLUSIONS: Professionals appear receptive to patient involvement, and willing to acquire the relevant skills. SDM and risk communication training did not appear to contribute differentially to this. Practical barriers such as time constraints should probably be addressed with greater priority than the precise content of training or continuing professional development initiatives if 'involvement' is to become a commoner experience for patients in primary care.

Attitude of Health Personnel↗
PubMed2002

Relationship power, decision making, and sexual relations: an exploratory study with couples of Mexican origin.

This study explored how couples of Mexican origin define power in intimate relationships, what makes men and women feel powerful in relationships, and the role of each partner in decision making about sexual and reproductive matters. Interviews were conducted with each partner of 39 sexually active couples and data were analyzed using content analysis. Results indicate that power is perceived as control over one s partner and the ability to make decisions. Women say they feel more powerful in relationships when they make unilateral decisions and have economic independence. Men feel powerful when they have control over their partner and bring home money. Respondents agreed that women make decisions about household matters and children, while men make decisions related to money. Findings indicate that whereas couples share decision making about sexual activities and contraceptive use, men are seen as initiators of sexual activity and women are more likely to suggest condom use.

Adult↗
PubMed2004

Shared governance in an integrated health care network.

The nursing practice model of shared governance is a key strategy for enhancing work environments in Magnet hospitals. Shared governance is a dynamic process that promotes collaboration, shared decision making, and accountability for practice through workforce empowerment. Although the principles of shared governance are universal, structure and process generally follow the needs of an organization based on its core values, mission, vision, and philosophy. This article details the shared governance structure of one health care network.

Adult↗
PubMed2003

When do patients and their physicians agree on diabetes treatment goals and strategies, and what difference does it make?

BACKGROUND: For patients with chronic illnesses, it is hypothesized that effective patient-provider collaboration contributes to improved patient self-care by promoting greater agreement on patient-specific treatment goals and strategies. However, this hypothesis has not been tested in actual encounters of patients with their own physicians. OBJECTIVE: To assess the extent to which patients with type 2 diabetes agree with their primary care providers (PCPs) on diabetes treatment goals and strategies, the factors that predict agreement, and whether greater agreement is associated with better patient self-management of diabetes. DESIGN: One hundred twenty-seven pairs of patients and their PCPs in two health systems were surveyed about their top 3 diabetes treatment goals (desired outcomes) and strategies to meet those goals. Using several measures to evaluate agreement, we explored whether patient characteristics, such as education and attitudes toward treatment, and patient-provider interaction styles, such as shared decision making, were associated with greater agreement on treatment goals and strategies. We then examined whether agreement was associated with higher patient assessments of their diabetes care self-efficacy and self-management. RESULTS: Overall, agreement on top treatment goals and strategies was low (all kappa were less than 0.40). In multivariable analyses, however, patients with more education, greater belief in the efficacy of their diabetes treatment, and who shared in treatment decision making with their providers were more likely to agree with their providers on treatment goals or strategies. Similarly, physician reports of having discussed more content areas of diabetes self-care were associated with greater agreement on treatment strategies. In turn, greater agreement on treatment goals and strategies was associated both with higher patient diabetes care self-efficacy and assessments of their diabetes self-management. CONCLUSION: Although patients and their PCPs in general had poor agreement on goals and strategies for managing diabetes, agreement was associated with higher patient self-efficacy and assessments of their diabetes self-management. This supports the hypothesis that enhancing patient-provider agreement on both overall treatment goals and specific strategies to meet these goals may lead to improved patient outcomes.

Adult↗
PubMedDate not supplied

Practical considerations in dialysis withdrawal: "to have that option is a blessing".

Cessation of life-support treatment is an appropriate option for situations in which the burdens of therapy substantially outweigh the benefits. Decisions to withdraw dialysis now precede 1 in 4 deaths of patients who have end-stage renal disease. Guidelines have been recently published to assist clinicians in making these complex and emotionally charged determinations, and they include: relying on shared decision making by all participants, obtaining informed consent, estimating the prognosis on dialysis, adopting a systematic approach for conflict resolution of disagreements, honoring advance directives, and ensuring the provision of palliative care. These principles are discussed in relation to an elderly man with dementia whose family decided to terminate maintenance hemodialysis.

Advance Directives↗
PubMedDate not supplied

Complications within consent.

The consent process is intended to protect patients, prevent complaint and litigation, and help practitioners to be accountable, to justify their decisions, and to inform and involve patients/parents in their health care. Medico-legal guidance poses uncertainties and dilemmas that can undermine these aims and deter some practitioners from informing and involving patients/parents in decision making. Greater recognition of contradictions and limitations in the guidance on consent could assist practitioners and patients/parents in their shared decision making.

Communication↗
PubMed2004

[Information and participation interests of patients with depression in clinical decision making in primary care].

A main flaw in the primary care of depression is the patients' skepticism about adequate treatment. Despite effective treatment options patients' medical demand is poor and their information insufficient. The present study aims to improve patients' information and their participation in decision making to enhance treatment motivation and satisfaction with treatment and clinical outcome. It is unclear, though, if patients are able to show interest in information and participation because of depression-specific deficits (e.g. an impairment of cognition and concentration). In a controlled study 232 patients with depression from 30 GP practices completed questionnaires assessing information and participation needs. Patients with all severity grades of depression are highly interested in information (mean = 85.2; range 0-100) and moderately interested in participating in decision making (mean = 46.8; range 0-100). Perceived involvement in care achieved a mean of 68.4 (range 0-100). The implementation of shared decision making in the primary care of depressive patients is reasonable and will be realised and evaluated within the scope of a targeted continuing education program for general practitioners.

Depression↗
PubMed2001

Variability in patient preferences for participating in medical decision making: implication for the use of decision support tools.

While there is an increasing emphasis on patient empowerment and shared decision making, evidence suggests that many patients do not wish to be involved in decisions about their own care. Previous research has found patient preferences for involvement in decision making to vary with age, socioeconomic status, illness experience, and the gravity of the decision. Furthermore, there is evidence that certain patients may experience disutility from being involved in decision making about the treatment of their health problems. We discuss the implications of these findings for the use of decision support tools and the difficulties of targeting their use towards those patients most likely to benefit. We argue that patients may be ill informed about what participation in decision making actually entails and unaware of the benefits they stand to gain by articulating their preferences to their clinician. Furthermore, clinicians are not good at accurately assessing patients' preferences, while patients may have unrealistic expectations about their clinician's ability to "know what is best" for them. Further research is required to understand variations in patients' preferences for information and involvement in decision making, and the factors that influence them.

Communication↗