Shared mind: communication, decision making, and autonomy in serious illness

Shared Decision Making in a Youth Mental Health Service Design and Research Project: Insights From the Pan-Canadian ACCESS Open Minds Network

Shared decision making (SDM) is the process by which health care providers and patients collaborate to make health care decisions. This collaboration leads to informed decision making and improved outcomes. However, research on SDM specific to the field of youth mental health is scarce. ACCESS Open Minds (ACCESS OM) is a youth mental health research and evaluation project that implemented and evaluated SDM practices within its various activities and operations. The ACCESS OM network spans a diversity of youth mental health settings across Canada, and includes various stakeholders such as youth, family members and carers, clinicians, researchers, and policy makers. The project values all types of knowledge (specifically, experiential, cultural, clinical, and scientific knowledge) as necessary to lead to better health research, care delivery, and outcomes for patients and their communities. Similarly, it acknowledges the lived experience of patients and, family and carers as expertise. Through the integration of SDM practices, ACCESS OM has formulated valuable insights that can be applied to other health problems and settings. This paper, written by youth and family council members, operational staff, and researchers from the project, will share challenges and solutions that arose in the integration of SDM practices within ACCESS OM's knowledge translation strategy, governance structures, clinical contexts, and capacity-building initiatives. Shared Decision Making in a Youth Mental Health Service Design and Research Project: Insights From the Pan-Canadian ACCESS Open Minds Network (MP4  234838 kb).

Treating Patients As People: What Do Hospital Patients Want Clinicians to Know About Them As a Person?

Background

There is little understanding or focus on the patient's personal communicative perspective during their experience of clinical treatment. An exploratory study and a follow-up study were conducted at a large safety net hospital to determine whether and what patients wanted clinicians to know more about them as a person.

Study Design

A convenience sample of 230 patients was selected from 9 different clinical units within the hospital for exploratory interviews to determine whether patients wanted their clinical team to know about them as a person. Based on these findings, additional personal preference data of patients were collected from a census sample of 387 patients selected from 2 intensive care unit units and 2 medical-surgical units.

Findings

The majority of patients in the exploratory study reported they wanted to tell their doctors/nurses some personal information about themselves, thought doctors/nurses could provide better care to them if they knew more about them as a person, and that communication between themselves and their doctors/nurses would improve if they knew more about them as a person. The follow-up study found that a majority of patients preferred that their clinicians call them by their first name and identified specific personal information they wanted to share with the clinical care team. The data also showed a meaningful number of patients who did not want to share this information with others. This split in patient preferences is an important reminder that being aware of personal preferences of patients does not necessarily mean an invitation to increase intimacy in all clinician-patient communications.

Living and dying with incurable cancer: a qualitative study on older patients' life values and healthcare professionals' responsivity

BACKGROUND

In ageing Western societies, many older persons live with and die from cancer. Despite that present-day healthcare aims to be patient-centered, scientific literature has little knowledge to offer about how cancer and its treatment impact older persons' various outlooks on life and underlying life values. Therefore, the aims of this paper are to: 1) describe outlooks on life and life values of older people (≥ 70) living with incurable cancer; 2) elicit how healthcare professionals react and respond to these.

METHODS

Semi-structured qualitative interviews with 12 older persons with advanced cancer and two group interviews with healthcare professionals were held and followed by an analysis with a grounded theory approach.

RESULTS

Several themes and subthemes emerged from the patient interview study: a) handling incurable cancer (the anticipatory outlook on "a reduced life", hope and, coping with an unpredictable disease) b) being supported by others ("being there", leaving a legacy, and having reliable healthcare professionals) and; c) making end-of-life choices (anticipatory fears, and place of death). The group interviews explained how healthcare professionals respond to the abovementioned themes in palliative care practice. Some barriers for (open) communication were expressed too by the latter, e.g., lack of continuity of care and advance care planning, and patients' humble attitudes.

CONCLUSIONS

Older adults living with incurable cancer showed particular outlooks on life and life values regarding advanced cancer and the accompanying last phase of life. This paper could support healthcare professionals and patients in jointly exploring and formulating these outlooks and values in the light of treatment plans.

Investigating the Association Between Internet Health Information Use and Patient Willingness to Communicate with Health Care Providers

Communication between health professionals and patients is an intergroup phenomenon where the health professional has the most power and status. Over the past few decades, there has been a steady increase in the availability to patients of information about healthcare and specific diseases on the Internet. In this paper, we ask whether the use of Internet health information assists patients to manage their consultations with health professionals better and whether it alters the intergroup dynamic by providing a more equal status for patients. In this study 370 participants from Australia and Canada completed a survey that included a 'willingness to communicate with health professionals' scale. They also commented on their use and trust of Internet health information. Thematic analysis suggests that patients' use of Internet health information serves as a broker between patients and their health provider in health consultations. We discuss the implications of these findings for health practitioners as they address how easier Internet access influences patient interactions with health professionals. We consider future research directions these finding provide in explaining communication behaviour in this context.

Uncertainty Management and Decision Making: Parents' Experiences During their First Visit to a Multidisciplinary Clinic for their Child's Vascular Anomaly

PURPOSE

To gain a better understanding of parental decision making in situations of uncertainty and multidisciplinary care, we explored parents' decision-making experiences while seeking care for their child's vascular anomaly at a multidisciplinary clinic at a large Midwestern children's hospital.

DESIGN AND METHODS

We collected data using semi-structured interviews with 29 parents after they met with multiple specialists for the care of their child's vascular anomaly.

RESULTS

The findings revealed parents' attempts to manage decision-related uncertainty about their child's vascular anomaly included seeking information, avoiding information, and seeking support from the specialists. Parents described how information management both facilitated and obstructed decision making.

CONCLUSIONS

Overall, the study reveals several benefits and challenges of making decisions about the management of uncertain childhood conditions, like vascular anomalies, in a multidisciplinary context. The information-rich environment produces information-management dilemmas that challenge parents' decision making efforts. Therefore, parents relied on the support of the team of specialists to make decisions about their child's treatment.

PRACTICE IMPLICATIONS

The study offers practical implications concerning the barriers of autonomy in decision making. Healthcare professionals should acknowledge the potential for parents' to have shifting information and decision-making goals and preferences, and should explicitly support parents throughout the decision-making process.

Healthcare Decision-Making of African-American Patients: Comparing Positivist and Postmodern Approaches to Care

Healthcare decision-making (HCDM) may be a potentially challenging time for any person. When considered against the backdrop of being a minority, experiencing disparate care based on racial bias, and confronting the implications of advanced serious illness, the practices and processes of HCDM become increasingly complex. The purpose of this paper is to consider the HCDM of African-American patients with advanced serious illness through the lens of positivism and postmodernism and to make the argument that postmodern nursing is the ideal ethical and equitable approach to HCDM. Postmodernism reengages nurses to consider HCDM of African-American patients with advanced serious illness as an individualized, contextualized, whole-person process, requiring all ways of knowing. A postmodern nursing approach may promote sustainable and human-centered health interventions that will reposition an often marginalized group to the center of practice, policy, and research progress.

