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

Developing a tool to support diagnostic delivery of dementia

It is increasingly recognised that there are challenges affecting the current delivery of dementia diagnoses. Steps are required to address this. Current good practice guidelines provide insufficient direction and interventions from other healthcare settings do not appear to fully translate to dementia care settings. This project has taken a sequential two-phase design to developing a tool specific to dementia diagnostic delivery. Interviews with 14 participants explored good diagnostic delivery. Thematic analysis produced key themes (overcoming barriers, navigation of multiple journeys and completing overt and covert tasks) that were used to inform the design of a tool for use by clinicians, patients and companions. The tool was evaluated for acceptability in focused group discussions with 13 participants, which indicated a desire to use the tool and that it could encourage good practice. Adaptations were highlighted and incorporated to improve acceptability. Future research is now required to further evaluate the tool.

Patients' and oncologists' views on family involvement in goals of care conversations

OBJECTIVE

Family members can significantly impact advanced cancer patients' treatment and are important participants in goals of care (GoC) conversations. Yet, research on patient and physician perspectives about family involvement and influence on GoC conversations is limited. Our purpose was to describe patients' and oncologists' perspectives about family involvement and influence on GoC conversations among patients with advanced cancer.

METHODS

We conducted semi-structured interviews at academic, community, and municipal hospitals (n = 4) with patients with advanced cancer (n = 39) and their oncologists (n = 21). Interviews were audiotaped and transcribed. We analyzed data using interpretive description. Three coders independently coded transcripts, compared codes, and resolved discrepancies.

RESULTS

We identified 4 themes common to patients and oncologists regarding family involvement in GoC conversations: (1) Presence and Duration of Family Involvement; (2) Family Expectations; (3) Protecting patients'/Family Members' Feelings; and (4) Patient-Family Disagreement. For patients, we identified 2 additional themes: (1) Family and Oncologist Relationship and (2) Effects of Cancer on Family. Both patients and oncologists emphasized the importance of family support for the patient's understanding of their illness and on patients' emotions. We also identified ways in which family involvement may benefit or prove challenging to GoC conversations.

CONCLUSIONS

Patients and oncologists have similar views about family involvement in GoC conversations. Learning how to communicate with family members should be a critical component of physician education in palliative care.

Inviting patients and care partners to read doctors' notes: OpenNotes and shared access to electronic medical records

We examined the acceptability and effects of delivering doctors' visit notes electronically (via OpenNotes) to patients and care partners with authorized access to patients' electronic medical records. Adult patients and care partners at Geisinger Health System were surveyed at baseline and after 12 months of exposure to OpenNotes. Reporting on care partner access to OpenNotes, patients and care partners stated that they had better agreement about patient treatment plans and more productive discussions about their care. At follow-up, patients were more confident in their ability to manage their health, felt better prepared for office visits, and reported understanding their care better than at baseline. Care partners were more likely to access and use patient portal functionality and reported improved communication with patients' providers at follow-up. Our findings suggest that offering patients and care partners access to doctors' notes is acceptable and improves communication and patients' confidence in managing their care.

"Let him speak:" a descriptive qualitative study of the roles and behaviors of family companions in primary care visits among older adults with cognitive impairment

OBJECTIVE

Cognitive impairment poses communication challenges in primary care. Although family "companions" commonly attend primary care visits of older adults with cognitive impairment, little is known about how their involvement affects communication. Therefore, we sought to understand how companion involvement affects the quality of primary care visit communication for older adults with cognitive impairment.

METHODS

Cross-sectional, descriptive qualitative study participants were as follows: (1) English-speaking adults age 65 or older with mild, moderate, or severe cognitive impairment; (2) family members or other unpaid companions who accompany older adults to primary care visits; and (3) primary care clinicians. Twenty semi-structured and in-depth qualitative interviews of older adults and their companions (N = 20 dyads) and two focus groups (N = 10 primary care clinicians) were conducted. Interviews and focus groups were transcribed and analyzed thematically.

RESULTS

Family companions commonly facilitate communication by advocating for patients, ensuring the accuracy of information exchange and understanding, and preserving rapport. Significant communication challenges were also identified, including patient and companion role ambiguity, competing visit agendas, and primary care clinician confusion regarding the most accurate source of information. Patients, companions, and clinicians each identified strategies to improve communication, chief among them being to identify, differentiate, and respect both patient and companion priorities and perspectives.

CONCLUSIONS

Family companions actively participate in primary care visits of older adults with cognitive impairment in ways that promote and inhibit effective communication. Findings suggest the need for strategies that more effectively and purposefully involve family in the care of primary care patients with cognitive impairment. Copyright © 2017 John Wiley & Sons, Ltd.

Decision-Making Preferences About Secondary Germline Findings That Arise From Tumor Genomic Profiling Among Patients With Advanced Cancers

Purpose

In patients with advanced cancers, tumor genomic profiling (TGP) can reveal secondary germline findings (SGFs) regarding inherited disease risks. This study examines the process by which patients with advanced cancers would make the decision about whether or not to learn these SGFs, and their preferences regarding specific challenging decision scenarios including whether patients should be required to receive SGFs and whether SGFs should be returned to family after a patient's death.

Patients and Methods

We conducted qualitative semi-structured interviews with 40 patients with advanced breast, bladder, colorectal, or lung cancer who had TGP. Data were collected regarding participants' perspectives about the hypothetical decision to learn their SGFs including their anticipated approach to the decision-making process, as well as their preferences about challenging decision scenarios. Data were evaluated using thematic content analysis.

Results

We identified themes regarding participants' preferred degree of decisional autonomy, perceived vital role of doctors, information needs, and anticipated process of deliberation. Although participants reported that this decision was ultimately their own, many wanted input from family and trusted others. Oncologists were expected to provide decision guidance and key clarifying information. Most participants stated that patients should be able to make a choice about receiving actionable SGFs, and a majority stated that SGFs should be available to family after a patient's death.

