Does the use of shared decision-making consultation behaviors increase treatment decision-making satisfaction among Chinese women facing decision for breast cancer surgery?

Objective

To assess the extent to which breast surgical consultations used shared decision making (SDM), identify factors associated with use of SDM, and assess if using SDM increases decision-making satisfaction.

Methods

Two hundred and eighty-three video-recorded diagnostic-treatment decision consultations between breast surgeons and women with breast cancer were assessed using the Decision Analysis System for Oncology (DAS-O) coding system designed for assessing SDM behaviors. Women completed a questionnaire at pre-consultation, one-week post-consultation and one-month post-surgery. Patient outcomes included decision conflict, patient satisfaction with medical consultation, and decision regret.

Results

Overall, the level of SDM behaviors was low. The extent of SDM behavior within consultation was related to greater consultation duration (p < 0.001), more than one treatment being offered (p < 0.001), and fewer questions raised by patients/companions (p < 0.05). While use of SDM consultation did not influence post-consultation decision conflict, it increased satisfaction with information given and explained, patients’ feelings of trust and confidence in their surgeons, and reduced post-surgical decision regret.

Conclusion

These breast surgical consultations mostly adopted informed treatment decision-making approaches. Using SDM improved patient consultation and decision satisfaction.

Practice implications

The study findings highlight a need to reinforce the importance of SDM in consultations among breast surgeons.     

The mediating role of decision-making conflict in the association between patient’s participation satisfaction and distress during medical decision-making among Chinese patients with pulmonary nodules

ObjectiveWhen diagnosed as having pulmonary nodules, patients may be mired in the conflict of medical decision-making and suffered from distress. The purpose of this study was to investigate the mediating role of decision-making conflict in the relationship between participation satisfaction in medical decision-making (PSMD) and distress among Chinese patients with incidental pulmonary nodules.MethodsA total of 163 outpatients with incidental pulmonary nodules detected in a tertiary hospital were recruited and investigated by Impact of Event Scale (IES), Decision Conflict Scale (DCS), participation satisfaction in medical decision-making Scale (PSMDS), and demographic questionnaire.ResultsThe mean IES score was 37.35 ± 16.65, representing a moderate level. PSMD was negatively associated with distress, while decision-making conflict was positively associated with distress. The final regression model contained three factors: having a first-degree relative diagnosed with lung cancer, worrying about getting lung cancer someday, and decision-making conflict. These three factors explained 49.4 % of the variance of distress. The total effect of PSMD on distress and indirect effect of SPMD on distress caused-by decision-making conflict were significant (P < 0.05). However, the direct effect of PSMD on distress was not significant.ConclusionsParticipation of patients in medical decision-making can lower their distress by reducing patient's decision-making conflict.Practice implicationsInterventions targeting at the decision-making conflict will help alleviate the distress level of patients with pulmonary nodules.Data availabilityThe data that support the findings of this study are available on request from the corresponding author.     

The couple's decision-making in IVF: one or two embryos at transfer?

BACKGROUND: The aim of this study was to evaluate the decision-making process and factors that contribute to the decision of IVF participants to choose one or two embryos at transfer. METHODS: Two hundred and seventy-four IVF patients equally distributed in males and females were personally interviewed using a semi-structured questionnaire which included 82 items. RESULTS: In the whole study population, previous childbirth [odds ratio (OR) 2.1; 95% confidence interval (CI) 1.9-3.6], and spare embryos to freeze (OR 23.6; 95% CI 11.2-54.5) emerged as the most important variables in patients who had one embryo transferred, while previous IVF treatments (OR 0.3; 95% CI 0.1-0.6) and the assumed increased pregnancy chance (OR 0.1; 95% CI 0.05-0.3) were the most important decision-making factors among those who had two embryos. The women were more satisfied with the information (83 versus 71%; P = 0.02), and more aware of the risks with twin pregnancies (77 versus 66%; P = 0.03) than the males. The women were also more concerned about their age. Knowledge about risks of multiple pregnancies was higher in females (77%) than in males (66%, P = 0.03). CONCLUSION: The results of this study indicate that despite good information about the risks for complications with multiple pregnancies, many patients wish to have two embryos transferred. Spare embryos to freeze, improvement of pregnancy rate in single embryo transfer and young age of the woman are predictive of choosing single embryo transfer. However, the final decision must always be made in agreement with the physician.     