Humour and laughing in patients with prolonged incurable cancer: an ethnographic study in a comprehensive cancer centre

PURPOSE

Most people are familiar with the expression 'laughter is the best medicine'. By enhancing cognitive flexibility and strengthening relationships, laughter can be considered a holistic care-approach. Yet, in medical oncology, especially the palliative phase, using humour can be considered inappropriate or taboo. We aimed to explore the acceptability and functions of humour and laughter in patients with prolonged incurable cancer.

METHODS

This study was performed in a Dutch Comprehensive Cancer Centre. We included four short conversations with patients, eighteen in-depth patient-interviews and eleven observational fieldnotes in which humour was a major topic of the conversation. We further administered an online questionnaire to thirty-three oncology clinicians about their experiences with humour. Qualitative data were thematically analysed. We specifically distinguished between humour and laughter.

RESULTS

Nearly all specialists reported using humour (97%), and all reported sometimes laughing during consultations; 83% experienced a positive effect of laughter. These results were in line with patients' experiences: Patients noted that humour always stayed alive despite medical difficulties. Apart from this human aspect, patients also used humour to broach difficult topics and downplay challenges. Patients and specialists acknowledged that using humour is sometimes inappropriate, partly because they did not always share the same humour. Laughter, in contrast, was regarded as 'lighter' than humour, and could, accordingly, more easily be implemented. Specialists cautioned against patients using laughter to avoid broaching difficult topics.

CONCLUSION

Many conversations were full of laughter. Hierarchy as usually experienced between healthcare professionals and patients/relatives seemed to disappear when using laughter. If applied appropriately, adding shared laughter may help optimize shared decision-making.

Surgeons' Views on Shared Decision-Making

PURPOSE

Shared decision-making (SDM) has a significant role in surgical encounters, where decisions are influenced by both clinician and patient preferences. Herein, we sought to explore surgeons' practices and beliefs about SDM.

METHODS

We performed a qualitative study consisting of semi-structured individual interviews with 18 surgeons from private practice and academic surgery practices in Baltimore, Maryland. We purposively sampled participants to maximize diversity of practice type (academic vs private), surgical specialty, gender, and experience level. Interview topics included benefits and challenges to patient involvement in decision-making, communicating uncertainty to patients, and use of decision aids. Interviews were audio-recorded and transcribed. Transcripts were analyzed using content analysis to identify themes.

RESULTS

Surgeons were supportive of patients being involved in decision-making, particularly in cases with uncertainty about treatment options. However, surgeons identified SDM as being more appropriate for patients whom surgeons perceived as interested in decision-making involvement and for decisions in which surgeons did not have strong preferences. Additionally, surgeons reported typically presenting only a subset of available options, remaining confident in their ability to filter less suitable options based on intuitive risk assessments. Surgeons differed in their approach to making recommendations, with some guiding patients towards what they saw as the correct or optimal decision while others sought to maintain neutrality and support of the patients' chosen decision.

CONCLUSIONS

Many surgeons do not believe SDM is universally optimal for every surgical decision. They instead use assessments of patient disposition or potential clinical uncertainty to guide their perceived appropriateness of using SDM.

Students' patient-centered-care attitudes: The contribution of self-efficacy, communication, and empathy

OBJECTIVES

Patient-centered-care (PCC) attitudes are important to enhance PCC behavior, but research on perceptions and attitudes that contribute to PCC attitudes is limited. We tested a new model, assessing whether the association between self-efficacy and PCC attitudes is mediated by communication and empathy attitudes. Furthermore, we assessed medical-school-stage and gender differences in these variables.

METHODS

Medical/dentistry students (N = 653) completed self-reported questionnaires. Analyses were performed using Pearson's-correlations, PROCESS macro, and independent samples t-tests.

RESULTS

The association between communication self-efficacy and PCC attitudes was completely mediated by communication and empathy attitudes. Students in clinical years had more positive attitudes toward PCC and empathy, and higher communication self-efficacy. Females had more positive attitudes toward PCC, communication, and empathy.

CONCLUSIONS

The results emphasize the importance of communication self-efficacy and the mediating role of communication and empathy attitudes in enhancing PCC attitudes. This highlights the need to focus on learners' affective matter (what they feel/think) about their competencies and attitudes.

PRACTICE IMPLICATIONS

Educational interventions should improve understanding of the benefits of applying good communication skills, of learning the importance of empathy and its relevance to patient care, and strengthening students' confidence in applying these skills. Attention to these is important for enhancing students' PCC attitudes.

The Tinnitus Retraining Therapy Trial's Standard of Care Control Condition: Rationale and Description of a Patient-Centered Protocol

Purpose The selection and design of control conditions are critical factors in minimizing the influence of unwanted variables in randomized controlled trials (RCTs). This article describes the rationale, design, and content of a standard of care control condition in a Phase III RCT of tinnitus retraining therapy. Method Existing tinnitus practices at military hospitals were identified and aligned with the American Speech-Language-Hearing Association's (2006) preferred practice patterns for tinnitus management and counseling and embedded in a patient-centered protocol to ensure uniformity and treatment fidelity. Results For those involved in the design of behavioral RCTs, the article identifies options and methods to consider in the selection and design of control conditions. Conclusion For those who provide tinnitus services, the standard of care protocol developed for the tinnitus retraining therapy trial constitutes a patient-centered approach to intervention that can be implemented clinically. Supplemental Material https://doi.org/10.23641/asha.9342503.

How do GPs and patients share the responsibility for cancer safety netting follow-up actions? A qualitative interview study of GPs and patients in Oxfordshire, UK

OBJECTIVE

To explore patients' and General Practitioners' (GPs) accounts of how responsibility for follow-up was perceived and shared in their experiences of cancer safety netting occurring within the past 6 months.

DESIGN

In-depth interviews were recorded and transcribed verbatim. Data were analysed through an abductive process, exploring anticipated and emergent themes. Conceptualisations of 'responsibility' were explored by drawing on a transactional to interdependent continuum drawing from the shared decision-making literature.

SETTINGS AND PARTICIPANTS

A purposive sample of 25 qualified GPs and 23 adult patients in Oxfordshire, UK.

RESULTS

The transactional sharing approach involves responsibility being passed from GP to patient. Patients expected and were willing to accept responsibility in this way as long as they received clear guidance from their GP and had capacity. In interdependent sharing, GPs principally aimed to reach consensus and share responsibility with the patient by explaining their rationale, uncertainty or by stressing the potential seriousness of the situation. Patients sharing this responsibility could be put at risk if no follow-up or timeframe was suggested, they had inadequate information, were falsely reassured or their concerns were not addressed at re-consultation.

