The collaborative autonomy model of medical decision-making

Patient autonomy in the era of the sustainability crisis

In the realm of medical ethics, the foundational principle of respecting patient autonomy holds significant importance, often emerging as a central concern in numerous ethically complex cases, as authorizing medical assistance in dying or healthy limb amputation on patient request. Even though advocates for either alternative regularly utilize prima facie principles to resolve ethical dilemmas, the interplay between these principles is often the core of the theoretical frameworks. As the ramifications of the sustainability crisis become increasingly evident, there is a growing need to integrate awareness for sustainability into medical decision-making, thus reintroducing potential conflict with patient autonomy. The contention of this study is that the ethical standards established in the 20th century may not adequately address the challenges that have arisen in the 21st century. The author suggests an advanced perception of patient autonomy that prioritizes fostering patients' knowledge, self-awareness, and sense of responsibility, going beyond a sole focus on their intrinsic values. Empowering patients could serve as a tool to align patient autonomy, beneficence, and the aim to reduce resource consumption.

Futility and Shared Decision-Making

Medical futility is an ancient and yet consistent challenge in clinical medicine. The means of balancing conflicting priorities and stakeholders' preferences has changed as much as the science that powers the understanding and treatment of disease. The introduction of patient self-determination and choice in medical decision-making shifted the locus of power in the physician-patient relationship but did not obviate the physician's responsibilities to provide benefit and prevent harm. As we have refined the process in time, new paradigms, specialists, and tools have been developed to help navigate the ever-changing landscape.

Doctors as Appointed Fiduciaries: A Supplemental Model for Medical Decision-Making

How should we respond to patients who do not wish to take on the responsibility and burdens of making decisions about their own care? In this paper, we argue that existing models of decision-making in modern healthcare are ill-equipped to cope with such patients and should be supplemented by an "appointed fiduciary" model where decision-making authority is formally transferred to a medical professional. Healthcare decisions are often complex and for patients can come at time of vulnerability. While this does not undermine their capacity, it can be excessively burdensome. Most existing models of decision-making mandate that patients with capacity must retain ultimate responsibility for decisions. An appointed fiduciary model provides a formalized mechanism through which those few patients who wish to defer responsibility can hand over decision-making authority. By providing a formal structure for deferring to an appointed fiduciary, the confusions and risks of the informal transfers that can occur in practice are avoided. Finally, we note how appropriate governance and law can provide safeguards against risks to the welfare of patients and medical professionals.

Who Should Make Medical Decisions When a Patient Lacks an Advance Directive?

Patients admitted to the hospital with neurological problems are sometimes incapacitated and unable to make end-of-life decisions. In these instances, without an advanced directive from the patient, clinicians and family members must make critical medical decisions without input from the patient. This paper looks at two cases - one child and one adult - in which neuroprognosis was uncertain, and physician and family members' beliefs on end-of-life care clash. We provide insight into these disagreements and reflect on how best to manage them. We argue that when considering withdrawing treatment, respecting autonomy is of paramount importance, while decision-making about continuing life-sustaining treatment requires clinicians to ensure surrogates are adequately educated about the principle of beneficence.

When is it considered reasonable to start a risky and uncomfortable treatment in critically ill patients? A random sample online questionnaire study

Background

Health care professionals have to judge the appropriateness of treatment in critical care on a daily basis. There is general consensus that critical care interventions should not be performed when they are inappropriate. It is not yet clear which chances of survival are considered necessary or which risk for serious disabilities is acceptable in quantitative terms for different stakeholders to start intensive care treatment.

Methods

We performed an anonymous online survey in a random sample of 1,052 participants recruited via email invitation and social media. Age, sex, nationality, education, professional involvement in health care, critical care medicine and treatment decisions in critical care medicine as well as personal experience with critical illness were assessed as potential influencing variables. Participants provided their opinion on the necessary chances of survival and the acceptable risk for serious disabilities to start a high-risk or uncomfortable therapy for themselves, relatives or for their patients on a scale of 0–100%.