Identifying residents’ educational needs to optimising postgraduate medical education about shared decision-making

ObjectiveTo investigate how to optimise resident engagement during workplace learning of shared decision-making (SDM) by understanding their educational needs.MethodsA qualitative multicentre study was conducted using video-stimulated interviews with 17 residents in General Practice. Video recordings of residents’ recent clinical encounters were used to facilitate reflection on their educational needs.ResultsData analysis resulted in five themes regarding residents’ educational needs for learning SDM: acquiring knowledge and skills needed to perform SDM; practising SDM; reflection and feedback; longitudinal and integrated training; and awareness and motivation for performing SDM.ConclusionResidents expressed a need for continuous attention to be paid to SDM during postgraduate medical education. That would help them engage in two parallel learning processes: acquiring the knowledge and skills necessary to perform SDM, and practising SDM in the clinical workplace. Alignment between the educational curriculum, workplace learning and resident learning activities is essential to operationalise SDM attitude, knowledge and skills into clinical performance.Practice ImplicationsThe identified educational needs provide ingredients for fostering the development of SDM proficiency. The findings suggest that residents and clinical supervisors need parallel training to bridge the gap between education and clinical practice when learning SDM.     

Could 13C MRI assist clinical decision-making for patients with heart disease?

Even at this early stage of development, it is clear that the imaging of hyperpolarized (13)C-enriched molecules and their metabolic products offers a new approach to the study of the physiology and disease of the heart. The technology is practical in humans and, for this reason, we consider whether a role in clinical decision-making should motivate further development. The range of interventions available to treat coronary and valvular heart disease is already extensive, and new options are imminent. Yet the appropriate management of patients with left ventricular dysfunction can be challenging because the mechanism of reduced function may be unclear and the ability of the ventricle to respond to therapy may be difficult to predict. Pyruvate is a promising early target for development as a diagnostic agent because it lies at a critical branch point in cardiac biochemistry. The rate of metabolism of hyperpolarized pyruvate to CO(2) relative to lactate may prove to be a useful indicator of preserved mitochondrial function, and therefore provide a specific signal of viable myocardium. Other species including physiological substrates and nonphysiological molecules may provide additional information. Once suitable technology becomes available, it is likely that clinical research will progress quickly. The ability to monitor directly specific metabolic pathways may lead to an improvement in the selection of patients who will benefit from interventions, pharmacologic or otherwise.     

Rational decision-making about treatment and care in dementia: A contradiction in terms?

Objective

To gain caregivers’ insights into the decision-making process in dementia patients with regard to treatment and care.

Methods

Four focus group interviews (n = 29).

Results

The decision-making process consists of three elementary components: (1) identifying an individual's needs; (2) exploring options; and (3) making a choice. The most important phase is the exploration phase as it is crucial for the acceptance of the disease. Furthermore, the decision is experienced more as an emotional choice than a rational one. It is influenced by personal preferences whereas practical aspects do not seem to play a substantial role.

Conclusion

Several aspects make decision-making in dementia different from decision-making in the context of other chronic diseases: (1) the difficulty accepting dementia; (2) the progressive nature of dementia; (3) patient's reliance on surrogate decision-making; and (4) strong emotions. Due to these aspects, the decision-making process is very time-consuming, especially the crucial exploration phase.

Practice implications

A more active role is required of both the caregiver and the health care professional especially in the exploration phase, enabling easier acceptance and adjustment to the disease. Acceptance is an important condition for reducing anxiety and resistance to care that may offer significant benefits in the future.     