CONCLUSION

GPs and patients exchange and share responsibility using a combination of transactional and interdependent styles, tailoring information based on patient characteristics and each party's level of concern. Clear action plans (written where necessary) at the end of every consultation would help patients decide when to re-consult. Further research should investigate how responsibility is shared within and outside the consultation, within primary care teams and with specialist services.

Collaborative work partnerships: Fuel for personal resilience

Collaborative work partnerships bring joy and meaning to one’s work. Additionally, outcomes and productivity from the partnership are often richer and more expansive, contributing more to the system and more to the profession than individuals alone. Using stories and examples from their 12-year work relationship, the authors will explore elements that contribute to successful collaboration. This article will highlight the importance of embracing vulnerability as a preparatory step to creating collaborative partnerships and will discuss a model to understand how a partnership can advance the relationship to a higher level. Finally, it will examine how relational coordination in work settings can support productive collaboration.

Sharing in care: engaging care partners in the care and communication of breast cancer patients

PURPOSE

Family is often overlooked in cancer care. We developed a patient-family agenda setting intervention to engage family in cancer care communication.

METHODS

We conducted a pilot randomized controlled trial (NCT03283553) of patients on active treatment for breast cancer and their family "care partner." Intervention dyads (n = 69) completed a self-administered checklist to clarify care partner roles, establish a shared visit agenda, and facilitate MyChart patient portal access. Control dyads (n = 63) received usual care. We assessed intervention acceptability and initial effects from post-visit surveys and MyChart utilization at 6 weeks.

RESULTS

At baseline, most patients (89.4%) but few care partners (1.5%) were registered for MyChart. Most patients (79.4%) wanted their care partner to have access to their records and 39.4% of care partners reported accessing MyChart. In completing the checklist, patients and care partners endorsed active communication roles for the care partner and identified a similar visit agenda: most (> 90%) reported the checklist was easy, useful, and recommended it to others. At 6 weeks, intervention (vs control) care partners were more likely to be registered for MyChart (75.4% vs 1.6%; p < 0.001), to have logged in (43.5% vs 0%; p < 0.001) and viewed clinical notes (30.4% vs 0%; p < 0.001), but were no more likely to exchange direct messages with clinicians (1.5% vs 0%; p = 0.175). No differences in patients' MyChart use were observed, but intervention patients more often viewed clinical notes (50.7% vs 9.5%; p < 0.001).

CONCLUSIONS

A patient-family agenda setting intervention was acceptable and affected online practices of cancer patients and care partners.

How Do Blood Cancer Doctors Discuss Prognosis? Findings from a National Survey of Hematologic Oncologists

Background: Although blood cancers are accompanied by a high level of prognostic uncertainty, little is known about when and how hematologic oncologists discuss prognosis. Objectives: Characterize reported practices and predictors of prognostic discussions for a cohort of hematologic oncologists. Design: Cross-sectional mailed survey in 2015. Setting/Subjects: U.S.-based hematologic oncologists providing clinical care for adult patients with blood cancers. Measurements: We conducted univariable and multivariable analyses assessing the association of clinician characteristics with reported frequency of initiation of prognostic discussions, type of terminology used, and whether prognosis is readdressed. Results: We received 349 surveys (response rate = 57.3%). The majority of respondents (60.3%) reported conducting prognostic discussions with "most" (>95%) of their patients. More than half (56.8%) preferred general/qualitative rather than specific/numeric terms when discussing prognosis. Although 91.3% reported that they typically first initiate prognostic discussions at diagnosis, 17.7% reported routinely never readdressing prognosis or waiting until death is imminent to revisit the topic. Hematologic oncologists with ≤15 years since medical school graduation (odds ratio [OR] 0.51; confidence interval (95% CI) 0.30-0.88) and those who considered prognostic uncertainty a barrier to quality end-of-life care (OR 0.57; 95% CI 0.35-0.90) had significantly lower odds of discussing prognosis with "most" patients. Conclusions: Although the majority of hematologic oncologists reported discussing prognosis with their patients, most prefer general/qualitative terms. Moreover, even though prognosis evolves during the disease course, nearly one in five reported never readdressing prognosis or only doing so near death. These findings suggest the need for structured interventions to improve prognostic communication for patients with blood cancers.

Empowering Young People Living With Juvenile Idiopathic Arthritis to Better Communicate With Families and Care Teams: Content Analysis of Semistructured Interviews

Background

Young people living with juvenile idiopathic arthritis (JIA) face a number of communication barriers for achieving optimal health as they transition from pediatric care into adult care. Despite growing interest in mobile or wireless technologies to support health (mHealth), it is uncertain how these engagement tools might support young people, their families, and care teams to optimize preference-based treatment strategies.

Objective

This study aims to examine how an mHealth patient support system (mPSS) might foster partnership between young people living with JIA, their families, and care teams.

Methods

Semistructured interviews with young people (5-15 years old), their families, and JIA care teams were conducted using researcher-developed interviews guides. Transcribed data were qualitatively analyzed using conventional content analysis.

Results

We conducted semistructured interviews with 15 young people, their parents, and 4 care team members. Content analysis revealed the potential of an mPSS to support productive dialogue between families and care teams. We identified four main themes: (1) young people with JIA face communication challenges, (2) normalizing illness through shared experience may improve adherence, (3) partnership opens windows into illness experiences, and (4) readiness to engage appears critical for clinic implementation.

Conclusions

A human-centered mPSS design that offers JIA patients the ability to track personally relevant illness concerns and needs can enhance communication, generate consensus-based treatment decisions, and improve efficiency and personalization of care. Technology that supports continuous learning and promotes better understanding of disease management may reduce practice burden while increasing patient engagement and autonomy in fostering lasting treatment decisions and ultimately supporting personalized care and improving outcomes.

Specific feedback makes medical students better communicators

BACKGROUND

Feedback is regarded a key element in teaching communication skills. However, specific aspects of feedback have not been systematically investigated in this context. Therefore, the aim of this study was to investigate the effectiveness of communication skills training (CST) integrating specific, structured and behavioral feedback.

METHODS

We condensed best practice recommendations for feedback in a CST for undergraduate medical students and compared the effect of specific, structured and behavior-orientated feedback (intervention group CST-behav) to general, experience-orientated feedback (CST- exp. as our control group) in a randomized controlled trial (RCT). We investigated changes on communication skills evaluated by independent raters, and evaluated by standardized patients (SP). To do that, every student was video-recorded in a pre and post assessment.

RESULTS

Sixty-six undergraduate medical students participated voluntarily in our study. Randomization did not result in equally skilled groups at baseline, so valid inter-group comparisons were not possible. Therefore, we analyzed the results of 34 students of our intervention group (CST-behav). Five out of seven domains in communication skills as evaluated by independent raters improved significantly, and there was a significant change in the global evaluation by SP.

CONCLUSIONS

Although we were unable to make between-group comparisons, the results of the within group pre-post evaluation suggest that specific feedback helps improve communication skills.