Results

Answers ranged from 0 to 100% for all questions. A three-peak pattern with different distributions of the peaks was observed. Sex, education, being a health care professional, being involved in treatment decisions and religiosity influence these opinions. Male respondents and those with a university education would agree that a risky and uncomfortable treatment should be started even with a low chance of survival for themselves, relatives and patients. More respondents would choose a lower necessary chance of survival (0–33% survival) when deciding for patients compared to themselves or relatives to start a risky and uncomfortable treatment. On the other hand, the majority of respondents would accept only a low risk of severe disability for both themselves and their patients.

Conclusion

No cut-off can be identified for the necessary chances of survival or the acceptable risk of disability to help quantify the “inappropriateness” of critical care treatment. Sex and education are the strongest influencing factors on this opinion. The large variation in personal opinions, depending on demographic and personality variables and education needs to be considered in the communication between health care professionals and patients or surrogates.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00705-4.

Trust, but Verify: Informed Consent, AI Technologies, and Public Health Emergencies

To use technology or engage with research or medical treatment typically requires user consent: agreeing to terms of use with technology or services, or providing informed consent for research participation, for clinical trials and medical intervention, or as one legal basis for processing personal data. Introducing AI technologies, where explainability and trustworthiness are focus items for both government guidelines and responsible technologists, imposes additional challenges. Understanding enough of the technology to be able to make an informed decision, or consent, is essential but involves an acceptance of uncertain outcomes. Further, the contribution of AI-enabled technologies not least during the COVID-19 pandemic raises ethical concerns about the governance associated with their development and deployment. Using three typical scenarios—contact tracing, big data analytics and research during public emergencies—this paper explores a trust-based alternative to consent. Unlike existing consent-based mechanisms, this approach sees consent as a typical behavioural response to perceived contextual characteristics. Decisions to engage derive from the assumption that all relevant stakeholders including research participants will negotiate on an ongoing basis. Accepting dynamic negotiation between the main stakeholders as proposed here introduces a specifically socio–psychological perspective into the debate about human responses to artificial intelligence. This trust-based consent process leads to a set of recommendations for the ethical use of advanced technologies as well as for the ethical review of applied research projects.

Readability Assessment of Online Patient Education Materials on Atrial Fibrillation

Health literacy is emerging as an important factor for medical outcomes as more patients turn to the internet for information about their disease. However educational materials on complex conditions such as atrial fibrillation tend to still be esoteric and result in compromised patient autonomy. We add to the current literature by examining the reading level of websites of major healthcare intuitions and general medicine websites. An online Google search using the term "atrial fibrillation" was used to collect patient educational material from the first 20 academic health institutions (AHI) and 20 non-affiliated general medicine websites (GMW). The materials were assessed for readability using nine (9) tests from the analysis software Readability Studio (Oleander Software Solutions Ltd., Maharashtra, India). The patient education materials from the AHI and GMW websites were written at a college freshman reading grade level (13.050 ± 0.845) and high school junior year reading level (11.64 ± 0.789) respectively. The GMW tend to have a wider range of readability levels, and many were scored at the 6th-grade level. In conclusion, the readability levels of patient education materials on atrial fibrillation from both the AHI and GMW are well above the 6th-grade level recommended by the NIH and AMA, posing a risk to the patients' understanding of the materials. The high readability scores found across all websites and the differences between the groups have been attributed to the various goals and target audiences of the material.

Ethical Considerations in End-of-life Care in the Face of Clinical Futility

Management of patients with terminal brain disorders can be medically, socially, and ethically complex. Although a growing number of feasible treatment options may exist, there are times when further treatment can no longer meaningfully improve either quality or length of life. Clinicians and patients should discuss goals of care while patients are capable of making their own decisions. However, because such discussions can be challenging, they are often postponed. These discussions are then conducted with patients' health care proxies after patients lose the capacity to make their own decisions. Disagreements may arise when a patient's surrogate desires continued aggressive interventions that are either biologically futile (incapable of producing the intended physiologic result) or potentially inappropriate (potentially capable of producing the patient's intended effect but in conflict with the medical team's ethical principles). This article explores best practices in addressing these types of conflicts in the critical care unit, but these concepts also broadly apply to other sites of care.