Is patient behavior during consultation associated with shared decision-making? A study of patients’ questions,cues and concerns in relation to observed shared decision-making in a cancer outpatient clinic

Objectives

To explore how cancer patients actively participate in consultations by asking questions and expressing emotional cues/concerns and to what extent this is associated with physician shared decision making (SDM) behavior.

Informed decision-making in prenatal screening for Down's syndrome: What knowledge is relevant?

Objective

To determine the content of decision-relevant knowledge needed for informed decision-making about (non-) participation in prenatal screening for Down's syndrome (DS), in order to develop a knowledge questionnaire for routine application in large-scale programme evaluations.

Methods

A generic list of content domains for knowledge about screening was extracted from the literature. Items reflecting specific knowledge domains were constructed. An expert group of professionals and pregnant women expressed whether domains and items represented decision-relevant information.

Results

All presented domains were scored as (very) important. Options when receiving an ‘increased probability for DS’ test result, the meaning of this result, the aim of the screening, and voluntary nature of the test were scored as most important. The condition being screened for, prevalence, and the screening procedure were scored as relatively less important, with a high amount of expert consensus.

Conclusion

A knowledge measure for prenatal screening for DS was developed, based on domains and items acquired by expert consensus.

Practice implications

This measure of decision-relevant knowledge can be used in routine, large-scale evaluations of the procedure for offering information about prenatal screening for DS.     

Shared decision-making – transferring research into practice: The Analytic Hierarchy Process (AHP)

ObjectiveTo illustrate how the Analytic Hierarchy Process (AHP) can be used to promote shared decision-making and enhance clinician–patient communication.MethodsTutorial review.ResultsThe AHP promotes shared decision-making by creating a framework that is used to define the decision, summarize the information available, prioritize information needs, elicit preferences and values, and foster meaningful communication among decision stakeholders.ConclusionsThe AHP and related multi-criteria methods have the potential for improving the quality of clinical decisions and overcoming current barriers to implementing shared decision-making in busy clinical settings. Further research is needed to determine the best way to implement these tools and to determine their effectiveness.Practice implicationsMany clinical decisions involve preference-based trade-offs between competing risks and benefits. The AHP is a well-developed method that provides a practical approach for improving patient–provider communication, clinical decision-making, and the quality of patient care in these situations.     

Shared decision-making in cardiology: Do patients want it and do doctors provide it?

Objective

Doctors should involve their patients in making decisions about their care. We studied patients with heart disease to assess if shared decision-making occurs and to study factors that predict patients’ choices or influence cardiologists’ behaviour.

Methods

85 patients attending for arteriography were assessed to elicit preferred involvement in decision-making, perception of involvement, and confidence in the decision.

Results

40% of patients wished to be involved in decisions. Preferences were unrelated to demographic factors. Cardiologists involved patients more in decisions concerning severe disease (p = 0.056). Involvement varied between cardiologists (p = 0.001). The mean duration of consultations was 5.5 min. Patients’ confidence in decisions correlated with duration (p = 0.001), explicit reference to a decision that needed to be made (p = 0.0026), and perceived, but not observed, involvement in decision-making (p = 0.05).

Conclusion

This study highlighted the complexity of doctor–patient communication. Irrespective of preferences for involvement, patients were more confident in decisions in which they perceived more involvement or which were the products of longer consultations.

Practice implications

Patients’ confidence in clinical decisions can be increased by increasing consultation length and increasing their perception of involvement. Patients perceive more involvement in decisions when doctors specifically identify the need for treatment decisions early in the consultation.     

Can patients’ preferences for involvement in decision-making regarding the use of medicines be predicted?