Adolescent and young adult women's recommendations for establishing comfort with family planning providers' communication about and assessment for intimate partner violence

BACKGROUND

Intimate partner violence (IPV) is a serious public health problem that disproportionately affects adolescent women seeking family planning services. Current clinical guidelines recommend routine IPV assessment yet provide limited guidance on how to establish patient comfort in addressing this sensitive issue. Few studies exist describing the perspectives of adolescent female patients who have experienced IPV and their suggestions on how providers should communicate about IPV.

METHODS

This study is a subset of a larger IPV intervention trial in family planning clinics. For this study, we chose a qualitative approach using individual interviews to explore patient perspectives in an open, in-depth manner without limiting potential responses with predetermined answers or investigator-imposed assumptions. We audio recorded clinic encounters for participating providers and patients and interviewed patient participants, asking them to listen to and reflect on how their provider talked about IPV in their audiorecorded clinic encounters.

RESULTS

The mean age for the 44 participants was 22.8 years old. Participants named 'comfort' as a main component for discussing and disclosing IPV in the clinical setting. The sub-themes associated with how to create patient comfort include: Build the patient-provider relationship, Provider should communicate like a friend/be on the patient's level, Patient needs to feel cared for by provider, and Appropriate timing and space.

CONCLUSION

Methods for establishing patient comfort via communication should be incorporated into and examined within sensitive healthcare areas such as IPV and can be extended to HIV, palliative, and oncological care to improve patient health outcomes.

The Patient-Professional Interaction Questionnaire (PPIQ) to assess patient centered care from the patient's perspective

OBJECTIVE

To investigate how patients evaluate the provision of patient-centered care (PCC) by healthcare professionals and psychometrically test a questionnaire to assess it. A tool previously developed for self-assessment of professionals' provision of PCC was adapted into a patient-rated form, named Patient-Professional Interaction Questionnaire (PPIQ).

METHODS

A sample of 1139 patients from six hospitals completed the 16-item PPIQ and the questionnaire structure, reliability, susceptibility to social desirability, and associations with other variables were tested.

RESULTS

The PPIQ confirmed the original four-factor structure (effective communication, interest in the patient's agenda, empathy, and patient involvement in care) and showed acceptable reliability and measurement invariance across both in-/out-patients and first/non-first encounter with the evaluated professional. Associations with patients' social desirability were negligible and effective communication was rated the highest among the PPIQ dimensions. PPIQ scores varied according to patients' educational level and type of professional evaluated, while associations between first/non-first encounter and PPIQ scores varied according to in-/out-patient.

CONCLUSION

The PPIQ is a psychometrically sound patient-rated measure of the provision of PCC by healthcare professionals.

PRACTICE IMPLICATIONS

The PPIQ has potential value in promoting quality patient-professional interactions in the hospital setting, as patients' reported experience is an important dimension of the clinician's performance.

Therapeutic Presence: Its Contribution to the Doctor-Patient Encounter

In this article, we propose a model of doctor-patient encounter that integrates the concept of therapeutic presence (TP), derived from psychotherapy research, as an indispensable substrate for the benefit of the therapeutic alliance between patient and doctor. To this end, the concepts of the doctor-patient relationship and doctor-patient communication are revisited to explore their therapeutic dimensions. The concept of TP is defined, and existing literature about the relationship between that concept, the therapeutic alliance, and mindfulness is reviewed, alongside an examination of related concepts that have developed within nursing and medicine. We conclude that TP emerges as a transtheoretical concept that can be integrated into our understanding of the doctor-patient encounter to improve both doctor-patient communication and the doctor-patient relationship. The way in which the biomedical model may limit a present medicine is discussed, and the means of integrating such a model of doctor-patient encounter into medical training and practice is analyzed.

Evaluation of a Novel Preference Assessment Tool for Patients with Multiple Sclerosis

Background

We developed a preference assessment tool to help assess patient goals, values, and preferences for multiple sclerosis (MS) management. All preference items in the tool were generated by people with MS. The aim of this study was to evaluate this tool in a national sample of people with MS.

Methods

English-speaking patients with MS aged 21 to 75 years with access to the internet were recruited. Participants completed the preference tool online, which included separate modules assessing three core preference areas: treatment goals, preferences for attributes of disease-modifying therapies, and factors influencing a change in treatment. The tool generated a summary of participants' treatment goals and preferences. Immediately after viewing the summary, participants were asked to evaluate the tool. Rankings of preference domains were compared with rankings obtained in another study.

Results

In 135 people with MS who completed the tool and evaluation, the highest ranked goal was brain health (memory, thinking, brain), followed by disability concerns (walking, strength, vision). Rankings were highly similar to those in the referent study. Nearly all participants reported that the tool helped them understand their goals and priorities regarding MS and that the summary appropriately reflected what is important to them. Most participants (87%) wanted to discuss their treatment goals and priorities with their clinician.

Conclusions

This preference assessment tool successfully captured patients' goals, values, and preferences for MS treatment and could potentially be used to help patients communicate their preferences to their clinician.

Family caregiver descriptions of stopping chemotherapy and end-of-life transitions

PURPOSE

The purpose of this study was to describe family caregivers' perspectives of the final month of life of patients with advanced cancer, particularly whether and how chemotherapy was discontinued and the effect of clinical decision-making on family caregivers' perceptions of the patient's experience of care at the end of life (EOL).

METHODS

Qualitative descriptive design using semi-structured interviews collected from 92 family caregivers of patients with end-stage cancer enrolled in a randomized clinical trial. We used a phased approach to data analysis including open coding, focused coding, and within and across analyses.

RESULTS

We identified three patterns of transitions characterizing the shift away from active cancer treatment: (1) "We Pretty Much Knew," characterized by explicit discussions about EOL care, seemingly shared understanding about prognosis and seamless transitions from disease-oriented treatment to comfort-oriented care, (2) "Beating the Odds," characterized by explicit discussions about disease-directed treatment and EOL care options, but no shared understanding about prognosis and often chaotic transitions to EOL care, and (3) "Left to Die," characterized by no recall of EOL discussions with transitions to EOL occurring in crisis.

CONCLUSIONS

As communication and palliative care interventions continue to develop to improve care for patients with advanced cancer, it is imperative that we take into account the different patterns of transition and their unique patient and caregiver needs near the end of life. Our findings reveal considerable, and potentially unwarranted, variation in transitions from active treatment to death.

On caring and sharing-Addressing psychological, biographical, and spiritual aspects in integrative cancer care: A qualitative interview study on physicians' perspectives

BACKGROUND

Patients confronted with a cancer diagnosis experience a variety of existential needs encompassing emotional, psychological, and spiritual areas of being. A patient-centered care approach addressing such existential issues is recognized as an essential aspect of health care. The aim of this study is to explore what role psychological, biographical, and spiritual factors play for experienced doctors working in integrative cancer care.

