Shared decision-making as an existential journey: Aiming for restored autonomous capacity

Cancer Patients' Experiences of Burden when Involved in Treatment Decision Making

PurposePatients are increasingly involved in decision making by their clinicians. Yet, there are concerns that involvement in decision making may cause emotional distress in patients. Little research has examined the nature of the burden experienced by patients confronted with a life-changing treatment decision. Therefore, we explored the nature and manifestations of burden experienced by patients with early-stage breast and prostate cancer regarding their involvement in decision making. We further aimed to identify patient-perceived causes and potential solutions for their experienced burden.MethodsWe used semi-structured interviews to explore the perspectives of patients with early-stage breast and prostate cancer. Patients (N = 24) were eligible if they were diagnosed in the past 6 mo and reported some degree of burden regarding their involvement in decision making. Two researchers independently inductively coded the interviews using thematic analysis.ResultsPatients described being burdened by the decision in various ways and at various moments in the decision-making process. Patients attributed their decision-related burden mainly to uncertainty, fear of making the wrong decision, insufficient guidance by their clinician, and feeling an overwhelming sense of responsibility for their treatment decision. Patients indicated various factors that mitigated their burden or facilitated decision making, including having sufficient time, the opportunity to discuss the choice with experts and/or family, and receiving advice or confirmation from family or the clinician.ConclusionThese findings suggest that decision-related burden could be caused by the uncertainty and anxiety patients experience and by a nonpreferred division of roles within the decision-making process.ImplicationsAccordingly, acknowledging patients' feelings by discussing the presence of uncertainty and distress might normalize the burden for patients. Moreover, clinicians could explore and adjust to patients' role preference in decision making and discuss what would facilitate the decision process for patients.HighlightsPatients experience emotional, cognitive, and physical burden from their involvement in decision making.Some of the burden appears to result from the way clinicians involve patients in decision making.In addition to information about options, benefits, and harms, patients require active support in their decision-making process.Clinicians could aim to avoid overfocus on patient autonomy and instead establish authentic, shared decisions, with a role for some clinician control if needed.

Analysis of Influencing Factors and Strategies of Implementing Shared Decision-Making Among Patients with Gastrointestinal Cancer: A Systematic Review and Meta-analysis of Qualitative Studies

BACKGROUND

Over the past 50 years, doctor-patient interactions have moved from paternalistic to patient-centered, emphasizing shared decision-making (SDM). SDM, which involves healthcare professionals and patients making clinical decisions together, is crucial for patient autonomy and is promoted worldwide, yet remains challenging to implement effectively. Our systematic review analyses the influencing factors of implementing shared decision-making in patients with colorectal cancer and summarizes coping strategies.

MATERIALS AND METHODS

A systematic search of the PubMed, Embase, Cochrane Library, Web of Science (Core library), Ovid, and EBSCO databases was performed from database inception to 1 September 2024 using a combination of subject words and free words. Qualitative studies on the factors affecting SDM for patients with gastrointestinal cancer were identified, the literature quality was evaluated using the Australian JBI Evidence-based Health Care Center quality evaluation standards for qualitative research, and the results were integrated by a pooled integration method.

RESULTS

A total of 37 results were extracted through meta-analysis, summarized into 9 themes, and summarized into 2 subthemes. The results were classified for nonmutually exclusive cases.

CONCLUSIONS

Medical staff should fully understand patients' needs and preferences for disease and treatment information, strengthen their communication skills regarding SDM, and actively provide effective treatment and care information for patients and their families to promote the implementation of SDM for patients with gastrointestinal tumors.