Patient decision aids: a content analysis based on a decision tree structure

INTRODUCTION

This paper presents the preliminary results of a decision-tree analysis of Patient Decision Aids (PDA). PDAs are online or offline tools used to structure health information, elicit relevant values and emphasize the decision as a process, in ways that help patients make more informed health decisions individually or with relevant others.

METHOD

Twenty PDAs are randomly selected from the International Patient Decision Aids Standards (IPDAS) ( https://decisionaid.ohri.ca/AZlist.html ) approved list. An evaluation tool is built bottom-up and top-down and results are described in terms of communicating uncertainty, completeness of the decision tree, ambiguous or misleading phrasing, overall strategies suggested within personal stories.

RESULTS

Twelve of the analyzed PDAs had branches of the decision tree which were not discussed in the tool and 6 had logically ambiguous phrasing. Many tools included dichotomous options, when the option range was wider. Several options were clustered within the "Do not take/Do not do" option and thus the PDA failed to provide all comparisons necessary to make a decision. Some tools employ expressions that do not differentiate between lack of information and known negative effects. Other tools provide unequal amounts or non-comparable bits of information about the options.

CONCLUSION

These results indicate a very loose range of interpretations of what constitutes an option, a treatment, and a treatment option. It thus emphasizes a gap between theory and practice in the evaluation of PDAs. Future developments of PDA evaluation tools should keep track of missing decision tree branches, accurate communication of uncertainty, ambiguity, and lack of knowledge and consider using measures for evaluating the completeness of the option spectrum at an agreed period in time.

A scoping review of interventions to promote the adoption of shared decision-making (SDM) among health care professionals in clinical practice

OBJECTIVES

To identify and summarize evidence on interventions to promote the adoption of shared decision-making (SDM) among health care professionals (HCPs) in clinical practice.

METHODS

Electronic databases including: MEDLINE, EMBASE, CINAHL, PsycINFO and Cochrane library were searched to determine eligible peer-reviewed articles. Grey literature was searched for additional interventions. Eligibility screening and data extraction were independently completed. Results are presented as written evidence summaries and tables.

RESULTS

Our search yielded 238 articles that met our inclusion criteria. Interventions mostly targeted physicians (46%), had multiple educational modalities (46%), and were administered in group settings (44%) before the clinical encounter (71%). Very few were developed based on the learning needs of targeted HCPs (24%). Many of the SDM outcome tools used for evaluation were developed for the respective study and lacked evidence of validity and reliability (30%).

CONCLUSION

We identified a sizable number of interventions to promote the adoption of SDM, however, these interventions were heterogeneous in their assessments for effectiveness and implementation. Therefore, it is a challenge to infer which strategies and practices are best to promote SDM adoption.

PRACTICE IMPLICATIONS

The need for evidence-based standards for developing SDM interventions targeting HCPs and assessing acceptability, effectiveness and implementation is suggested.

New perspectives on substituted relational autonomy for shared decision-making in critical care

In critical care when unconscious patients are assisted by machines, humanity is mainly ensured by respect for autonomy, realised through advance directives or, mostly, reconstructed by cooperation with relatives. Whereas patient-centred approaches are widely discussed and fostered, managing communication in complex, especially end-of-life, situations in open intensive care units is still a point of debate and a possible source of conflict and moral distress. In particular, healthcare teams are often sceptical about the growing role of families in shared decision-making and their ability to represent patients’ preferences. New perspectives on substituted relational autonomy are needed for overcoming this climate of suspicion and are discussed through recent literature in the field of medical ethics.

Readability of Sports Injury and Prevention Patient Education Materials From the American Academy of Orthopaedic Surgeons Website

Introduction:

The purpose of this study is to evaluate the readability of 114 Sports Injury and Prevention patient education materials provided by the American Academy of Orthopaedic Surgeons (AAOS).

Methods:

We evaluated all articles written in English posted under the Sports Injury and Prevention section of the AAOS website using readability software to compute six readability scores, which we compared with the eighth-grade level using a two-tailed one-sample Student t-test.