Conclusion

These results provide insight into SGFs decision-making processes of patients with advanced cancers, which can allow clinicians to provide patients optimal decision support in this context. Patients with advanced cancers have specific information needs and decision-making preferences that educational and communication interventions should address to ensure that patients make informed choices about learning SGFs.

Development and Initial Validation of the Caregiver Perceptions About Communication With Clinical Team Members (CAPACITY) Measure

Despite the important role that family caregivers play managing the care of persons with complex health needs, little is known about how caregivers perceive themselves to be recognized and valued by health care professionals. Our objective was to develop and validate a novel measure, the CAregiver Perceptions About CommunIcation with Clinical Team members (CAPACITY) instrument. Questions focus on perceived quality of communication with the health care team and the extent to which caregivers believe that the health care team considers their capacity and preferences in decision making. A confirmatory factor analysis supported a two-factor solution addressing communication and capacity. Internal consistency reliability was .90 for the communication domain and .93 for the capacity domain. Correlations between these two subscales and individual difference measures provided evidence of convergent and discriminant validity. The CAPACITY instrument may be a useful performance measure that quantifies the extent to which caregivers' experience person- and family-centered health care.

Caregiver, patient, and nurse visit communication patterns in cancer home hospice

OBJECTIVE

Few studies have examined the triadic communication between patients, spouse caregivers, and nurses in the home hospice setting. Thus, little is known about the types of communication patterns that unfold. The goals of the study were to, first, identify common patterns of communication in nurse-patient-caregiver home hospice visits and, second, to identify nurse, caregiver-patient dyad, and visit characteristics that predict visit communication patterns.

METHOD

Nurses (N = 58) and hospice cancer patient and spouse caregiver dyads (N = 101; 202 individuals) were recruited from 10 hospice agencies. Nurses audio recorded visits to patient/caregiver homes from study enrollment until patient death. All patient, caregiver, and nurse utterances from the audio recordings were coded using an adapted Roter interaction analysis system. Using identified codes, cluster analysis was conducted to identify communication patterns within hospice visits. Logistic regression was used with demographic variables to predict visit communication patterns.

RESULTS

Six visit communication patterns were identified and were defined largely by 2 dimensions: (1) either the patient, the caregiver, or the patient and caregiver dyad interacting with the nurse and (2) the relatively high or low expression of distress during the visit. Time until death significantly predicted several clusters.

CONCLUSION

This study leads the way in outlining triadic communication patterns in cancer home hospice visits. Our findings have implications for nursing education, letting future nurses know what to expect, and lays the foundation for future research to determine effectiveness and interventions to improve health care communication.

Treatment decision-making in chronic diseases: What are the family members' roles, needs and attitudes? A systematic review

OBJECTIVE

This systematic review aims to examine the roles of family members (FMs) in treatment decision-making for adult patients without cognitive or psychiatric disorders affecting their ability to participate in decision-making.

METHODOLOGY

A comprehensive, systematic search of the Cochrane Library, PsycINFO, PubMed and ScienceDirect databases, with relevant keywords, was conducted. Two authors evaluated the eligibility of the studies independently, then cross-checked for accuracy. The quality of included studies were assessed using standardized criteria.

RESULTS

Out of the 12.137 studies identified, 40 were included. Results highlighted the different roles and influences FMs have in the decision-making process. Moreover, several factors ranging from personal to cultural and family-related factors influence their level of involvement. Regardless of the illness, some similarities in family influence exist (e.g., social support). However, the type of family involvement varies according to the illness, the treatment choice and the patients' culture.

CONCLUSION

FMs have an important role in the decision-making process. In fact, the final decision is often made by the patients after consulting their families. FMs can support both patients and medical teams, and thus facilitate the process.

PRACTICE IMPLICATIONS

Physicians should include FMs in treatment decision-making when the patients and their FMs wish to be included.

Evolving roles and structures of triadic engagement in healthcare

Purpose

The purpose of this paper is to focus on the changing nature of healthcare service encounters by studying the phenomenon of triadic engagement incorporating interactions between patients, local and virtual networks and healthcare professionals.

Design/methodology/approach

An 18-month longitudinal ethnographic study documents interactions in naturally occurring healthcare consultations. Professionals (n=13) and patients (n=24) within primary and secondary care units were recruited. Analysis of observations, field notes and interviews provides an integrated picture of triadic engagement.

Findings

Triadic engagement is conceptualised against a two-level framework. First, the structure of triadic consultations is identified in terms of the human voice, virtual voice and networked voice. These are related to: companions’ contributions to discussions and the virtual network impact. Second, evolving roles are mapped to three phases of transformation: enhancement; empowerment; emancipation. Triadic engagement varied across conditions.

Research limitations/implications

These changing roles and structures evidence an increasing emphasis on the responsible consumer and patients/companions to utilise information/support in making health-related decisions. The nature and role of third voices requires clear delineation.

Practical implications

Structures of consultations should be rethought around the diversity of patient/companion behaviours and expectations as patients undertake self-service activities. Implications for policy and practice are: the parallel set of local/virtual informational and service activities; a network orientation to healthcare; tailoring of support resources/guides for professionals and third parties to inform support practices.

Originality/value

Contributions are made to understanding triadic engagement and forwarding the agenda on patient-centred care. Longitudinal illumination of consultations is offered through an exceptional level of access to observe consultations.

The mediating role of spirituality (meaning, peace, faith) between psychological distress and mental adjustment in cancer patients

OBJECTIVE

The objectives of this study were (a) to determine the psychometric properties of the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp) scale and (b) to provide that FACIT scores behave one-dimensional to establish the mediating role of spiritual well-being in psychological distress and mental adjustment in a sample of patients with non-metastatic, resected cancer.

