Decision-making in nephrology: shared decision making?

Shared decision-making is considered an important ideal for physician-patient interaction. The ideal states that health-related values should be discussed together. It raises two questions: (a) for which decisions is the ideal of shared decision-making relevant? (b) Which aspects of treatment should be discussed? The nephrological practice under consideration in this article answers question (a) as follows: decisions about the type of dialysis are shared decisions, while decisions about the moment to start dialysis are medical decisions that should be taken by nephrologists. This situation can be criticized as important health-related values play a role in decisions about starting dialysis. Question (b) is answered in the nephrological practice under consideration by discussing at least all important health-related aspects that raise uncertainty about its worth for a patient. This approach to question (b) is morally and practically defensible.     

How does decision complexity affect shared decision making? An analysis of patient-provider antiretroviral initiation dialogue

ObjectivesThis study analyzed patient-provider dialogue regarding anti-retroviral therapy (ART) initiation, assessing the degree to which shared decision making (SDM) occurred.MethodsWe analyzed 24 audio-recorded dialogues between 14 HIV providers and their patients regarding ART initiation. We coded transcribed dialogues for seven SDM elements. We stratified dialogues into three levels of decision complexity (basic, intermediate, complex) based on patient CD4 counts and evaluated SDM criteria fulfillment at each level of decision complexity.ResultsThere were five basic, twelve intermediate, and seven complex decisions in our sample. While only two met the defined criteria for SDM, the mean number of SDM elements present increased with each level of decision complexity. Discussion of the clinical issue requiring the decision occurred most frequently (88%), while discussion of pros/cons (13%), patient’s understanding (21%), and decision alternatives (29%) occurred least frequently.Conclusion/Practice implicationsWhile few dialogues met the defined SDM criteria, providers are having conversations that respond to decision complexity. Clinicians should be aware that discussion of pros/cons, alternatives, and uncertainties are frequently skipped, even when these elements are clearly relevant, as in complex decisions. In addition, rhetorical questions to assess patient preferences and understanding are insufficient to fully engage patients in SDM.     

Does training general practitioners result in more shared decision making during consultations?

ObjectiveWe conducted a clustered randomised controlled trial to study the effects of shared decision making (SDM) on patient recovery. This study aims to determine whether GPs trained in SDM and reinforcing patients’ treatment expectations showed more trained behaviour during their consultations than untrained GPs.MethodsWe compared 86 consultations conducted by 23 trained GPs with 89 consultations completed by 19 untrained GPs. The primary outcomes were SDM, as measured by the OPTION scale, and positive reinforcement, as measured by global observation. Secondary outcomes were the level of autonomy in decision making and the duration of the consultation.ResultsIntervention consultations scored significantly higher on most elements of the OPTION scale, and on the autonomy scale; however, they were three minutes longer in duration, and the mean OPTION score of the intervention group remained below average.ConclusionTraining GPs resulted in more SDM behaviour and more autonomy for the patient; however, this increase is not attributable to the adoption of a patient perspective. Furthermore, while we aimed to demonstrate that SDM facilitates the reinforcement of patients’ positive expectations, the measurement of this behaviour was not reliable.Practice implicationsIn supporting SDM, professionals should give greater attention to patients’ treatment expectations.     

Shared decision making: What is the work?

Cooperation has emerged as a fundamental characteristic of human society, and many argue that this ability is the basis for the phenomenal development in our capability as a species. When we focus our attention to the interactions that occur in healthcare, we inevitably notice power asymmetry due to unequal knowledge, experience, and status. However, as many have argued since the 1970s, there is an ethical imperative to respect the agency of individuals, offer information, collaborate, and support deliberation when difficult decisions arise. This process is particularly important when reasonable alternative courses of action exist and where the priorities and preferences of individuals would be expected to sway such decisions. This position article argues that this process, commonly described as shared decision making, involves work that is cognitive, emotional, and relational, and, particularly if people are ill, should have the underpinning goal of restoring autonomy. It covers the origin of the term and describes the core components; it describes how to do the cognitive, emotional, and relational work that is required, and offers a model to guide the process.     

Does shared decision making increase prostate screening uptake in countries with a low prevalence of prostate cancer?

BackgroundMen over 50 should discuss the benefits and harms of prostate-specific antigen (PSA) testing with their doctors.ObjectivesTo investigate whether shared decision making (SDM) increases the uptake of prostate cancer screening practices among Saudi men.MethodsThis community-based study recruited men aged ≥ 50 years between January and April 2019. Sociodemographic characteristics, history, and current medical condition information were collected. SDM information with regards to prostate cancer screening was discussed.ResultsIn total, 2034 Saudi men, aged between 50 and 88 years, agreed to participate in the current study. Prostate examination for early detection of cancer was recommended for 35.4% (720) of subjects. Of the subjects, 23.3% (473) reported that the physicians discussed the advantages and benefits of PSA testing, whereas only 5.6% (114) stated that the physicians explained the disadvantages and drawbacks of PSA testing.ConclusionOur findings suggest that less than one fourth discussed the advantages and disadvantages of PSA testing with their physicians; of these, less than one third underwent PSA blood tests. Improvements are needed in SDM for and against PSA screening. SDM does not affect the intensity of PSA testing. Primary health care physicians should be actively involved in the SDM process.     