METHOD

The qualitative study was based on in-depth interviews with 35 purposively sampled doctors, all practicing integrative oncology in the field of anthroposophic medicine in hospitals and/or office-based practices in Germany and other countries. Data were analyzed using structured content analysis.

RESULTS

Psychological, biographical, and spiritual factors are important issues in integrative cancer care. Prevailing themes identified in this study were enabling patients to participate in life, promoting autonomy and coping, stabilizing patients emotionally and cognitively, overcoming the disease, and-primarily if addressed by patients-integrating spiritual issues. Doctors offered conversation, counseling, and time, but also referred to art, music, literature, and nature, so that patients' ongoing emotional, psychological, and spiritual needs could be explored and addressed. Doctors' attitudes with regard to existential issues were seen as important, as was maintaining an attitude of openness towards existential issues.

CONCLUSION

Doctors in integrative cancer care utilize different methods to explore the needs of patients and employ a variety of treatment methods that address not just patients' medical issues but their existential concerns as well.

The ecology of patient and caregiver participation in consultations involving advanced cancer

OBJECTIVE

To identify predictors of participation of patients with advanced cancer in clinical encounters with oncologists and to assess the impact of patient and caregiver participation on perceptions of physician support.

METHODS

This is a secondary data analysis from the Values and Options in Cancer Care study, a cluster randomized clinical trial of a patient-centered communication intervention. Patients and caregivers completed pre-visit and post-visit health and communication measures. Audio recorded patient-caregiver (when present)-physician encounters were coded for active patient/caregiver participation behaviors (eg, question asking, expressing concern) and for physicians' facilitative communication (eg, partnership-building, support). Mixed linear regression models were used to identify patient, physician, and situational factors predicting patient and patient plus caregiver communication behaviors and post-visit outcomes.

RESULTS

Physician partnership building predicted greater expressions of concern and more assertive responses from patients and patient-caregiver pairs. Patients' perceptions of greater connectedness with their physician predicted fewer patient expressions of concern. Patient perceptions of physician respect for their autonomy were lower among patients accompanied by caregivers. Caregiver perceptions of physician respect for patient autonomy decreased with increasing patient age and varied by site.

CONCLUSIONS

In advanced cancer care, patient and caregiver communication is affected by ecological factors within their consultations. Physicians can support greater patient participation in clinical encounters through facilitative communication such as partnership-building and supportive talk. The presence of a caregiver complicates this environment, but partnership building techniques may help promote patient and caregiver participation during these visits.

Physician Communication to Enhance Patient Acupuncture Engagement in Family Medicine

Integrating complementary therapies (acupuncture) into conventional medicine has garnered recent support. Given the health benefits, low cost, and minimal risks, the military has advocated for acupuncture and begun training family medicine physicians. Little is known about the role of physician communication in patients' acupuncture engagement (uptake and adherence) in conventional medicine settings. We interviewed physicians (N = 15) and patients (N = 17) to capture physician communication they perceived affected treatment engagement. Data for each group were thematically analyzed. Physicians and patients prioritized different communication approaches and associated strategies. Physicians identified four approaches that enhance treatment engagement: (1) using shared decision-making (e.g., treatment options); (2) not being pushy (e.g., in tone); (3) carefully choosing language (e.g., Eastern versus Western terms); and (4) explaining treatment outcomes (e.g., efficacy). Patients also prioritized explaining treatment outcomes but differently (e.g., timing clarity), with two additional approaches: (5) talking with the same physician (e.g., continuity) and (6) being responsive to patient (e.g., flexibility). Findings highlight how physicians and patients prioritize patient-centered communication differently and how it is embedded within a unique, complex therapy. Data showcase authentic narratives that could be translated into physician communication skills training to promote treatment engagement in integrative care.

The Experience of Persons With Hematological Malignancy When Communicating With Health Care Professionals

This study aimed to elucidate the experiences of Japanese persons with hematological malignancy (PHMs) in communicating with health care professionals (HCPs), from diagnosis to the end of life, as recalled by their families. We interviewed 14 bereaved families and analyzed the data using the basic techniques of grounded theory. We found that PHMs lived to the fullest possible when they experienced ownership of their illness process despite their disease. The ownership was made possible by active communication from HCPs: first, acknowledging the PHM's way of life, including reaching out from the HCPs and appreciating sincerely PHMs' hopes and will; and second, paving the way ahead, including giving prospects and offering choices. The study underlines that rather than just providing information about the disease, HCPs need to actively ask about and show respect for the PHM's way of life. Only after achieving this can HCPs communicate possible future pathways with PHMs.

Engaging Patients in Decisions About Cancer Screening: Exploring the Decision Journey Through the Use of a Patient Portal

INTRODUCTION

Engaging patients to make informed choices is paramount but difficult in busy practices. This study sought to engage patients outside the clinical setting to better understand how they approach cancer screening decisions, including their primary concerns and their preferences for finalizing their decision.

METHODS

Twelve primary care practices offering patients an online personal health record invited eligible patients to complete a 17-item online interactive module. Among 11,458 registered users, invitations to complete the module were sent to adults aged 50-74 years who were overdue for colorectal cancer screening and to women aged 40-49 years and men aged 55-69 who had not undergone a recent mammogram or prostate-specific antigen test, respectively.

RESULTS

The module was started by 2,355 patients and completed by 903 patients. Most respondents (76.8%) knew they were eligible for screening. Preferred next steps were talking to the clinician (76.6%), reading/research (28.6%), and consulting trusted friends/family (16.4%). Priority topics included how much screening improves life expectancy, comparative test performance, and the prevalence/health risks of the cancer. Leading fears were getting cancer/delayed detection (79.2%), abnormal results (40.5%), and testing complications (39.1%), the last referring to false test results, medical complications, or unnecessary treatments. Men eligible for prostate-specific antigen screening were more likely than women eligible for mammography to express concerns about testing complications and to prioritize weighing pros and cons over gut feelings (p<0.05).

CONCLUSIONS

Although this sample was predisposed to screening, most patients wanted help in finalizing their decision. Many wanted to weigh the pros and cons and expressed fears of potential harms from screening. Understanding how patients approach decisions may help design more effective engagement strategies.

Development of a Framework Based on Reflective MCDA to Support Patient-Clinician Shared Decision-Making: The Case of the Management of Gastroenteropancreatic Neuroendocrine Tumors (GEP-NET) in the United States

Introduction

Well- or moderately differentiated gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are often slow-growing, and some patients with unresectable, asymptomatic, non-functioning tumors may face the choice between watchful waiting (WW), or somatostatin analogues (SSA) to delay progression. We developed a comprehensive multi-criteria decision analysis (MCDA) framework to help patients and physicians clarify their values and preferences, consider each decision criterion, and support communication and shared decision-making.