Results:

The mean reading grade level calculated by each readability test was markedly higher than the eighth-grade level. We reported mean ± SD for each test: Flesch-Kincaid grade level (8.95 ± 1.51; P < 0.001), Simple Measure of Gobbledygook (11.53 ± 1.18; P < 0.001), Coleman-Liau index (11.16 ± 1.33; P < 0.001), Gunning Fog index (11.06 ± 1.63; P < 0.001), New Dale-Chall (9.49 ± 1.66; P < 0.001), and FORCAST formulas (10.96 ± 0.60; P < 0.001).

Discussion:

This study shows that patient education materials provided by the AAOS concerning sports injury and prevention are written at a readability level too high for patients to understand. On average, patient materials are written at least 2.5 grade levels higher than national recommendations. Only 7% of the 114 articles had readability scores in line with national recommendations. These findings indicate a need for revised patient education materials geared toward bringing the readability level down to the recommended eighth-grade level.

Intersection of prognosis and palliation in neurocritical care

PURPOSE OF REVIEW

Difficult discussions regarding end-of-life care are common in neurocritical care. Because of a patient's neurological impairment, decisions regarding continuing or limiting aggressive care must often be made by patients' families in conjunction with medical providers. This review provides perspective on three major aspects of this circumstance: prognostication, family-physician discussions, and determination of death (specifically as it impacts on organ donation).

RECENT FINDINGS

Numerous studies have now demonstrated that prediction models developed from populations of brain-injured patients may be misleading when applied to individual patients. Early care limitations may lead to the self-fulfilling prophecy of poor outcomes because of care decisions rather than disease course. A shared decision-making approach that emphasizes transmission of information and trust between families and medical providers is ethically appropriate in severely brain-injured patients and as part of the transition to end-of-life palliative care. Standard definitions of death by neurological criteria exist, although worldwide variation and the relationship to organ donation make this complex.

SUMMARY

End-of-life care in patients with severe brain injuries is common and represents a complex intersection of prognostication, family communication, and decision-making. Skills to optimize this should be emphasized in neurocritical care providers.

Shared Decision-Making in Acute Surgical Illness: The Surgeon's Perspective

BACKGROUND

Surgical patients increasingly have more comorbidities and are of an older age, complicating surgical decision-making in emergent situations. Little is known about surgeons' perceptions of shared decision-making in these settings.

STUDY DESIGN

Twenty semi-structured interviews were conducted with practicing surgeons at 2 large academic medical centers. Thirteen questions and 2 case vignettes were used to assess perceptions of decision-making, considerations when deciding whether to offer to operate, and communication patterns with patients and families.

RESULTS

Thematic analysis revealed 6 major themes: responsibility for the decision to operate, perceived futility, surgeon judgment, surgeon introspection, pressure to operate, and costs of the operation. Perceived futility was universally considered a contraindication to surgical intervention. However, the challenge of defining futility led participants to emphasize the importance of patients' self-determined risk-to-benefit analysis when considering surgical intervention. More experienced surgeons reported greater comfort with communicating to patients that a condition was not amenable to an operation and reserved the right to refuse to operate.

CONCLUSIONS

Due to external pressures and uncertainty, some providers err on the side of operative intervention, despite suspected futility. Greater experience allows surgeons to withstand external pressures, be confident in their assessments of perceived futility, and guide patients and their families away from additional interventions.

The SDM 3 Circle Model: A Literature Synthesis and Adaptation for Shared Decision Making in the Hospital

Patient engagement through shared decision-making (SDM) is increasingly seen as a key component for patient safety, patient satisfaction, and quality of care. Current SDM models do not adequately account for medical and environmental contexts, which may influence medical decisions in the hospital. We identified leading SDM models and reviews to inductively construct a novel SDM model appropriate for the inpatient setting. A team of medicine and pediatric hospitalists reviewed the literature to integrate core SDM concepts and processes and iteratively constructed a synthesized draft model. We then solicited broad SDM expert feedback on the draft model for validation and further refinement. The SDM 3 Circle Model identifies 3 core categories of variables that dynamically interact within an "environmental frame." The resulting Venn diagram includes overlapping circles for (1) patient/family, (2) provider/team, and (3) medical context. The environmental frame includes all external, contextual factors that may influence any of the 3 circles. Existing multistep SDM process models were then rearticulated and contextualized to illustrate how a shared decision might be made. The SDM 3 Circle Model accounts for important environmental and contextual characteristics that vary across settings. The visual emphasis generated by each "circle" and by the environmental frame direct attention to often overlooked interactive forces and has the potential to more precisely define, promote, and improve SDM. This model provides a framework to develop interventions to improve quality and patient safety through SDM and patient engagement for hospitalists.