METHOD

A total of 504 consecutive patients completed the FACIT-Sp, Brief Symptom Inventory, and Mini-Mental Adjustment to Cancer scales. The dimensionality and structure of the scale were assessed by semi-confirmatory factor analysis; the reliability of the derived scale scores was evaluated using the omega coefficient, and regression analysis appraised the FACIT-Sp's mediating role between psychological distress and mental adjustment.

RESULTS

A clear and theoretically interpretable solution in two factors that agreed generally with solutions reported in other languages was obtained for the FACIT item scores and omega reliabilities of the derived Meaning/Peace (0.85) and Faith (0.86) scales were acceptable. The oblique solution in two factors was compatible with an essentially unidimensional solution of general well-being and associated strongly with psychological distress and mental adjustment. Spiritual well-being acted as a partial mediator between psychological distress and mental adjustment strategies, such as fighting spirit, hope, and cognitive avoidance.

CONCLUSIONS

The Spanish version of the FACIT-Sp scale is a reliable and valid clinical evaluation tool, and further highlights the potential clinical implications of spirituality for improving quality of life and adjustment to cancer.

[Why and how to promote decision-making autonomy of cancer patients?]

Involvement of patients in decision-making about their health has been promoted nationally and internationally since several years. Despite this, patient (and their relatives) participation remains insufficient and one of the objectives of the current French national cancer policy (Plan cancer 2014-2019) is to give everyone the possibility to play an active role in the management of their care. This overview focuses on decision-making autonomy of cancer patients through two main questions: why and how to promote it? After a brief review of the decision-making models described in the literature in the past decades insisting on the major role of the decisional context and the dynamic character of this context, this article presents a selection of published works which aimed to respond to those 2 questions.

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.

Communication with patients and the duration of family medicine consultations

OBJECTIVE

To determine the distribution of consultation times, the factors that determine their length, and their relationship with a more participative, patient-centred consulting style.

DESIGN

Cross-sectional multicentre study.

LOCATION

Primary Healthcare Centres in Andalusia, Spain.

PARTICIPANTS

A total of 119 tutors and family medicine physician residents.

PRINCIPAL MEASUREMENTS

Consultation length and communication with the patient were analysed using the CICCAA scale (Connect, Identify, Understand, Consent, Help) during 436 interviews in Primary Care.

RESULTS

The mean duration of consultations was 8.8min (sd: 3.6). The consultation tended to be longer when the physician had a patient-centred approach (10.37±4.19min vs 7.54±2.98min; p=0.001), and when there was joint decision-making (9.79±3.96min vs 7.73±3.42min: p=0.001). In the multivariable model, longer consultations were associated with obtaining higher scores on the CICAA scale, a wider range of reasons for consultation, whether they came accompanied, in urban centres, and a smaller number of daily visits (r²=0.32). There was no correlation between physician or patient gender, or problem type.

CONCLUSION

A more patient centred medical profile, increased shared decision-making, a wider range of reasons for consultation, whether they came accompanied, in urban centres, and less professional pressure all seem to be associated with a longer consultation.

Crossing the perspectives of patients, families, and physicians on cancer treatment: A qualitative study

Purpose

Patients, family members, and physicians participate in cancer care, but their perspectives about what is helpful during cancer treatment have rarely been compared. The aim of this study was to compare these three perspectives.

Methods

Multicenter qualitative study (with previously published protocol) based on 90 semi-structured interviews. Participants (purposively selected until data saturation) came from three different subsamples: (i) patients with cancer (n=30), (ii) their relatives (n=30), and (iii) their referring physicians (n=10, interviewed more than once).

Results

Our analysis found 3 main axes (perceived positive effects of cancer treatment, perceived negative effects of cancer treatment, doctor-physician relationship), each composed of 2 main themes. The findings showed that patients, families, and physicians shared the long-term objective of increasing survival (while reducing side effects). However, patients and relatives also pointed out the importance of living with cancer each day and thus of factors helping them to live as well as possible in daily life. The physicians difficulty in coping with patients suffering may limit their access to elements that can improve patients capacity to live as well as possible.

Conclusions

During cancer treatment (and not only at the end of life), attention should be given to enhancing the capacity of patients to live as well as possible (not only as long as possible) to meet the goals of patient-centered care and satisfy this important need of patients and families.

Twelve tips for just in time teaching of communication skills for difficult conversations in the clinical setting

The ability to communicate well with patients and other members of the healthcare team is a vital skill for physicians to have, but one that is often not emphasized in medical education. Learners of all levels can obtain and develop good communication skills regardless of their natural ability in this area, and the clinical setting represents an underutilized resource to accomplish this task. With this in mind, we have reviewed the growing body of literature on the subject and organized our findings into twelve tips to help educators capitalize on these missed opportunities. While our emphasis is helping learners with difficult discussions, these tips can be easily adapted to any other clinical encounter requiring clear communication. Teaching effective communication skills in the clinical setting requires some extra time, but the steps outlined should not take more than a few minutes to complete. Taking the time to develop these skills in our learners will make a significant difference not only their lives but also their patients and their families.

