Shared decision-making in question

Lay Etiology, Self-Efficacy and Patient Activation Among Cancer Patients

BACKGROUND

We aimed at clarifying correlations between lay etiologies, self-efficacy, and patient activation among cancer patients.

METHODS

Patients with different kinds of cancer answered a questionnaire on self-efficacy, lay etiology, and patient activation.

RESULTS

639 patients participated. Psychological reasons/stress (43.3%) and destiny (41.6%) were the most cited causes. Lay etiology was influenced by demographics, self-efficacy, and patient activation. Men, younger people, and active patients more often described internal causes of cancer, women and religious patients more often external causes. Patients with higher scores of self-efficacy were more often convinced of external cancer causes.

CONCLUSION

By identifying individual disease theories, physicians may improve patient-physician communication.

Working in partnership: the application of shared decision-making to health visitor practice

AIMS AND OBJECTIVES

To explore the processes that support shared decision-making when health visitors and parents are creating plans to improve the well-being of babies and children.

BACKGROUND

Worldwide, there is a focus on promoting children's well-being to enhance the population health. Within the United Kingdom, health visitors have a key responsibility for working in partnership with parents to support this agenda. Despite evidence that the application of 'shared decision-making' frameworks can increase patient participation, improve patient satisfaction and improve health outcomes, there is limited research linking shared decision-making with health visitor practice.

DESIGN

A qualitative, descriptive study.

METHODS

The study was undertaken in two phases: in Phase 1, data were collected by audio recording two health visitor-parent decision-making conversations, in the absence of the researcher, where decisions around planning for a baby or child were being made as part of usual care, and then the participants' experiences were sought through individual questionnaires. In Phase 2, semistructured interviews were conducted with nine health visitors and nine parents in relation to their recent experiences of planning care.

RESULTS

Evidence of supportive processes included having a shared understanding around the issue needing to be addressed; being able to identify interventions that were accessible for the family; engaging in decision-making through deep, meaningful conversations using sensitive and responsive approaches; and establishing positive relationships between health visitors and parents, significant others within the family and other professionals.

CONCLUSION

Despite evidence of strong, trusting relationships between parents and health visitors, there were times when shared decision-making was unable to take place due to the absence of supportive processes.

RELEVANCE TO CLINICAL PRACTICE

Health visitors are aware that planning interventions with parents can be complex. These findings indicate the value of using a shared decision-making framework to structure planning, as application of a framework identified the processes that support a collaborative approach in practice.

Communication needs of medical tourists: an exploratory study in Thailand

Purpose

– The aim of this paper is to contribute a conceptualization of the information and communication needs of medical tourists from Western countries in an Asian health care context.

Design/methodology/approach

– Multi-phase, semi-structured, in-depth interviews and observations were conducted with 27 multi-source informants who have communication experience in the international healthcare setting.

Findings

– Multi-level information provision should be used to address communicative incongruence in Asian healthcare provider – Western patient encounters as was self-reported by the participants and observed by authors. The use of an informative communication model is proposed in order to facilitate interaction and the effective transfer of information with Western patients to overcome negative, underlying emotions and enable autonomous decision making by the patients.

Research limitations/implications

– This exploratory study is focused on Western patients and Asian practitioners in Thailand. Future research in other countries and with patients from other geographical areas could expand to generalize findings.

Practical implications

– Fostering information sharing with Western patients by using an integrative communication model can improve patient satisfaction and health outcomes. The need for developing and implementing these improved practices for communicating with Western patients is reflected by the healthcare industry's current developmental trends helping to lead to a future of health service internationalization.

Originality/value

– This is the first empirical study to provide insights concerning the communication needs and coping strategies of Western patients with Asian doctors in developing countries.

[Patient-centered communication in the physician-patient relationship]

As a result of increasing demands for more patient-centeredness in the German health care system, physician-patient communication has been subject to transformation. Physicians are being requested to take into account their patients' communicative needs, including information, shared decision making, and emotional support, more vigorously than they had been in the past. A cooperative model of the physician-patient relationship is considered most suitable for fulfilling these needs and for empowering patients to make informed decisions regarding their own health care. However, a large body of evidence exists-particularly regarding communication between cancer patients and their doctors-that shows that patients' needs are not adequately addressed or met. This potential for optimization is all the more important because targeting patients' needs during doctor-patient communication not only improves patients' satisfaction with the communication, quality of life, and well-being, but may also produce better treatment outcomes.

Researching involvement in health care practices: interrupting or reproducing medicalization?