Methods

The framework was adapted from a generic MCDA framework (EVIDEM) with patient and clinician input. During a workshop, patients and clinicians expressed their individual values and preferences (criteria weights) and, on the basis of two scenarios (treatment vs WW; SSA-1 [lanreotide] vs SSA-2 [octreotide]) with evidence from a literature review, expressed how consideration of each criterion would impact their decision in favor of either option (score), and shared their knowledge and insights verbally and in writing.

Results

The framework included benefit-risk criteria and modulating factors, such as disease severity, quality of evidence, costs, and constraints. Overall and progression-free survival being most important, criteria weights ranged widely, highlighting variations in individual values and the need to share them. Scoring and considering each criterion prompted a rich exchange of perspectives and uncovered individual assumptions and interpretations. At the group level, type of benefit, disease severity, effectiveness, and quality of evidence favored treatment; cost aspects favored WW (scenario 1). For scenario 2, most criteria did not favor either option.

Conclusions

Patients and clinicians consider many aspects in decision-making. The MCDA framework provided a common interpretive frame to structure this complexity, support individual reflection, and share perspectives.

Funding

Ipsen Pharma.

Electronic supplementary material

The online version of this article (10.1007/s12325-017-0653-1) contains supplementary material, which is available to authorized users.

Involvement of people with dementia in making decisions about their lives: a qualitative study that appraises shared decision-making concerning daycare

OBJECTIVE

To explore how people with dementia, their informal caregivers and their professionals participate in decision making about daycare and to develop a typology of participation trajectories.

DESIGN

A qualitative study with a prospective, multiperspective design, based on 244 semistructured interviews, conducted during three interview rounds over the course of a year. Analysis was by means of content analysis and typology construction.

SETTING

Community settings and nursing homes in the Netherlands.

PARTICIPANTS

19 people with dementia, 36 of their informal caregivers and 38 of their professionals (including nurses, daycare employees and case managers).

RESULTS

The participants' responses related to three critical points in the decision-making trajectory about daycare: (1) the initial positive or negative expectations of daycare; (2) negotiation about trying out daycare by promoting, resisting or attuning to others; and (3) trying daycare, which resulted in positive or negative reactions from people with dementia and led to a decision. The ways in which care networks proceeded through these three critical points resulted in a typology of participation trajectories, including (1) working together positively toward daycare, (2) bringing conflicting perspectives together toward trying daycare and (3) not reaching commitment to try daycare.

CONCLUSION

Shared decision making with people with dementia is possible and requires and adapted process of decision making. Our results show that initial preferences based on information alone may change when people with dementia experience daycare. It is important to have a try-out period so that people with dementia can experience daycare without having to decide whether to continue it. Whereas shared decision making in general aims at moving from initial preferences to informed preferences, professionals should focus more on moving from initial preferences to experienced preferences for people with dementia. Professionals can play a crucial role in facilitating the possibilities for a try-out period.

A Qualitative Exploration of Clinician Views and Experiences of Treatment Decision-Making in Bipolar II Disorder

This study qualitatively explored clinicians' views and experiences of treatment decision-making in BPII. Semi-structured interviews were conducted with 20 practising clinicians (n = 10 clinical psychologists, n = 6 GPs, n = 4 psychiatrists) with experience in treating adult outpatients with BPII. Interviews were audiotaped, transcribed verbatim and thematically analysed using framework methods. Professional experience, and preferences for patient involvement in decision-making were also assessed. Qualitative analyses yielded four inter-related themes: (1) (non-)acceptance of diagnosis and treatment; (2) types of decisions; (3) treatment uncertainty and balancing act; and (4) decision-making in consultations. Clinician preferences for treatment, professional experience, and self-reported preferences for patient/family involvement seemed to influence decision-making. This study is the first to explore clinician views and experiences of treatment decision-making in BPII. Findings demonstrate how clinician-related factors may shape treatment decision-making, and suggest potential problems such as patient perceptions of lower-than-preferred involvement.

The TRIO Framework: Conceptual insights into family caregiver involvement and influence throughout cancer treatment decision-making

OBJECTIVE

Family caregivers are regularly involved in cancer consultations and treatment decision-making (DM). Yet there is limited conceptual description of caregiver influence/involvement in DM. To address this, an empirically-grounded conceptual framework of triadic DM (TRIO Framework) and corresponding graphical aid (TRIO Triangle) were developed.

METHODS

Jabareen's model for conceptual framework development informed multiple phases of development/validation, incorporation of empirical research and theory, and iterative revisions by an expert advisory group.

RESULTS

Findings coalesced into six empirically-grounded conceptual insights: i) Caregiver influence over a decision is variable amongst different groups; ii) Caregiver influence is variable within the one triad over time; iii) Caregivers are involved in various ways in the wider DM process; iv) DM is not only amongst three, but can occur among wider social networks; v) Many factors may affect the form and extent of caregiver involvement in DM; vi) Caregiver influence over, and involvement in, DM is linked to their everyday involvement in illness care/management.

CONCLUSION

The TRIO Framework/Triangle may serve as a useful guide for future empirical, ethical and/or theoretical work.

PRACTICE IMPLICATIONS

This Framework can deepen clinicians's and researcher's understanding of the diverse and varying scope of caregiver involvement and influence in DM.

Life values of elderly people suffering from incurable cancer: A literature review

OBJECTIVE

Due to aging Western societies, older patients suffering from incurable cancer will present themselves more often to health care professionals. To be of service to these severely ill elderly patients, more knowledge is needed on which life values are guiding them through their last phases of life. This review aims to describe which life values play an important part in the lives of elderly people suffering from incurable cancer.

METHODS

We conducted a literature review with a structured search to identify empirical studies (January 1950-February 2016) using six databases.

RESULTS

The analysis of thirty articles resulted in the extensive description of eight life values: comfort, continuity, humility, dignity, honesty, optimism, hope and preparedness.

CONCLUSION

Elderly patients suffering from incurable cancer use the abovementioned life values to give meaning to a life interrupted by disease. Furthermore, these values will play a role in communication and decision-making.

PRACTICE IMPLICATIONS

Knowledge about life values can help professionals discuss and clarify personal preferences with elderly patients suffering from incurable cancer, contributing to more personalized care and treatment. Communication should focus on to what extent patient empowerment, life-prolonging treatment and the involvement of the patient's supporting systems suit the wishes of these patients.

Unexpected Effects of a System-Distributed Mobile Application in Maternity Care: A Randomized Controlled Trial

BACKGROUND

As pregnant mothers increasingly engage in shared decision making regarding prenatal decisions, such as induction of labor, the patient's level of activation may influence pregnancy outcomes. One potential tool to increase patient activation in the clinical setting is mobile applications. However, research is limited in comparing mobile apps with other modalities of patient education and engagement tools.

AIM

This study was designed to test the effectiveness of a mobile app as a replacement for a spiral notebook guide as a patient education and engagement tool in the prenatal clinical setting.

METHOD

This randomized controlled trial was conducted in the Women's Health Clinic and Family Health Clinic of three hospitals. Repeated-measures analysis of covariance was used to test intervention effects in the study sample of 205 patients.