Who Decides: Me or We? Family Involvement in Medical Decision Making in Eastern and Western Countries

Background. Research suggests that desired family involvement (FI) in medical decision making may depend on cultural values. Unfortunately, the field lacks cross-cultural studies that test this assumption. As a result, providers may be guided by incomplete information or cultural biases rather than patient preferences. Methods. Researchers developed 6 culturally relevant disease scenarios varying from low to high medical seriousness. Quota samples of approximately 290 middle-aged urban residents in Australia, China, Malaysia, India, South Korea, Thailand, and the USA completed an online survey that examined desired levels of FI and identified individual difference predictors in each country. All reliability coefficients were acceptable. Regression models met standard assumptions. Results. The strongest finding across all 7 countries was that those who desired higher self-involvement (SI) in medical decision making also wanted lower FI. On the other hand, respondents who valued relational-interdependence tended to want their families involved – a key finding in 5 of 7 countries. In addition, in 4 of 7 countries, respondents who valued social hierarchy desired higher FI. Other antecedents were less consistent. Conclusion. These results suggest that it is important for health providers to avoid East–West cultural stereotypes. There are meaningful numbers of patients in all 7 countries who want to be individually involved and those individuals tend to prefer lower FI. On the other hand, more interdependent patients are likely to want families involved in many of the countries studied. Thus, individual differences within culture appear to be important in predicting whether a patient desires FI. For this reason, avoiding culture-based assumptions about desired FI during medical decision making is central to providing more effective patient centered care.

Information and decision-making needs of psychiatric patients: the perspective of relatives

Background

Mental illness may strongly affect relatives’ lives. Therefore, it is important to empower relatives by providing health information according to their preferences.

Methods

An online cross-sectional survey was conducted using a purpose-designed questionnaire on online health information and decision-support needs.

Results

Prevalent reasons for online health information search of the 185 participating relatives were the need for general information and the insufficiency of the information given by the health care provider. The most difficult treatment decisions concerned the treatment setting (inpatient or outpatient) as well as the psychopharmacological treatment.

Discussion

Since psychiatric patients’ relatives report extensive information and decision-support needs, it is essential to address their needs in health information material. Assessment of relatives’ needs when developing health information materials is recommended.

Patient companions in the Turkish healthcare system: the role, expectations and problems

The purpose of this study was to determine the roles, expectations and problems of patient companions and to develop solutions to the difficulties encountered by the nurses, patients and their companions. A qualitative approach with semi-structured face-to-face interviews was used during May and June 2014 to collect data. A convenience sample of participants was selected from the nurses, patients and their companions. Content analysis was used for the data. The results of this study revealed that the need for companions is important to the current Turkish healthcare system, but it has many drawbacks. As companions are witness to a patient's declining health and family, social and financial problems, their role should be to support their patients emotionally or socially, but they should not perform medical tasks. Therefore, the agencies responsible for managing the use of patient companions should regularly review its function by communicating often with the patients and their caregivers. Open communication between patient companions and all those responsible for patient care could improve the present difficulties which exist.

Surrogate health information seeking in Europe: Influence of source type and social network variables

OBJECTIVES

Health information seeking on behalf of others is an important form of social support by which laypeople provide important sources of information for patients. Based on social network theory, we analyze whether this phenomenon also occurs in offline sources. We also seek to learn more about the type of relationships between information seekers and patients, as research to date indicates that surrogate seeking mostly occurs in close relationships between the seeker and the patient.

METHODS

Using a large-scale representative survey from the 28 member states of the European Union (N=26,566), our data comprise all respondents who reported seeking health information online or offline (n=18,750; 70.6%).

RESULTS

Within the past year, 61.0% of the online health information seekers and 61.1% of the offline health information seekers had searched on behalf of someone else. Independent of the information channel, surrogate seekers primarily searched for health information for family members (online: 89.8%; offline: 92.8%); they were significantly less likely to search for information on behalf of someone with whom they had weaker ties, such as colleagues (online: 25.1%; offline: 24.4%). In a multilevel generalized linear model, living together with someone was by far the most relevant determinant for surrogate seeking, with differences between countries or Internet activity being less important.

CONCLUSION

These results support the assumptions of social network theory. Implications are discussed, especially with regard to the provision of adequate health information.

Examining the context and helpfulness of family companion contributions to older adults' primary care visits

OBJECTIVE

Older adults commonly involve family (broadly defined) in their care. We examined communication behaviors of family companions during older adults' primary care visits, including whether these behaviors vary with respect to how older adults manage their health, preferences for involving family in medical decision-making, and ratings of companion helpfulness.

METHODS

Analysis of audio-taped primary care visits of older patients who were accompanied by a family companion (n=30 dyads) and linked patient surveys.

RESULTS

Family companions predominantly facilitated doctor and patient information exchange. More than half of companion communication behaviors were directed at improving doctor understanding of the patient. Companions were more verbally active during visits of patients who delegated the management of their health to others than visits of patients who co-managed or self-managed their health. Companions were rated as more helpful by patients who preferred active involvement of family in medical decision-making.

CONCLUSION

Family companion participation and helpfulness in primary care communication varies by patients' preferences for involving family in medical decision-making and approach to manage their health.

PRACTICE IMPLICATIONS

Research to examine the effects of clarifying patient and family companion expectations for primary care visits could inform strategies to improve the patient-centeredness of medical communication.

A patient in the clinic; a person in the world. Why shared decision making needs to center on the person rather than the medical encounter

Interest in shared decision making (SDM) has increased and become widely promoted. However, from both practical and measurement perspectives, SDM's origin as an outgrowth of patient autonomy has resulted in narrowly conceptualizing and operationalizing decision making. The narrow focus on individual patient autonomy fails in four main ways: 1) excluding several facets of the roles, actions, and influences of decision partners in decision making; 2) focusing solely on the medical encounter; 3) ignoring the informational environment to which patients have access; and 4) treating each encounter as independent of all others. In addition to creating a research agenda that could answer important outstanding questions about how decisions are made and the consequences thereof, reconceiving SDM as centered on the person rather than the medical encounter has the potential to transform how illness is experienced by patients and families and how clinicians find meaning in their work.