In this paper we reflect upon and problematize the ways in which 'patient involvement' is interpreted in a substantial proportion of the research literature on involvement and shared decision making. Drawing upon an analysis of this literature we raise concerns about the 'medicalization of involvement' embedded in, and reproduced by, some dominant research lenses, suggesting that this medicalization has powerful discursive and material effects. For example, we suggest that it tends to normalize and arguably trivialize intrinsically problematic and contentious concepts such as 'patient preferences' and, at the same time, to obscure the full range of possibilities for reciprocity in the exchanges between the medical world of the professional and the experiential and narrative world of the patient. We argue that richer conceptualizations of collaboration in clinical work are both possible and very much needed, and we indicate some examples of scholarly resources and perspectives that point towards richer and more defensible accounts of involvement. Overall we call for more attention to the idea of 'epistemic involvement' and much greater cross-fertilization between different epistemological paradigms in this area of research.

Breast reconstruction and psychosocial adjustment: what have we learned and where do we go from here?

For women with breast cancer, there are many treatment options, with surgery often the primary treatment for early-stage disease. An increasing number of women are choosing to have reconstruction following their mastectomies. Both surgical and medical treatments for breast cancer are increasingly evaluated not only on the basis of their safety and medical outcomes but also their impact on women's psychosocial and quality of life (QOL). The objective of this article is to describe current knowledge regarding the psychosocial adjustment of women undergoing reconstruction, identify limitations in the existing literature, and offer suggestions for the direction of future work in this area. Though most studies have found comparable general QOL in women who have different surgical treatments for breast cancer, some research suggests that reconstruction may provide benefits in terms of body image and sexuality, especially compared with women who have mastectomies only. Most of the existing studies have failed to consider the potential importance of demographic- and treatment-related variables on women's psychosocial adjustment. As reconstruction procedures continue to be developed and refined, the impact of these procedures on women's short- and long-term psychosocial adjustment and QOL is needed.

Contending mediated risk messages: a grounded theory of the physician-patient discussion of a prescription medication's changing risk

OBJECTIVE

This study investigated the process and message strategies physicians use to communicate the changing risk of medication to patients with chronic medical conditions. The study purposes were to identify mediated messages' effects on the risk discussion and to develop a model of the changing risk communication process.

METHODS

Using a grounded theory approach, this study systematically analyzed physician reports of clinic risk communication to explain how the process occurs inductively.

RESULTS

Overall, physicians described an intermediate model of the patient-physician relationship, identifying two types of patients. The communicatively active patient talked to salient others about and scanned media for health information and recognized when known risks of the medication have changed. The communicatively non-active patient may have passive exposure to health information but did not recognize known risks have changed. Physicians reported a difference in medical discussions with communicatively active patients compared to communicatively non-active patients.

CONCLUSION

Theory generated here includes media exposure as a critical influence in the clinical risk discussion and the physician's response to those mediated messages as a distinguishing characteristic.

PRACTICE IMPLICATIONS

A practical application of this generated theory is how it can be used to address the potential barriers of communicating about medication risk.

Health information seeking: a review of measures and methods

OBJECTIVE

Outlines the methods and measures commonly used to study active health information seeking and prescribes important considerations in advancing the study of patient information seeking.

METHODS

A systematic review of the literature from 1978 to 2010. A single bibliometric database, PsychInfo, identified 648 articles of health information seeking. The 129 articles included in the review were coded by type of sample, measures (n=12) utilized to study health information seeking, and types of study methods (n=5).

RESULTS

A majority of studies used non-clinical samples and measured general health information seeking (i.e., whether the participant engaged in a search for health information) through cross-sectional study designs.

CONCLUSIONS

There are varying samples, measures, and designs used to identify those who do or do not seek health information. Future research should look into how health information seeking influences health management and should uncover the social and relational functions of health information seeking using more advanced (and less routinely applied) measures and methods of studying health information seeking.

PRACTICE IMPLICATIONS

More people are actively searching for health information and health providers should address this in their discussions with patients.

"Practicing medicine": patient perceptions of physician communication and the process of prescription

OBJECTIVE

This study explores patient perceptions of physician communication regarding prescription medications and develops a theory of the effects of perceived physician communication on the patient decision-making process of medication taking.

METHODS

Using a grounded theory approach, this study systematically analyzed patient narratives of communication with physicians regarding prescription medications and the patient's resulting medication taking and adherence behavior.

RESULTS

Participants described concern about side effects, lack of perceived need for medications, and healthcare system factors as barriers to medication adherence. Overall, participants seemed to assess the utility of communication about these issues based on their perceptions of their physician as the source of the message.