Medical Care as Flea Market Bargaining? An International Interdisciplinary Study of Varieties of Shared Decision Making in Physician-Patient Interactions

Phenomenon: Shared decision making (SDM) is a core ideal in the interaction between healthcare providers and patients, but the implementation of the SDM ideal in clinical routines has been a relatively slow process. Approach: In a sociological study, 71 interactions between physicians and simulated patients enacting chronic heart failure were video-recorded in China, Germany, the Netherlands, and Turkey as part of a quasi-experimental research design. Participating physicians varied in specialty and level of experience. The secondary analysis presented in this article used content analysis to study core components of SDM in all of the 71 interactions and a grounded theory approach to observe how physicians responded actively to patients even though they did not actively employ the SDM ideal. Findings: Full realization of the SDM ideal remains an exception, but various aspects of SDM in physician-patient interaction were observed in all four locations. Analyses of longer interactions show dynamic processes of interaction that sometimes surprised both patient and physician. We observed varieties of SDM that differ from the SDM ideal but arguably achieve what the SDM ideal is intended to achieve. Our analysis suggests a need to revisit the SDM ideal-to consider whether varieties of SDM may be acceptable, even valuable, in their own right. Insights: The gap between the SDM ideal and SDM as implemented in clinical practice may in part be explained by the tendency of medicine to define and teach SDM through a narrow lens of checklist evaluations. The authors support the argument that SDM defies a checklist approach. SDM is not uniform, but nuanced, dependent on circumstances and setting. As SDM is co-produced by patients and physicians in a dynamic process of interaction, medical researchers should consider and medical learners should be exposed to varieties of SDM-related practice rather than a single idealized model. Observing and discussing worked examples contributes to the physician's development of realistic expectations and personal professional growth.

Navigating Power Imbalances and Stigma in Mental Healthcare. Patient-Reported Barriers and Facilitators to Participation in Shared Decision-Making in Mental Health Care, a Qualitative Meta-Summary

BACKGROUND

The use of shared decision-making (SDM) in mental healthcare has been viewed as at least as important as its use in non-mental healthcare settings, but it still does not routinely take place in this setting. To further explore SDM processes with people with lived experience, we provide a qualitative meta-summary on patient-reported barriers and facilitators to participation in SDM within the context of mental healthcare.

METHODS

Within the set of selected studies for a larger qualitative meta-summary, using five databases, we selected the studies that had surveyed patients with mental illness for further analysis in this paper. Search terms were based on the concepts: 'decision making', 'patient participation', 'patient perceptions' and 'study design' of patient reporting, including patient surveys, interviews and focus groups.

RESULTS

Out of the 90 studies that had been selected for the larger review, we selected 13 articles concerning mental illness for more detailed analysis in this review. In total, we identified 29 different influencing factors and we found 6 major barriers: 'Lack of choice', 'Not being respected as a person', 'Feeling stigma from physician', 'Disease burden', 'Power imbalance' and 'Low self-efficacy to participate'. 'Clear information provision about options', 'Being respected as a person, being taken into account', 'Good physician-patient relationship' and 'Belief in the importance of one's own role' were the main facilitators.

CONCLUSIONS

Stigma and self-stigma still seem to persist in mental healthcare and continue to suppress patients' self-efficacy to participate in SDM in this setting. There is much discussion of inclusion and diversity worldwide, and these themes are just as topical for patients with mental health problems. Further work seems necessary to eradicate all stigma and self-stigma in this setting when striving for care that could be 'as shared as possible'.

PATIENT AND PUBLIC CONTRIBUTION

The authors wish to thank Mr. Walter Geuens, a person with lived experience in mental healthcare, for his careful reading and thorough feedback on the final paper.

More than an extra set of ears: A video-based analysis exploring the role of companions in routine oncology visits

PURPOSE

Patients with advanced cancer commonly bring a companion to medical appointments, often a family member. Despite increasing focus on family involvement, few studies are based on observations of real-life consultations. This study aimed to explore how companions contribute to the information exchange process during advanced cancer outpatient visits.

METHODS

Data were ten videos of routine oncology visits. We identified when and how companions participated using microanalysis of clinical interaction.

FINDINGS

Companion participation varied greatly. They tended to speak up spontaneously, contributing medical, personal, and contextual information that might otherwise have remained unsaid. They both brought information into the discussion and facilitated information exchanged between the physician and patient. Companions displayed few of their own concerns.