Efficacy of the doktormitSDM training module in supporting shared decision making − Results from a multicenter double-blind randomized controlled trial

ObjectiveTraining to improve physicians’ shared decision making (SDM) competencies with proven effectiveness and efficiency is rare. This study evaluated the brief in situ training module ‘doktormitSDM’.MethodsIn a multicenter RCT, each physician recorded four consultations, each of which included a diagnostic or treatment decision (N = 152 consultations from seven medical specialties).The doktormitSDM training module included two video-based individual coaching sessions (15 min) at the physicians’ workplaces, supplemented by a manual and a video tutorial.Primary endpoint was the compound measure SDMmass (based on the MAPPIN’SDM system) which incorporates patient and observer perceptions of involvement and doctor-patient concordance on perceived involvement.ResultsSDMmass increased significantly in the intervention group compared to the controls (effect size 0.58; p= 0.05; t-test). This effect tended to persist at follow-up (effect size 0.63; p=0.06). Patients’ perceived involvement increased accordingly (effect sizes 0.9/.58; p=0.01/.07).ConclusionThe doktormitSDM training module is effective and efficient at improving SDM competencies. This is the first SDM training to be evaluated with a compound measure simultaneously considering doctor, patient and observer ratings.Practice implicationsOwing to its very brief form and its reference to the doctors’ own consultation videos, the doktormitSDM training module meets clinicians’ needs and time constraints.     

Is there a three neuron arc in the cat utriculo-trochlear pathway?

Summary The utriculo-ocular pathway was examined in decerebrated and anesthetized cats, in which all the vestibular afferents in the labyrinth, except for those innervating the utricular (UT) macula, had been transected. The UT nerve was stimulated with tungsten electrodes which were insulated except for 200 m at the tips. Stimulation of the UT nerve evoked a small negative (N₁) potential in the vestibular nuclei, with a threshold (N₁T) less than 25 A. The stimulus evoked disynaptic EPSPs in ipsilateral abducens (AB) motoneurons. The threshold and latency of the excitatory postsynaptic potentials (EPSPs) was 1.3 × N₁T and 1.2 ms, respectively, in accordance with the data of Schwindt et al. (1973). On the other hand, EPSPs with a clear rising phase and short latency, suggesting the existence of a disynaptic pathway, were never observed in any contralateral troch-lear (TR) motoneurons, even when triple shocks at intensities of up to 4 × N₁T were applied. This stimulus strength was strong enough to activate the UT nerve. Thus it seems very likely that a disynaptic pathway from the UT nerve to contralateral TR motoneurons, is absent or very poorly organized.     

Is there a critical period for the acquisition of segmental analysis?

Twelve Portuguese illiterate adults were required to delete the initial consonant of a spoken pseudoword and were provided with both explicit instructions and continuous corrective feedback. Nine of them displayed rapid improvements in performance. This suggests that there is no critical period for acquiring the ability of segmental analysis of speech.     

Is there a role for palmitoylethanolamide in the treatment of depression?

Depression is a common brain disorder affecting about 350 million people worldwide. Although the pharmacological treatment currently available can produce benefits in the majority of cases, residual depressive symptoms, cognitive deficits, functional impairment, and increase in frequency of relapses are frequently present in unipolar and bipolar depressed patients correctly treated. In the last years, numerous evidences have demonstrated the involvement of endocannabinoid system in the pathophysiology of mood disorders. Considering the recent findings about the antidepressant effect of palmitoylethanolamide in animal model, we have hypothesized the potential antidepressant effect of this fatty acid amide in unipolar and bipolar depressed patients.     

Spontaneous mental associations with the words “side effect”: Implications for informed and shared decision making

ObjectiveTo gain insight into patients’ medical decisions by exploring the content of laypeople’s spontaneous mental associations with the term “side effect.”MethodsAn online cross-sectional survey asked 144 women aged 40–74, “What are the first three things you think of when you hear the words ‘side effect?”' Data were analyzed using content analysis, chi-square, and Fisher’s exact tests.Results17 codes emerged and were grouped into 4 themes and a Miscellaneous category: Health Problems (70.8% of participants), Decision-Relevant Evaluations (52.8%), Negative Affect (30.6%), Practical Considerations (18.1%) and Miscellaneous (9.7%). The 4 most frequently identified codes were: Risk (36.1%), Health Problems-Specific Symptoms (35.4%), Health Problems-General Terms (32.6%), and Negative Affect-Strong (19.4%). Code and theme frequencies were generally similar across demographic groups (ps > 0.05).ConclusionThe term “side effect” spontaneously elicited comments related to identifying health problems and expressing negative emotions. This might explain why the mere possibility of side effects triggers negative affect for people making medical decisions. Some respondents also mentioned decision-relevant evaluations and practical considerations in response to side effects.Practice implicationsAddressing commonly-held associations and acknowledging negative affects provoked by side effects are first steps healthcare providers can take towards improving informed and shared patient decision making.     

Surgeons’ perspective on shared decision making in trauma surgery. A national survey

Objective

This study aimed to answer the following research question: What is the knowledge, opinion, and experience of trauma surgeons with respect to shared decision making (SDM)?