CONCLUSION

The theory generated here includes patient assessments of their physician's credibility (trustworthiness and expertise) as a critical influence in how chronically-ill patients process information about the need for prescribed therapy. Trial and error to find appropriate medications seemed to deteriorate patients' perceptions of their physicians' credibility.

PRACTICE IMPLICATIONS

A practical application of this theory is the recommendation for physicians to increase perceived expertise by clearly outlining treatment processes at the outset of treatment, presenting efficacy and timeline expectations for finding appropriate medications.

The role of nurses and patients' involvement in the clinical decision-making process

This paper is a literature review based on articles in the nursing field about shared clinical decision. The objectives are to examine the role of nurses and patients in the decision-making process in the context of clinical practice. To support these themes, a review of recent literature was conducted with the following results: patients prefer shared decision-making with professionals who should support and provide information to patients in order to overcome the barriers hampering patients' involvement in decision-making. There is a clear need for more research studies that address the problems in the clinical decision-making process so as to contribute to healthcare improvement.

[Patients' preferences and decision-making: state of the art and applications in cancer]

BACKGROUND

This paper deals with the physician-patient encounter. In France, the current legal framework allows patients to be informed (patients' rights to health information) and to participate to decisions regarding their own health. In such a context, this paper aims to give the reader the broad key components of the so-called 'patient treatment preferences elicitation process' in breast cancer, our research area.

METHODS AND RESULTS

We first present the general context, with a definition of the different physician-patient models. We then present decision aids, tools that aim to provide high-quality information to patients in the decision-making process. Finally, based on our previous studies and on examples drawn from the international literature, we present the empirical process of patients' preferences elicitation, which not only increases patients' knowledge of and satisfaction with the decision made, but also allows patients to be part of their disease management.

CONCLUSION

Far from being a phenomenon in the air supported by a legal system, this method developed in the 90s allows patients and more generally healthcare users to be autonomous without constraining them to a choice.

Shared medical information: Expectations of breast cancer patients

Allowing cancer patients to hold medical records containing essential information for managing their disease may improve their satisfaction and the coordination of their medical care.

OBJECTIVE

Our aim was to determine breast cancer patients' interest in and expectations of such medical records and the exchange of information during their treatment.

METHODS

Eighty-six hospital physicians were selected to distribute an anonymous questionnaire to all of the breast cancer patients they saw in consultations.

RESULTS

Out of 194 patients asked, 140 (72%) participated in the survey. Forty-eight percent were "highly satisfied", 47% were "quite satisfied" with their involvement in their treatment and 43% preferred to play a relatively passive role in decisions concerning treatments. When offered, 79% agreed to hold paper medical records containing test results, reports and letters. Many found these medical records to be useful and a possible means for improving communication. Others, however, expressed reservations concerning privacy or losing or forgetting the records.

CONCLUSION

The principle of shared medical records could satisfy the majority of breast cancer patients. Experimenting with this concept in the field would enable practitioners to better determine the content of the records and how they can be used on a practical basis.

An integrative model of shared decision making in medical encounters

OBJECTIVE

Given the fluidity with which the term shared decision making (SDM) is used in teaching, assessment and research, we conducted a focused and systematic review of articles that specifically address SDM to determine the range of conceptual definitions.

METHODS

In April 2005, we ran a Pubmed (Medline) search to identify articles published through 31 December 2003 with the words shared decision making in the title or abstract. The search yielded 681 citations, 342 of which were about SDM in the context of physician-patient encounters and published in English. We read and reviewed the full text of all 342 articles, and got any non-redundant references to SDM, which yielded an additional 76 articles.

RESULTS

Of the 418 articles examined, 161 (38.5%) had a conceptual definition of SDM. We identified 31 separate concepts used to explicate SDM, but only "patient values/preferences" (67.1%) and "options" (50.9%) appeared in more than half the 161 definitions. Relatively few articles explicitly recognized and integrated previous work.

CONCLUSION

Our review reveals that there is no shared definition of SDM. We propose a definition that integrates the extant literature base and outlines essential elements that must be present for patients and providers to engage in the process of SDM.

PRACTICE IMPLICATIONS

The integrative definition of SDM is intended to provide a useful foundation for describing and operationalizing SDM in further research.