CONCLUSIONS

The findings suggest that companions may be an important resource during oncology visits, not only for the patient, but also for healthcare providers aiming for person-centered care to the individual patient.

Is shared decision making an aspect of palliative care integration? An observation of collaboration between oncologists and palliative care professionals

BACKGROUND

Early palliative care interventions in oncology, as recommended by international oncology societies, promote patient understanding and support decision-making. At the same time, shared decision-making models are being developed to enhance patient participation as part of a new model of patient-physician relationship. For patients with palliative needs, this participation is essential and helps to avoid futile and aggressive treatments at the end of life. The aim of this study is to observe decision making during meetings between oncology and palliative care professionals, focusing particularly on the components of shared decision-making models, but also on the role played by palliative care professionals.

METHODS

We conducted a non-participant observation of multidisciplinary meetings and outpatient clinic activities in two Comprehensive Cancer Centres in France. Field notes were then coded using thematic content analysis. Deductive analysis was conducted using the observation grid developed from Elwyn's three-talk model.

RESULTS

Only a few elements of the different models of shared decision-making are apparent in the multidisciplinary meetings. Palliative care professionals emphasise the importance of involving patients and providing them with information about the advantages and disadvantages of different treatment options. However, patient involvement in decision-making remains difficult in daily practice. Decisions to discontinue oncological treatment are often driven by clinical and biological signs of terminal evolution rather than shared decision-making.

CONCLUSIONS

There are still cultural and organisational barriers to actual implementation of early integrated onco-palliative care. Promotion of shared decision making can be a strong lever of change which is frequently mobilised by palliative care teams.

Role of the Surgeon in De-Escalating Emotion During a Breast Cancer Surgery Consultation: A Qualitative Study of Patients' Experiences in Alliance A231701CD

BACKGROUND

Patient engagement in decision making can improve satisfaction with care. Studies demonstrate that patients' emotional states can be significant barriers to engaging in shared decision making.

OBJECTIVE

We sought to examine how emotion associated with a breast cancer diagnosis impacts patient experiences during the surgical consultation, and explore opportunities for surgeons to mitigate the impact of emotion.

METHODS

We conducted 30 semi-structured interviews with patients who participated in the decision aid arm of Alliance A231701CD, had low engagement, and experienced barriers to engagement. We used qualitative content analysis to analyze the interview data and organize it into overarching themes.

RESULTS

Participants recalled strong emotions with their diagnosis, describing it as devastating and shocking. Although several participants said that their emotional reaction to the diagnosis lessened over time, others expressed still feeling very anxious. Participants described ways in which their surgeon helped to de-escalate their emotional state, beginning with the establishment of rapport and continuing through treatment planning. Participants valued surgeons who they perceived to be personable and compassionate, treated them as an individual, provided reassuring and matter-of-fact information about their cancer, and efficiently communicated plans for next steps.

CONCLUSIONS

Patients with breast cancer are often emotionally overwhelmed during their surgical consults, which impedes their ability to listen and participate in decision making. However, surgeon behaviors can help de-escalate emotions. Addressing emotion is critical to support patients in reaching a decision for breast cancer surgery and is likely to improve patient satisfaction with the decision process.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov identifier: NCT03766009.

Proposing surgery at the prosthetic clinic: managing patient resistance

OBJECTIVE

Investigating doctors' communicative practices for recommending surgery to amputees when the proposal counters patients' expectation.

METHOD

Conversation Analysis of 77 videorecorded medical consultations at an Italian prosthesis clinic.

RESULTS

Compared to the direct format doctors used to prescribe prosthesis, when suggesting surgery doctors adopted a more circuitous, indirect approach. They used a range of communication strategies, orientating to patients' likely resistance - indeed, patients were frequently observed to reject surgical options.