A systematic review of effectiveness of decision aids to assist older patients at the end of life

OBJECTIVE

To describe the range of decision aids (DAs) available to enable informed choice for older patients at the end of life and assess their effectiveness or acceptability.

METHODS

Search strategy covered PubMed, Scopus, Ovid MEDLINE, EMBASE, EBM Reviews, CINAHL and PsycInfo between 1995 and 2015. The quality criteria framework endorsed by the International Patient Decision Aids Standards (IPDAS) was used to assess usefulness.

RESULTS

Seventeen DA interventions for patients, their surrogates or health professionals were included. Half the DAs were designed for self-administration and few described use of facilitators for decision-making.

TREATMENT

options and associated harms and benefits, and patient preferences were most commonly included. Patient values, treatment goals, numeric disease-specific prognostic information and financial implications of decisions were generally not covered. DAs at the end of life are generally acceptable by users, and appear to increase knowledge and reduce decisional conflict but this effectiveness is mainly based on low-level evidence.

CONCLUSIONS

Continuing evaluation of DAs in routine practice to support advance care planning is worth exploring further. In particular, this would be useful for conditions such as cancer, or situations such as major surgery where prognostic data is known, or in dementia where concordance on primary goals of care between surrogates and the treating team can be improved.

PRACTICE IMPLICATIONS

Given the sensitivities of end-of-life, self-administered DAs are inappropriate in this context and genuine informed decision-making cannot happen while those gaps in the instruments remain.

Family presence and participation during medical visits of heart failure patients: An analysis of survey and audiotaped communication data

OBJECTIVE

To describe the frequency, roles, and utility of family companion involvement in the care of patients with Heart Failure (HF) care and to examine the association between audiotaped patient, companion, and provider communication behaviors.

METHODS

We collected survey data and audiotaped a single medical visit for 93 HF patients (36 brought a companion into the examination room) and their cardiology provider. Communication data was analyzed using the Roter Interaction Analysis System.

RESULTS

There were 32% more positive rapport-building statements (p<0.01) and almost three times as many social rapport-building statements (p<0.01) from patients and companions in accompanied visits versus unaccompanied patient visits. There were less psychosocial information giving statements in accompanied visits compared to unaccompanied patient visits (p<0.01.) Providers made 25% more biomedical information giving statements (p=0.04) and almost three times more social rapport-building statements (p<0.01) in accompanied visits. Providers asked fewer biomedical and psychosocial questions in accompanied versus unaccompanied visits. Providers made 16% fewer partnership-building statements in accompanied versus unaccompanied visits (p=0.01).

CONCLUSIONS

Our findings are mixed regarding the benefits of accompaniment for facilitating patient-provider communication based on survey and audiotaped data.

PRACTICE IMPLICATIONS

Strategies to enhance engagement during visits, such as pre-visit question prompt lists, may be beneficial.

What is a good medical decision? A research agenda guided by perspectives from multiple stakeholders

Informed and shared decision making are critical aspects of patient-centered care, which has contributed to an emphasis on decision support interventions to promote good medical decision making. However, researchers and healthcare providers have not reached a consensus on what defines a good decision, nor how to evaluate it. This position paper, informed by conference sessions featuring diverse stakeholders held at the 2015 Society of Behavioral Medicine and Society for Medical Decision Making annual meetings, describes key concepts that influence the decision making process itself and that may change what it means to make a good decision: interpersonal factors, structural constraints, affective influences, and values clarification methods. This paper also proposes specific research questions within each of these priority areas, with the goal of moving medical decision making research to a more comprehensive definition of a good medical decision, and enhancing the ability to measure and improve the decision making process.

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.

Encouraging early discussion of life expectancy and end-of-life care: A randomised controlled trial of a nurse-led communication support program for patients and caregivers

BACKGROUND

Patients are often not given the information needed to understand their prognosis and make informed treatment choices, with many consequently experiencing less than optimal care and quality-of-life at end-of-life.

OBJECTIVES

To evaluate the efficacy of a nurse-facilitated communication support program for patients with advanced, incurable cancer to assist them in discussing prognosis and end-of-life care.

DESIGN

A parallel-group randomised controlled trial design was used.

SETTINGS

This trial was conducted at six cancer treatment centres affiliated with major hospitals in Sydney, Australia.

PARTICIPANTS

110 patients with advanced, incurable cancer participated.

METHODS

The communication support program included guided exploration of a question prompt list, communication challenges, patient values and concerns and the value of discussing end-of-life care early, with oncologists cued to endorse question-asking and question prompt list use. Patients were randomised after baseline measure completion, a regular oncology consultation was audio-recorded and a follow-up questionnaire was completed one month later. Communication, health-related quality-of-life and satisfaction measures and a manualised consultation-coding scheme were used. Descriptive, Mixed Modelling and Generalised Linear Mixed Modelling analyses were conducted using SPSS version 22.

RESULTS

Communication support program recipients gave significantly more cues for discussion of prognosis, end-of-life care, future care options and general issues not targeted by the intervention during recorded consultations, but did not ask more questions about these issues or overall. Oncologists' question prompt list and question asking endorsement was inconsistent. Communication support program recipients' self-efficacy in knowing what questions to ask their doctor significantly improved at follow-up while control arm patients' self-efficacy declined. The communication support program did not impact patients' health-related quality-of-life or the likelihood that their health information or shared decision-making preferences would be met. Satisfaction with the communication support program was high.

CONCLUSIONS

Given the importance of clarifying prognostic expectations and end-of-life care wishes in the advanced cancer context, the communication support program appears to be an effective and well-received solution to encourage early information seeking related to these issues though, its long-term impact remains unclear. The manualised nature of the intervention, designed with existing clinical staff in mind, may make it suited for implementation in a clinical setting, though additional work is needed to identify why question asking was unaffected and establish its impact later in the illness trajectory.