Patient-doctor decision-making about treatment within the consultation--a critical analysis of models

This paper highlights some of the limitations of models of patient involvement in decision-making and explores the reasons for, and implications of, these limitations. Taking the three models of interpretative, shared and informed decision-making as examples, we focus on two limitations of the models: (1) neglect of which decisions the patient should be involved in (the framing problem) and (2) how the patient should be involved in decision-making (the nature of reasoning problem). Although there will inevitably be a gap between models and practice--this much is in the nature of the models--we suggest that these two issues are substantially neglected by the models and yet are fundamental to understanding patient-doctor decision-making. We also suggest that the fundamental problem that lies behind these limitations is insufficient attention to, and explicitness about, the dilemmas of professional ethics, which are played out in the professional-patient relationships that the models are supposed to represent, particularly with respect to the issue of expert and lay accountability.

Virtually he@lthy: the impact of internet use on disease experience and the doctor-patient relationship

In the current study, the author explores the complex effects and contradictory roles of the Internet as a source of empowerment and control, and as a site of "risk management." Drawing on a study of the Internet usage of Australian men with prostate cancer, the author investigates how access to information and online support affects men's experiences of disease and, in particular, the possible implications of Internet-informed patients for the doctor-patient relationship. The data reveal that accessing information and/or support online can have a profound effect on men's experiences of prostate cancer, providing a method of taking some control over their disease and limiting inhibitions experienced in face-to-face encounters. However, it is also clear that some medical specialists view Internet-informed patients as a challenge to their power within medical encounters and, as a result, employ disciplinary strategies that reinforce traditional patient roles and alienate patients who use the Internet.

Patient-professional communication research in cancer: an integrative review of research methods in the context of a conceptual framework

This paper uses the conceptual framework of Feldman-Stewart et al. to organize and review the types of research methodologies used to investigate various aspects of patient-health care professional communication in the context of cancer. Research methods employed are classified as either non-experimental or experimental. Non-experimental designs include naturalistic observational studies (e.g. participant observation, audio- or videotaping of interactions) and retrospective introspective descriptions (e.g. self-report questionnaires, qualitative interview methods). Experimental designs often involve interventions aimed at improving communication, such as physician or patient training, and the use of technology to enhance communication (e.g. audiotapes, computers). Using the conceptualization of the communication framework description, we argue that the outcome measures used in these studies address either primary goals, enabling goals, or secondary communication outcomes. Outcomes that are related to primary goals of the communication exchange include assessing the level of understanding of information conveyed, aspects of decision making, planning around treatments, or general provision of care. Outcomes related to enabling goals focus on elements that affect the ability to achieve primary goals. Outcomes secondary to the communication do not relate directly to what the communication is attempting to achieve. We conclude by identifying priority areas for further research, such as identifying the goals of both participants, understanding how particular aspects of the communication process affect their ability to achieve their goals, and examining the external environment in which communication takes place.

Preferences for different methods of communicating information regarding adjuvant chemotherapy for breast cancer

Many patients play an active role in determining their cancer treatments, and the communication of medical information influences patient decision-making. This study examined participants' preferences between various methods of communicating quantitative risks and benefits of adjuvant chemotherapy. Using clinical vignettes, participants were first asked to decide whether or not to endorse chemotherapy and were subsequently asked about their preferences for the methods used to communicate the risks and benefits. Participants preferred the absolute survival benefit method over negatively framed methods, such as relative or absolute risk reduction. We also present analysis of qualitative data which supports the conclusions drawn from quantitative analyses. In summary, the absolute survival benefit was shown to be the superior method of communicating quantitative risks and benefits of chemotherapy. Failure to use clear and concise methods of communicating quantitative risk and benefit information may compromise efforts to obtain informed consent for treatment.

The communication goals and needs of cancer patients: a review

The aim of this review paper is to critique the empirical literature pertaining to the communication needs and goals of cancer patients, and to provide direction for research in this area. According to the conceptual framework of Feldman-Stewart et al., patient-physician communication occurs for the fundamental purpose of addressing each participant's goal(s). This review is divided into two categories of goals: (a) optimal medical management of the cancer, and (b) optimal attention to the patient's psychosocial response to cancer. Optimal medical management includes discussions about disease status and the treatment plan, and the effectiveness of these discussions is frequently determined by assessing patient understanding, satisfaction, and well-being. The literature suggests that cancer patients continue to have unmet communication needs, and communication outcomes are enhanced when physicians attend to the emotional needs of patients. Research gaps in communication research are highlighted, including the need for additional study of several external factors affecting the patient and provider.