OBJECTIVE: The current study aimed to develop a model of patients' preferences for involvement in decision-making concerning the use of medicines for chronic conditions in the UK and test it in a large representative sample of patients with one of two clinical conditions. METHODS: Following a structured literature review, an instrument was developed which measured the variables that had been identified as predictors of patients' preferences for involvement in decision making in previous research. Five hundred and sixteen patients with rheumatoid arthritis or type 2 diabetes were recruited from outpatient and primary care clinics and asked to complete the instrument. RESULTS: Multivariate analysis revealed that age, social class and clinical condition were associated with preferences for involvement in decision-making concerning the use of medicines for chronic illness but gender, ethnic group, concerns about medicines, beliefs about necessity of medicines, health status, quality of life and time since diagnosis were not. In total, the fitted model explained only 14% of the variance. CONCLUSION: This study has demonstrated that current research does not provide a basis for predicting patients' preferences for involvement in decision-making. PRACTICE IMPLICATIONS: Building concordant relationships may depend on practitioners developing strategies to establish individuals' preferences for involvement in decision-making as part of the ongoing prescriber-patient relationship.     

Does a brief state mindfulness induction moderate disgust-driven social avoidance and decision-making? An experimental investigation

Journal of Behavioral Medicine - In this experimental study, we evaluated whether manipulated disgust and mindfulness predicted social avoidance in bowel health contexts. Community participants...     

Physician–patient–companion communication and decision-making: A systematic review of triadic medical consultations

Objective

To systematically review quantitative and qualitative studies exploring physician–adult patient–adult companion (triadic) communication and/or decision-making within all medical encounters.

Methods

Studies were identified via database searches and reference lists. One author assessed eligibility of studies, verified by two co-authors. Data were extracted by one author and cross-checked for accuracy. Two authors assessed the quality of included articles using standardized criteria.

Results

Of the 8409 titles identified, 52 studies were included. Summary statements and tables were developed for each of five identified themes. Results indicated companions regularly attended consultations, were frequently perceived as helpful, and assumed a variety of roles. However, their involvement often raised challenges. Patients with increased need were more often accompanied. Some companion behaviours were felt to be more helpful (e.g. informational support) and less helpful (e.g. dominating/demanding behaviours), and preferences for involvement varied widely.

Conclusion

Triadic communication in medical encounters can be helpful but challenging. Based on analysis of included studies, preliminary strategies for health professionals are proposed.

Practice implications

Preliminary strategies for health professionals include (i) encourage/involve companions, (ii) highlight helpful companion behaviours, (iii) clarify and agree upon role preferences of patient/companions. Future studies should develop and evaluate specific strategies for optimizing triadic consultations.     

Existential decision-making in a fatal progressive disease: how much do legal and medical frameworks matter?

Background

Healthcare legislation in European countries is similar in many respects. Most importantly, the framework of informed consent determines that physicians have the duty to provide detailed information about available therapeutic options and that patients have the right to refuse measures that contradict their personal values. However, when it comes to end-of-life decision-making a number of differences exist in the more specific regulations of individual countries. These differences and how they might nevertheless impact patient’s choices will be addressed in the current debate.

Main text

In this article we show how the legal and medical frameworks of Germany, Poland and Sweden differ with regard to end-of-life decisions for patients with a fatal progressive disease. Taking Amyotrophic Lateral Sclerosis (ALS) as an example, we systematically compare clinical guidelines and healthcare law, pointing out the country-specific differences most relevant for existential decision-making. A fictional case report discusses the implications of these differences for a patient with ALS living in either of the three countries. Patients with ALS in Germany, Poland and Sweden are confronted with a similar spectrum of treatment options. However, the analysis of the normative frameworks shows that the conditions for making existential decisions differ considerably in Germany, Poland and Sweden. Specifically, these differences concern (1) the legal status of advance directives, (2) the conditions under which life-sustaining therapies are started or withheld, and (3) the legal regulations on assisted dying.

Conclusion

According to the presented data, regulations of terminating life-sustaining treatments and the framework of “informed consent” are quite differently understood and implemented in the legal setting of the three countries. It is possible, and even likely, that these differences in the legal and medical frameworks have a considerable influence on existential decisions of patients with ALS.

     

Shared decision-making in physical therapy: A cross-sectional study on physiotherapists’ knowledge,attitudes and self-reported use

Objective

This study aimed a) to investigate knowledge, attitudes, and self-reported use of shared decision-making (SDM) among physiotherapists in Germany, b) to explore their association with demographic characteristics, and c) to assess barriers to the implementation of SDM.