Attitudes Toward Family Involvement in Cancer Treatment Decision Making: The Perspectives of Patients, Family Caregivers, and Their Oncologists

BACKGROUND

To investigate how cancer patients, family caregiver, and their treating oncologist view the risks and benefits of family involvement in cancer treatment decision making (TDM) or the degree to which these perceptions may differ.

PATIENTS AND METHODS

A nationwide, multicenter survey was conducted with 134 oncologists and 725 of their patients and accompanying caregivers. Participant answered to modified Control Preferences Scale and investigator-developed questionnaire regarding family involvement in cancer TDM.

RESULTS

Most participants (>90%) thought that family should be involved in cancer TDM. When asked if the oncologist should allow family involvement if the patient did not want them involved, most patients and caregivers (>85%) thought they should. However, under this circumstance, only 56.0% of oncologists supported family involvement. Patients were significantly more likely to skew their responses toward patient rather than family decisional control than were their caregivers (P < .003); oncologists were more likely to skew their responses toward patient rather than family decisional control than caregivers (P < .001). Most respondents thought that family involvement is helpful and neither hamper patient autonomy nor complicate cancer TDM process. Oncologists were largely positive, but less so in these ratings than either patients or caregivers (P < .002).

CONCLUSIONS

Patients, family caregivers, and, to a lesser degree, oncologists expect and valued family involvement in cancer TDM. These findings support a reconsideration of traditional models focused on protection of patient autonomy to a more contextualized form of relational autonomy, whereby the patient and family caregivers can be seen as a unit for autonomous decision.

Involvement in Decision Making and Satisfaction With Treatment Among Partners of Patients With Newly Diagnosed Localized Prostate Cancer

PURPOSE/OBJECTIVES

To examine partner involvement in treatment decision making for localized prostate cancer, congruence between partner involvement and patient preference, reasons for partner noninvolvement, and partner satisfaction with patient treatment
.

DESIGN

Cross-sectional exploratory study.

SETTING

100 counties in North Carolina.

SAMPLE

281 partners of men with newly diagnosed localized prostate cancer.

METHODS

Participants completed a phone survey. Logistic regression analyses were used.

MAIN RESEARCH VARIABLES

Partners' involvement in treatment decision making, partner satisfaction with treatment, activities of partner involvement, and reasons for noninvolvement.

FINDINGS

Of the 228 partners (81%) related to decision making, 205 (73%) were very satisfied with the treatment the patients received, and partner involvement was congruent with patient preference in 242 partners (86%). Partners reported several reasons for noninvolvement.

CONCLUSIONS

Most partners engaged in multiple activities during treatment decision making for localized prostate cancer and were satisfied with the patient's treatment. Partner involvement was mostly congruent with patient preference.

IMPLICATIONS FOR NURSING

Partners' active involvement in treatment decision making for localized prostate cancer (e.g., being involved in patients' conversations with doctors) should be encouraged and facilitated for those who prefer this type of decision making. 
.

Health information exchange for patients with intellectual disabilities: a general practice perspective

BACKGROUND

Inadequate health information exchange (HIE) between patients with intellectual disabilities (ID), their carers, and GPs may lead to ineffective treatment and poor treatment compliance. Factors influencing HIE are largely unexplored in previous research.

AIM

To provide insight into the perceived HIE facilitators of GPs and general practice assistants, and the barriers in GP consultations for patients with ID.

DESIGN AND SETTING

An interview-based study with GPs (n = 19) and general practice assistants (n = 11) in the Netherlands.

METHOD

Semi-structured interviews were conducted on topics relating to stages during and around GP consultation. Transcripts were coded and analysed using framework analysis.

RESULTS

The main themes were impaired medical history taking and clinical decision making, and fragile patient follow-up. Factors negatively influencing HIE related to patient communication skills and professional carers' actions in preparing the consultation and in collecting, recording, and sharing information. HIE barriers resulted in risk of delay in diagnosis and treatment, misdiagnosis, unnecessary tests, and ineffective treatment regimens. HIE facilitators were described in terms of GP adjustments in communication, planning of consultations, and efforts to compensate for fragile follow-up situations.

CONCLUSION

Inadequate HIE should be seen as a chain of events leading to less effective consultations, substandard treatment, and insufficient patient follow-up. The results indicate a mismatch between GPs' expectations about professional carers' competencies, responsibilities, and roles in HIE and the setting in which professional carers operate. Further research should focus on how daily GP practice can be attuned to the practicalities of HIE with patients with ID and their professional carers.

Correlates of family involvement before and during medical visits among older adults with high-risk diabetes

AIMS

To examine the characteristics of patients with diabetes who regularly receive help from a supporter in preparing for and attending medical visits, and the association between this help and clinical risk factors for diabetes complications.

METHODS

We linked survey data about family involvement for patients in the Veterans Health Administration system with poorly controlled Type 2 diabetes (n = 588; mean 67 years; 97% male) with health record data on blood pressure, glycaemic control and prescription-fill gaps. We used multivariable regression to assess whether supporter presence and, among patients with supporters, supporter role (visit preparation, accompaniment to medical visit or no involvement) were associated with concurrent trends in clinical risk factors over 2 years, adjusting for sociodemographic and health characteristics.

RESULTS

Most patients (78%) had a main health supporter; of these, more had regular support for preparing for appointments (69%) than were regularly accompanied to them (45%). Patients with preparation help only were younger and more educated than accompanied patients. Support presence and type was not significantly associated with clinical risk factors.

CONCLUSIONS

Family help preparing for appointments was common among these patients with high-risk diabetes. In its current form, family support for medical visits may not affect clinical factors in the short term. Supporters helping patients engage in medical visits may need training and assistance to have an impact on the clinical trajectory of patients with diabetes.