Predictors of patients' choices for breast-conserving therapy or mastectomy: a prospective study

A study was undertaken to describe the treatment preferences and choices of patients with breast cancer, and to identify predictors of undergoing breast-conserving therapy (BCT) or mastectomy (MT). Consecutive patients with stage I/II breast cancer were eligible. Information about predictor variables, including socio-demographics, quality of life, patients' concerns, decision style, decisional conflict and perceived preference of the surgeon was collected at baseline, before decision making and surgery. Patients received standard information (n=88) or a decision aid (n=92) as a supplement to support decision making. A total of 180 patients participated in the study. In all, 72% decided to have BCT (n=123); 28% chose MT (n=49). Multivariate analysis showed that what patients perceived to be their surgeons' preference and the patients' concerns regarding breast loss and local tumour recurrence were the strongest predictors of treatment preference. Treatment preferences in itself were highly predictive of the treatment decision. The decision aid did not influence treatment choice. The results of this study demonstrate that patients' concerns and their perceptions of the treatment preferences of the physicians are important factors in patients' decision making. Adequate information and communication are essential to base treatment decisions on realistic concerns, and the treatment preferences of patients.

Assessment of genetic testing and related counseling services: current research and future directions

With the recent completion of the sequencing of the Human Genome, genetic testing will increasingly become available for a greater number of medical conditions, many of which are those that manifest in adulthood (e.g., various cancers, cardiovascular disease, diabetes) or for which little or no treatments are available (e.g., Alzheimer disease). Genetic services, defined here as those relating to genetic testing and counseling, will be with helping more individuals deal with medical information that affects their health directly, as opposed to affecting primarily the health of their offspring. This paper reviews the existing research in the genetic testing and counseling literature and presents an evaluation framework outlining the intended outcomes of genetic services. The purpose of this framework is to provide an overview of the potential outcomes of these services and highlight constructs for future research in this area. In addition, other issues that will affect the assessment of genetic services are raised, using examples from the existing literature. Ultimately, the goal of this paper is to highlight and suggest directions researchers can take to produce the information needed to guide genetic testing and counseling practice. Moreover, as genetic knowledge is increasingly applied towards the prevention and treatment of various common, chronic disease conditions, genetic information will have implications for providers outside of the traditional medical genetics realm, such as primary care providers and public health practitioners. A better understanding of the outcomes of genetic testing and counseling will provide a basis from which to ensure an appropriate application of genetic information by all those who eventually provide care and "genetic" services.

The content and amount of information given by medical oncologists when telling patients with advanced cancer what their treatment options are. palliative chemotherapy and watchful-waiting

This study aimed to determine the content and the amount of information given by medical oncologists when proposing palliative chemotherapy and whether this information given is influenced by patient or physician background characteristics. In a prospective study, 95 patients with incurable cancer were interviewed before they consulted their medical oncologist. Their first consultation was audiotaped, and their eventual decision scored. A coding scheme comprised six categories of information given during the consultation. Medical oncologists mentioned or explained the disease course (53%), symptoms (35%) and prognosis (39%). Most patients were told about the absence of cure (84%). Watchful-waiting was mentioned to only half of the patients, either in one sentence (23%) or explained more extensively (27%). Multilevel analysis revealed that the patients' age, patient's marital status, and consulting in an academic hospital explained 38% of the amount of information given. Most of the physicians' attention is spent on the 'active' treatment option. Older patients, married patients and patients in academic hospitals receive more information.

When the treatment goal is not cure: are cancer patients equipped to make informed decisions?

PURPOSE

Informed decision making now is considered the underpinning of ethical medical practice. We aimed to determine the extent to which patients with incurable cancer are adequately informed of their prognosis and treatment options and encouraged to participate in treatment decisions.

PATIENTS AND METHODS

One hundred eighteen cancer patients with incurable disease presenting for an initial consultation with one of nine oncologists at two Sydney tertiary referral hospitals participated in the study. Consultations were recorded on audiotape to permit a content analysis of doctor-patient interactions. We devised a coding system to assess disclosure of information and to evaluate doctor encouragement of patient participation in treatment decision making. Patient recall, satisfaction, anxiety, and perceptions of the decision-making process were assessed to determine the effects of informed decision making on patient outcomes.

RESULTS

Most patients were informed about the aim of anticancer treatment (84.7%), that their disease was incurable (74.6%), and about life expectancy (57.6%). An alternative to anticancer treatments was presented to 44.1%, 36.4% were informed about how anticancer treatment would affect quality of life, and 29.7% were offered a management choice. Oncologists checked patient understanding in only 10.2% of consultations. Although greater information disclosure did not seem to elevate anxiety levels, greater patient participation in the decision-making process was associated with increased anxiety levels (P =.0005), which persisted over a 2-week time span.

CONCLUSION

Most patients were well informed, but important gaps remain, especially concerning information about prognosis and alternatives to anticancer treatment. These gaps invite the question concerning whether patients are led toward anticancer treatment.