CONCLUSIONS

Considering patients' expectations is part of a patient centred approach, hence the cautious ways in which doctors introduce the option of surgery. Moreover, doctors do not pursue recommending surgery when patients display their reluctance or resistance.

PRACTICE IMPLICATIONS

Doctors in prosthetics clinics might adopt a more balanced communicative strategy that takes into account patients' perspectives, concerns and expectations, whilst but also providing patients with the necessary information to collaborate meaningfully to decision making.

Development and alpha testing of a patient shared decision aid for prosthesis design for new lower limb prosthesis users

BACKGROUND

After lower limb amputation, several prosthesis design options exist. However, prosthesis design decisions do not always reflect a prosthesis user's needs, values, and preferences.

OBJECTIVE

To develop a patient decision aid (PDA) prototype for prosthetists and new prosthesis users facing prosthesis design decisions after lower limb amputation, and to assess its usability, accuracy, and comprehensibility.

STUDY DESIGN

Exploratory mixed methods.

METHODS

PDA development was informed by a qualitative needs assessment and guided by the International Patient Decision Aid Standards. The PDA was evaluated by steering groups of experienced prosthesis users and prosthetic professionals (prosthetists and researchers) to test usability, accuracy, and comprehensibility through focus groups, individual interviews, and rating on a Likert scale ranging from 1 to 10.

RESULTS

The resulting PDA included 6 sections: (1) Amputation and Early Recovery, (2) Communication, (3) Values, (4) Prosthesis Design, (5) Preferences, and (6) Prosthetic Journey. Usability, accuracy, and comprehensibility were rated as 9.2, 9.6, and 9.6, respectively, by prosthetic professionals, and 9.4, 9.6, and 9.6, respectively, by prosthesis users.

DISCUSSION

The PDA incorporated guidance by relevant stakeholders and was rated favorably, emphasizing a need for shared decision-making support in prosthesis design. One challenge was determining the amount of information in the PDA, highlighting the diversity in end users' informational needs. Future iterations of the PDA should undergo beta testing in clinical settings.

CONCLUSIONS

A standardized, iterative method was used to develop a PDA for new lower limb prosthesis users and prosthetists when considering prosthesis design decisions. The PDA was considered useable, accurate, and comprehensible.

Shared decision-making in underserved populations with multiple sclerosis: A systematic review

BACKGROUND

The concept of shared decision-making (SDM) is valuable to ensure patients receive individualized care. SDM occurs when healthcare providers engage patients in making personal healthcare decisions that could contribute to better long-term outcomes. With the ever-increasing landscape of treatment options available, SDM can be challenging but valuable for patients. Patients from underserved populations are potentially less likely to engage in SDM, impacting their long-term care. This systematic literature review aimed to explore SDM in these patient populations.

METHODS

Relevant articles were retrieved from PubMed using key search terms, without any restriction on publication date. All searches and data retrieval were conducted between May 25, 2022, and August 17, 2022, and abstracts were reviewed by two independent reviewers. A thematic analysis was used to present the data.

RESULTS

All search terms yielded 418 articles; 89 were included (33 involving patients with multiple sclerosis [MS]). Reported mean percentage of patients with MS (including from underserved populations) who preferred SDM was 52 % (range: 37.5-71.5; n = 4). Differences in racial/ethnic assimilation of information communicated by clinicians were reported, impacted by the lower literacy level and certain cultural health beliefs in groups of underserved populations. Primary care clinicians play a key role in providing information to patients in underserved populations.

CONCLUSIONS

There is a clear benefit for SDM for patients with MS, and without it, patients report dissatisfaction, decisional regret, and lack of confidence in the medical system. However, there are several challenges, including the need for further examination of social determinants of health, for underserved patient populations which still need to be addressed.

Exploring Healthcare Paradoxes in Hospital Haemodialysis-A Qualitative Study

INTRODUCTION

The complex logics of healthcare systems inherit paradoxes that can lead to interpersonal conflicts impacting both patients and professionals. In this study, we aimed to identify and explore tensions and conflicts arising from paradoxes within hospital haemodialysis.