RESULTS

Mothers used a mobile app interface to more frequently record information about their pregnancy; however, across time, mothers using a mobile app reported a significant decrease in patient activation.

DISCUSSION

The unexpected negative effects in the group of patients randomized to the mobile app prompt these authors to recommend that health systems pause before distributing their own version of mobile apps that may decrease patient activation.

CONCLUSION

Mobile apps can be inherently empowering and engaging, but how a system encourages their use may ultimately determine their adoption and success.

Teaching medical students to express empathy by exploring patient emotions and experiences in standardized medical encounters

OBJECTIVES

To increase medical students' ability to detect contextual and emotional cues and to respond empathetically to patients.

METHODS

a training course in communication skills and patient-centered care with different teaching activities (didactic, reflective and interactive: workshops and encounters with simulated patients) was delivered to third-year medical students just before their clerkships. The program was evaluated by an external observer (OE) and simulated patients (SP) in 2 or 3 videotaped encounters.

RESULTS

Students improved significantly from baseline to 3rd interview in all communicative skills and domains explored both in OE (32.4%) and SP (38.3%) measurement. At the end of the course students detected significantly more clues and made more empathetic expressions.

CONCLUSIONS

The course seems to improve the ability of students to explore the illness experience, showing more empathy in a more genuine way. This was carried out in consultations lasting 10min.

PRACTICAL IMPLICATIONS

The program is effective and feasible to be applied as a regular formative activity. Further research is needed to assess whether this training program is applicable to students in more advanced educational levels and if it has any additional outcomes.

Integrating caring into patient-centered care through interprofessional education and ethics: The Caring Project

In an era of health care that is driven by biological and technical advances, there is a need to safeguard the caring component of care, the humanistic part of care. With this in mind, the authors constructed a Patient-Centered Caring model consisting of three overlapping constructs: delivering customer service, understanding the illness experience, and providing trauma-informed care. These practices operate within an interprofessional competency context. The authors describe an interprofessional educational project focused on understanding the illness experience and providing trauma-informed care to faculty, staff, and administrators in an inpatient psychiatric setting. The authors discuss the project through a number of ethical lenses that may help explicate the ethics of patient-centered care and caring and can be useful in the development of interprofessional competence.

Distributed Cognition in Cancer Treatment Decision Making: An Application of the DECIDE Decision-Making Styles Typology

Distributed cognition occurs when cognitive and affective schemas are shared between two or more people during interpersonal discussion. Although extant research focuses on distributed cognition in decision making between health care providers and patients, studies show that caregivers are also highly influential in the treatment decisions of patients. However, there are little empirical data describing how and when families exert influence. The current article addresses this gap by examining decisional support in the context of cancer randomized clinical trial (RCT) decision making. Data are drawn from in-depth interviews with rural, Appalachian cancer patients ( N = 46). Analysis of transcript data yielded empirical support for four distinct models of health decision making. The implications of these findings for developing interventions to improve the quality of treatment decision making and overall well-being are discussed.

Getting on the same page: Communication, patient involvement and shared understanding of "decisions" in oncology

Background

Patients and clinicians do not often agree on whether a decision has been made about cancer care. This could be explained by factors related to communication quality and/or the type of decision being made.

Methods

We used a self‐developed coding scheme to code a random sample of 128 encounters in which patients and clinicians either agreed (n=64) or disagreed (n=64) that a cancer care decision was made and tested for associations between concordance and key communication behaviours. We also identified and characterized cancer care decisions by topic and level of patient involvement and looked for trends.

Results

We identified 378 cancer care decisions across 128 encounters. Explicit decisions were most commonly made about topics wherein decision control could be easily delegated to a clear and present expert (eg either the patient or the clinician). Related to this, level of patient involvement varied significantly by decision topic. Explicit decisions were rarely made in an observable way about social, non‐clinical or self‐management related topics, although patients and clinicians both reported having made a cancer care decision in encounters where no decisions were observed. We found no association between communication behaviours and concordance in our sample.

Conclusions

What counts as a “decision” in cancer care may be constructed within disparate social roles that leave many agendas unaddressed and decisions unmade. Changing the content of conversations to encourage explicit decisions about self‐management and life context‐related topics may have greater value in enabling shared understanding than promoting communication behaviours among already high‐performing communicators.

The evolution of uncertainty in second opinions about prostate cancer treatment

Background

People who have cancer increasingly seek second opinions. Yet, we know little about what motivates patients to seek them and how beneficial they are. Uncertainty—experienced by patients or communicated by physician and patient—may be crucial throughout the second opinion process.

Objective

This study sought to investigate (1) how uncertainty influences men with prostate cancer to seek second opinions and (2) how second opinions may affect these patients’ sense of uncertainty and subsequent experiences with their care.

Methods

A qualitative study using semi‐structured interviews was performed. Men with localized or advanced prostate cancer (n=23) were interviewed by telephone about their motivations and experiences with seeking second opinions and the uncertainties they experienced. Analysis was performed using the constant comparative method.

Results

Patients sought second opinions because they were uncertain about receiving too little or biased information, experienced insufficient support in coming to a treatment decision, or because physicians expressed different levels of uncertainty than they did (“unshared uncertainty”). Uncertainty was reduced by the second opinion process for most patients, whereas for others, it increased or was sustained. This evolution depended on the way uncertainty was addressed during the second opinion consultation.

Conclusions

Second opinions may be a useful tool for some but not all patients. They should be used judiciously and not be viewed as a solution for current limitations to health‐care organization. An important yet challenging task for physicians is to focus less on information per se and more on how to assist patients manage irreducible uncertainty.

Applying a deliberation model to the analysis of consultations in haemophilia: Implications for doctor-patient communication

OBJECTIVE

Literature highlights the importance of communication in order to achieve patient's adherence. However, the specific dialogical components likely to favor patient adherence are not clear. In this study, the deliberation dialogue model was applied as an ideal model of optimal deliberation to real physician-patient consultations in the field of hemophilia in order to identify misalignments with the model and possible improvements in physician-patient communication.

METHODS

By applying the deliberation model, we analyzed a corpus of 30 check-up consultations in hemophilia.

RESULTS

Of 30 consultations, 24 (80%) contained 43 deliberation dialogues. Twenty-two (51%) deliberation dialogues were complete (e.g., included an opening stage with a clear statement of the problem, an argumentation stage in which both physician and patient participated, and a closing stage with an explicit patient commitment), whereas 21 (49%) deliberations were incomplete. These featured: Lack of/partial argumentation stage; Lack of closing stage; Lack of/partial argumentation stage and lack of closing stage.

CONCLUSIONS

The deliberation model can be applied to empirical data and allows to identify causes for suboptimal realizations of deliberation.

PRACTICE IMPLICATIONS

Once a problem is acknowledged, attention could be paid to engage hemophilic patients in the argumentation stages and elicit their explicit commitment.