Communication, Leadership, and Decision-Making in the Neuro-ICU

The Neuro-ICU is a multidisciplinary location that presents peculiar challenges and opportunities for patients with life-threatening neurological disease. Communication skills are essential in supporting caregivers and other embedded providers (e.g., neurosurgeons, advanced practice providers, nurses, pharmacists), through leadership. Limitations to prognostication complicate how decisions are made on behalf of non-communicative patients. Cognitive dysfunction and durable reductions in health-related quality of life are difficult to predict, and the diagnosis of brain death may be challenging and confounded by medications and comorbidities. The Neuro-ICU team, as well as utilization of additional consultants, can be structured to optimize care. Future research should explore how to further improve the composition, communication and interactions of the Neuro-ICU team to maximize outcomes, minimize caregiver burden, and promote collegiality.

Shared Medical Decision Making in Consideration of Opioid Therapy in a Patient With Restless Legs Syndrome

Treating patients with restless legs syndrome (RLS) may pose a significant challenge to the clinician if those with intractable disease worsen with chronic treatment. Opioids are established as effective treatment for refractory RLS; however, some patients may be reluctant to try opioids because of the risk of dependency. Understanding the physician's duty to the patient through the framework of a shared decision-making model allows the neurologist to propose opioid therapy despite possible initial reluctance by the patient when the neurologist believes that this therapy is the most medically reasonable approach to optimizing the patient's well-being.

Frequency of satisfaction and dissatisfaction with practice among rural-based, group-employed physicians and non-physician practitioners

BACKGROUND

Widespread dissatisfaction among United States (U.S.) clinicians could endanger ongoing reforms. Practitioners in rural/underserved areas withstand stressors that are unique to or accentuated in those settings. Medical professionals employed by integrating delivery systems are often distressed by the cacophony of organizational change(s) that such consolidation portends. We investigated the factors associated with dis/satisfaction with rural practice among doctors/non-physician practitioners employed by an integrated healthcare delivery network serving 9 counties of upstate New York, during a time of organizational transition.

METHODS

We linked administrative data about practice units with cross-sectional data from a self-administered multi-dimensional questionnaire that contained practitioner demographics plus valid scales assessing autonomy/relatedness needs, risk aversion, tolerance for uncertainty/ambiguity, meaningfulness of patient care, and workload. We targeted medical professionals on the institutional payroll for inclusion. We excluded those who retired, resigned or were fired during the study launch, plus members of the advisory board and research team. Fixed-effects beta regressions were performed to test univariate associations between each factor and the percent of time a provider was dis/satisfied. Factors that manifested significant fixed effects were entered into multivariate, inflated beta regression models of the proportion of time that practitioners were dis/satisfied, incorporating clustering by practice unit as a random effect.

RESULTS

Of the 473 eligible participants. 308 (65.1 %) completed the questionnaire. 59.1 % of respondents were doctoral-level; 40.9 % mid-level practitioners. Practitioners with heavier workloads and/or greater uncertainty intolerance were less likely to enjoy top-quintile satisfaction; those deriving greater meaning from practice were more likely. Higher meaningfulness and gratified relational needs increased one's likelihood of being in the lowest quintile of dissatisfaction; heavier workload and greater intolerance of uncertainty reduced that likelihood. Practitioner demographics and most practice unit characteristics did not manifest any independent effect.

CONCLUSIONS

Mutable factors, such as workload, work meaningfulness, relational needs, uncertainty/ambiguity tolerance, and risk-taking attitudes displayed the strongest association with practitioner satisfaction/dissatisfaction, independent of demographics and practice unit characteristics. Organizational efforts should be dedicated to a redesign of group-employment models, including more equitable division of clinical labor, building supportive peer networks, and uncertainty/risk tolerance coaching, to improve the quality of work life among rural practitioners.