The role of companions in outpatient seizure clinic interactions: A pilot study

PURPOSE

This study explored contributions that patients' companions (seizure witnesses) make to interactions in the seizure clinic and whether the nature of the companions' interactional contributions can help with the differentiation of epilepsy and psychogenic nonepileptic seizures (PNES).

METHODS

Conversation analysis methods were used to examine video recordings and transcripts of neurologists' interactions with patients referred to a specialist seizure clinic and their companions.

RESULTS

The companions' behavior correlated with interactional features previously observed to distinguish patients with epilepsy from patients with PNES. Patients with PNES, but not those with epilepsy, tended to exhibit interactional resistance to the doctor's efforts to find out more about their seizure experiences and, thereby, encouraged greater interactional contribution from companions.

CONCLUSION

The contributions that companions make (in part, prompted by patient's interactional behavior) may provide additional diagnostic pointers in this clinical setting, and a number of candidate features that may help clinicians distinguish between epilepsy and PNES when the patient is accompanied by a seizure witness are described. However, companion contributions may limit the doctor's ability to identify linguistic and interactional features with previously demonstrated diagnostic potential in the conversational contributions made by patients themselves. To help offset potential diagnostic losses, doctors may need to explicitly discuss the role of the companion in the consultation when a seizure witness (or another companion) accompanies the patient.

Family involvement in cancer treatment decision-making: A qualitative study of patient, family, and clinician attitudes and experiences

OBJECTIVE

Little is known about how family are involved in cancer treatment decision-making. This study aimed to qualitatively explore Australian oncology clinicians', patients', and family members' attitudes towards, and experiences of, family involvement in decision-making.

METHODS

Semi-structured interviews were conducted with 30 cancer patients, 33 family members, 10 oncology nurses and 11 oncologists. Framework analysis methods were used.

RESULTS

Three main themes were uncovered: (i) how family are involved in the decision-making process: specific behaviours of family across 5 (extended) decision-making stages; (ii) attitudes towards family involvement in the decision-making process: balancing patient authority with the rights of the family; and (iii) factors influencing family involvement: patient, family, cultural, relationship, and decision.

CONCLUSION

This study highlighted many specific behaviours of family throughout the decision-making process, the complex participant attitudes toward retaining patient authority whilst including the family, and insight into influencing factors. These findings will inform a conceptual framework describing family involvement in decision-making.

PRACTICE IMPLICATIONS

Clinicians could ascertain participant preferences and remain open to the varying forms of family involvement in decision-making. Given the important role of family in the decision-making process, family inclusive consultation strategies are needed.

Communication and decision-making in mental health: A systematic review focusing on Bipolar disorder

OBJECTIVES

To systematically review studies of communication and decision-making in mental health-based samples including BP patients.

METHODS

Qualitative systematic review of studies using PsychINFO, MEDLINE, SCOPUS, CINAHL, and EMBASE (January 2000-March 2015). One author assessed study eligibility, verified by two co-authors. Data were independently extracted by two authors, and cross-checked by another co-author. Two independent raters assessed eligible studies using a validated quality appraisal.

RESULTS

Of 519 articles retrieved, 13 studies were included (i.e., 10 quantitative/1 qualitative/1 mixed-methods). All were cross-sectional; twelve were rated good/strong quality (>70%). Four inter-related themes emerged: patient characteristics and patient preferences, quality of patient-clinician interactions, and influence of SDM/patient-centred approach on patient outcomes. Overall BP patients, like others, have unmet decision-making needs, and desire greater involvement. Clinician consultation behaviour influenced patient involvement; interpersonal aspects (e.g., empathy, listening well) fostered therapeutic relationships and positive patient outcomes, including: improved treatment adherence, patient satisfaction with care, and reduced suicidal ideation.

CONCLUSIONS

This review reveals a paucity of studies reporting bipolar-specific findings. To inform targeted BP interventions, greater elucidation of unmet decision-making needs is needed.

PRACTICE IMPLICATIONS

Eliciting patient preferences and developing a collaborative therapeutic alliance may be particularly important in BP, promoting improved patient outcomes.

A Narrative Review of Patient and Family Engagement: The "Foundation" of the Medical "Home"

BACKGROUND

Patient and family engagement (PFE) is vital to the spirit of the medical home. This article reflects the efforts of an expert consensus panel, the Patient and Family Engagement Workgroup, as part of the Society of General Internal Medicine's 2013 Research Conference.

OBJECTIVE

To review extant literature on PFE in pediatric and adult medicine and quality improvement, highlight emerging best practices and models, suggest questions for future research, and provide references to tools and resources to facilitate implementation of PFE strategies.

METHODS

We conducted a narrative review of relevant articles published from 2000 to 2015. Additional information was retrieved from personal contact with experts and recommended sources from workgroup members.

RESULTS

Despite the theoretical importance of PFE and policy recommendations that PFE occurs at all levels across the health care system, evidence of effectiveness is limited, particularly for quality improvement. There is some evidence that PFE is effective, mostly related to engagement in the care of individual patients, but the evidence is mixed and few studies have assessed the effect of PFE on health outcomes. Measurement issues and the lack of a single comprehensive conceptual model pose challenges to progress in this field. Recommendations for future research and a list of practical tools and resources to facilitate PFE are provided.

CONCLUSIONS

Although PFE appeals to patients, families, providers, and policy-makers, research is needed to assess outcomes beyond satisfaction, address implementation barriers, and support engagement in practice redesign and quality improvement. Partnering with patients and families has great potential to support high-quality health care and optimize outcomes.