Acquired and Participatory Competencies in Health Professions Education: Definition and Assessment in Global Health

Many health professions education programs in high-income countries (HICs) have adopted a competency-based approach to learning. Although global health programs have followed this trend, defining and assessing competencies has proven problematic, particularly in resource-constrained settings of low- and middle-income countries (LMICs) where HIC students and trainees perform elective work. In part, this is due to programs failing to take sufficient account of local learning, cultural, and health contexts.A major divide between HIC and LMIC settings is that the learning contexts of HICs are predominantly individualist, whereas those of LMICs are generally collectivist. Individualist cultures view learning as something that the individual acquires independent of context and can possess; collectivist cultures view learning as arising dynamically from specific contexts through group participation.To bridge the individualist-collectivist learning divide, the author proposes that competencies be classified as either acquired or participatory. Acquired competencies can be transferred across contexts and assessed using traditional psychometric approaches; participatory competencies are linked to contexts and require alternative assessment approaches. The author proposes assessing participatory competencies through the approach of self-directed assessment seeking, which includes multiple members of the health care team as assessors.The proposed classification of competencies as acquired or participatory may apply across health professions. The author suggests advancing participatory competencies through mental models of sharing. In global health education, the author recommends developing three new competency domains rooted in participatory learning, collectivism, and sharing: resourceful learning; transprofessionalism and transformative learning; and social justice and health equity.

What do young Australian women want (when talking to doctors about contraception)?

Background

Access to most contraceptives in Australia requires a prescription from a doctor, and it has been shown that doctors can influence women’s decision-making with respect to contraception. However, little research has documented how women experience their interactions with doctors within the context of a contraceptive consultation. Understanding such experiences may contribute to our knowledge of factors that may influence women’s contraceptive decisions more broadly.

Methods

We report on findings from the Contraceptive Use, Pregnancy Intentions and Decisions (CUPID) survey of young Australian women, a large-scale longitudinal study of 3,795 women aged 18–23 years. We performed a computer-assisted search for occurrences of words that indicated an interaction within the 1,038 responses to an open-ended question about contraception and pregnancy. We then applied a combination of conventional and summative content analysis techniques to the 158 comments where women mentioned an interaction about contraception with a doctor.

Results

Our analysis showed that women desire consistent and accurate contraception information from doctors, in addition to information about options other than the oral contraceptive pill. Some young women reported frustrations about the choice limitations imposed by doctors, perceived by these women to be due to their young age. Several women expressed disappointment that their doctor did not fully discuss the potential side-effects of contraceptives with them, and that doctors made assumptions about the woman’s reasons for seeking contraception. Some women described discomfort in having contraception-related discussions, and some perceived their doctor to be unsupportive or judgmental.

Conclusions

Both the content and the process of a contraceptive consultation are important to young Australian women, and may be relevant contributors to their choice and ongoing use of a contraceptive method. These findings provide useful insights into aspects of the patient-provider interaction that will enhance the efficacy of the contraceptive consultation. It is recommended that doctors adopt patient-centred, shared decision-making strategies to support women in making choices about contraception that suit their individual circumstances. We also acknowledge the need to involve other health care providers, other than doctors, in educating, informing, and assisting women to make the best contraceptive choice for themselves.

The influence of contextual factors on patient involvement during follow-up consultations after colorectal cancer surgery: a case study

AIMS AND OBJECTIVES

To identify the contextual factors that influence individual patient involvement during colorectal cancer surgical follow-up consultations.

BACKGROUND

The healthcare system is subject to the requirement and expectation of greater involvement of patients and relatives. Increased patient involvement requires the development and implementation of new communication initiatives. Research shows that it is also necessary to consider the contextual circumstances surrounding patient involvement in specific situations.

DESIGN

Case study of a single Danish outpatient clinic, which allows the issues and circumstances involved in an everyday situation to be captured.

METHOD

12 nonparticipative observations of outpatient visits and, subsequently, seven in-depth patient interviews.

ANALYSIS

Content analysis based on a dialogical, interactive framework, which underpinned the identification of current contextual factors.

RESULTS

The results showed five contextual factors that seemed to have an impact on patient involvement. The first, 'Two dimensions of patient involvement: treatment-oriented and person-oriented' highlighted a dual interpretation of patient involvement in the consultation situation. The two dimensions seemed to be influenced by four additional factors: 'Doctors leading the agenda', 'Traditional health professional roles', 'Unclear responsibilities' and 'Guidance primarily focused on treatment'.

CONCLUSION

The results showed how patient involvement in clinical practice could be understood as a two-way movement, in which patients are invited to participate in clinical practice, while health professionals are invited to participate in the patients' lives. The movement will change from situation to situation and is influenced by several contextual factors.

RELEVANCE TO CLINICAL PRACTICE

The results can help doctors and nurses to navigate using a goal-oriented approach towards patient involvement. The study makes visible the need for research-based development of the independent role of the nursing profession in cancer care follow-up, with a view to enhanced patient-centred care.

A qualitative exploration of patient and family views and experiences of treatment decision-making in bipolar II disorder

BACKGROUND

Treatment decision-making in bipolar II disorder (BPII) is challenging, yet the decision support needs of patients and family remain unknown.

AIM

To explore patient and family perspectives of treatment decision-making in BPII.

METHOD

Semistructured, qualitative interviews were conducted with 28 patients with BPII-diagnosis and 13 family members with experience in treatment decision-making in the outpatient setting. Interviews were audiotaped, transcribed verbatim and analysed thematically using framework methods. Participant demographics, clinical characteristics and preferences for patient decision-making involvement were assessed.

RESULTS

Four inter-related themes emerged: (1) Attitudes and response to diagnosis and treatment; (2) Influences on decision-making; (3) The nature and flow of decision-making; (4) Decision support and challenges. Views differed according to patient involvement preferences, time since diagnosis and patients' current mood symptoms.

CONCLUSIONS

This is the first known study to provide in-depth patient and family insights into the key factors influencing BPII treatment decision-making, and potential improvements and challenges to this process. Findings will inform the development of BPII treatment decision-making resources that better meet the informational and decision-support priorities of end users.

DECLARATION OF INTEREST

This research was partly funded by a Postgraduate Research Grant awarded to the first author by the University of Sydney. No conflicts of interest declared.

Factors predicting desired autonomy in medical decisions: Risk-taking and gambling behaviors

This study investigated factors that influence patients’ desired level of autonomy in medical decisions. Analyses included previously supported demographic variables in addition to risk-taking and gambling behaviors, which exhibit a strong relationship with overall health and decision-making, but have not been investigated in conjunction with medical autonomy. Participants (N = 203) completed measures on Amazon’s Mechanical Turk, including two measures of autonomy. Two hierarchical regressions revealed that the predictors explained a significant amount of variance for both measures, but the contribution of predictor variables was incongruent between models. Possible causes for this incongruence and implications for patient–physician interactions are discussed.