Verbal Social Support for Newly Diagnosed Breast Cancer Patients during Surgical Decision-Making Visits

This study reports an analysis of verbal social support strategies directed by surgeons and patients' companions to breast cancer patients using the social support behavior code (SSBC). Additionally, the influence of companions on the provision of social support is examined. Forty-six videotapes of appointments where treatment regimens were being decided were analyzed. Results demonstrated that the majority of units spoken by surgeons were coded as verbal social support, primarily in the form of informational social support. Companions' social support was lower (relative to surgeons) in nearly every category of social support assessed. Patients who brought companions were found to receive more network social support from surgeons. Overall, these results point to low emotional support from surgeons and companions for patients during these appointments, which indicates a need for modifications in empathy training for medical providers.

Role of relatives of ethnic minority patients in patient safety in hospital care: a qualitative study

OBJECTIVE

Relatives of ethnic minority patients often play an important role in the care process during hospitalisation. Our objective was to analyse the role of these relatives in relation to the safety of patients during hospital care.

SETTING

Four large urban hospitals with an ethnic diverse patient population.

PARTICIPANTS

On hospital admission of ethnic minority patients, 20 cases were purposively sampled in which relatives were observed to play a role in the care process.

OUTCOME MEASURES

We used documents (patient records) and added eight cases with qualitative interviews with healthcare providers, patients and/or their relatives to investigate the relation between the role of relatives and patient safety. An inductive approach followed by selective coding was used to analyse the data.

RESULTS

Besides giving social support, family members took on themselves the role of the interpreter, the role of substitutes of the patient and the role of care provider. The taking over of these roles can have positive and negative effects on patient safety.

CONCLUSIONS

When family members take over various roles during hospitalisation of a relative, this can lead to a safety risk and a safety protection for the patient involved. Although healthcare providers should not hand over their responsibilities to the relatives of patients, optimising collaboration with relatives who are willing to take part in the care process may improve patient safety.

Patients, care partners, and shared access to the patient portal: online practices at an integrated health system

OBJECTIVE

To describe the characteristics and online practices of patients and "care partners" who share explicit access to a patient portal account at a large integrated health system that implemented shared access functionality in 2003.

MATERIALS AND METHODS

Survey of 323 patients and 389 care partners at Geisinger Health System with linked information regarding access and use of patient portal functionality.

RESULTS

Few (0.4%) registered adult patient portal users shared access to their account. Patients varied in age (range: 18-102); more than half had a high school education or less (53.6%). Patient motivations for sharing access included: to help manage care (41.9%), for emergency reasons (29.7%), lack of technology experience (18.4%), or care partner request (10.0%). Care partners were parents (39.8%), adult children (27.9%), spouses (26.2%), and other relatives (6.1%). Patients were more likely than care partners to have inadequate health literacy (54.8% versus 8.8%, P < .001) and less confident in their ability to manage their care (53.0% versus 88.1%; P < .001). Care partners were more likely than patients to perform health management activities electronically (95.5% versus 48.4%; P < .001), access the patient portal (89.2% versus 30.3%; P < .001), and use patient portal functionality such as secure messaging (39.6% versus 13.9%; P < .001). Care partners used their own credentials (89.1%) and patient credentials (23.3%) to access the patient portal.

DISCUSSION AND CONCLUSION

Shared access is an underused strategy that may bridge patients' health literacy deficits and lack of technology experience and that helps but does not fully resolve concerns regarding patient and care partner identity credentials.

Person-centred care: an overview of reviews

BACKGROUND

Existing evidence suggests that a person-centred approach can improve coordination and access to health care and services.

OBJECTIVES

This overview sought to: (1) identify and define components of person-centred care; (2) explore nursing and health-care provider behaviours that are person-centred; and (3) identify systems level supports required to enable person-centred care.

METHODS

An overview of reviews was conducted to locate synthesized literature published between June 2005 and April 2014. Two independent reviewers screened, extracted data and quality appraised the sources. Results were synthesized narratively.

RESULTS

A total of 46 articles were deemed relevant to this overview. This paper synthesizes the results of 43 of the 46 articles. A universal definition of person-centred care was not found, however; common components, associated health-care provider behaviours and the organizational supports required for person-centred care are discussed.

CONCLUSIONS

Key findings from this review outline that health-care providers and organizations need to promote person-centred care by engaging persons in partnerships, shared decision-making, and meaningful participation in health system improvement.

Communication differences when patients and caregivers are seen separately or together

BACKGROUND

Southern Adelaide Palliative Care Services introduced a nurse-led early introduction to a palliative care clinic in 2011. The clinic offers a thorough psychosocial assessment and the provision of information and an introduction to future care planning. The patients and their caregivers are seen together by the nurse practitioner initially for a physical assessment. They are then seen by a social worker to focus on advanced care planning and assessment of social and emotional factors. After the social work visit, the patient and caregiver are separated, and the patient sees the psychosocial nurse for coping and adjustment to illness and the carer sees the caregiver network facilitator to assess their informal supports to assist in the role of community-based caregiving. The pilot study looks at the nature of communication in the clinic where patient and carer are together and compares that to when they are separated.

METHODS

A total of 33 patients and their caregivers agreed for their coversations to be tape recorded between May and November of 2013. All tape recordings were transcribed verbatim. Ten patient transcripts (n=40) have been coded for quantitative analysis. The codes identify content and function of speech, cues for information and emotion and whether they are responded to by clinicians.

RESULTS

Pilot results reveal that caregivers contribute little in the combined clinics and dominate the conversation in the private clinic. Patients, when seen alone, predominantly express emotion related cues, opposed to cues for information. The clinicians focus on their area of specialty, which results in little duplication in this clinic setting.

CONCLUSION

An earlier evaluation of this clinic found that patients and their caregivers appreciate being separated in the clinic setting to have time and privacy to reveal fears and feelings related to end-of-life care. This current study quantifies the patient and caregiver experience and confirms those earlier findings.