METHODS

We conducted a secondary supplementary analysis to previously collected qualitative data, including individual interviews with 11 patients and 10 nephrologists and focus groups involving a total of 13 haemodialysis nurses. Data were collected in Norway through three primary studies focused on exploring experiences of patient participation. For the current study, we employed thematic analysis.

RESULTS

Patient-professional conflicts emerged in three fundamental areas: (1) the hospital haemodialysis treatment, in which patients' views of treatment diverged from those of professionals, (2) patient-professional responsibility that became a negotiation point, with differing views on responsibilities, and (3) time, in which professional time took precedence over patients' time, indirectly impacting patients due to resource allocation. These conflicts stemmed from paradoxes driven by unevenly validated principles, conflict of interest, and conceptual ambiguity.

CONCLUSION

Altering healthcare logics by bringing in new perspectives or clarifying conceptual ambiguity could mitigate patient-professional conflicts. However, changing existing healthcare logics may give rise to new paradoxes and conflicts, which health services at various levels must address.

PATIENT OR PUBLIC CONTRIBUTION

This secondary analysis utilized previously collected data from a project that did not involve patient or public contribution.

The Encounter of Two Worlds: Divided Narratives of Decision-Making on Cancer Treatment Between Physicians and Patients

INTRODUCTION

Divided narratives pose long-standing difficulties in physician and patient communication. In decision-making on cancer treatment, divided narratives between physicians and patients hinder mutual understanding and agreement over the illness and its treatment. For effective decision-making on treatments, it is necessary to investigate the similarities and differences in these divided narratives.

METHODS

This study adopted a qualitative research design of narrative inquiry to examine the data, which included interviews with 32 cancer patients and 16 paired physicians in two hospitals in China. Data analysis was conducted using grounded theory to generate findings.

RESULTS

Both physicians and patients were concerned about goals and obstacles to their decision-making on cancer treatment. Four common aspects of goal setting were identified from the divided narratives: decision pools, treatment goals, identity practice and preferred identity. Four common obstacles were identified: pains and trust, communication gap, financial issues and complex family. However, the meanings attached to these eight aspects differed between physicians and patients.

CONCLUSION

Cancer treatment decision-making is an encounter of the scientific world and lifeworld. A divided narrative approach can identify the similarities and differences in the decision-making on cancer treatment between physicians and patients. Physicians generally adopt a rational decision-making approach, whereas patients generally adopt a relational decision-making approach. Despite the common concerns in their goals and obstacles, physicians and patients differed in their contextualized interpretations, which demonstrates the physicians' and the patients' pursuit of preferred identities in decision-making. The results of this study provide a new perspective to treatment decision-making, emphasizing the importance of narrative integration in reaching mutual agreement.

PATIENT AND PUBLIC CONTRIBUTION

The findings were shared with 15 cancer patients and caregivers for feedback and advice in June 2024. This study was also presented at the international conferences of COMET (International and Interdisciplinary Conference on Communication, Medicine, and Ethics) and ICCH (International Conference on Communication in Healthcare) 2023 for continuous feedback and comments.

Documentation of shared decision-making in diagnostic testing for dementia in Dutch general practice: A retrospective study in electronic patient records

OBJECTIVE

To explore (1) documentation of shared decision-making (SDM) in diagnostic testing for dementia in electronic patient records (EPR) in general practice and (2) study whether documentation of SDM is related to specific patient characteristics.

METHODS

In this retrospective observational study, EPRs of 228 patients in three Dutch general practices were explored for the documentation of SDM elements using Elwyn's model (team talk, option talk, decision talk). Patient characteristics (gender, age, comorbidities, chronic polypharmacy, the number of consultations on memory complaints) and decision outcome (wait-and-see, GP diagnostics, referral) were also extracted.

RESULTS

In EPRs of most patients (62.6 %), at least one SDM element was documented. Most often this concerned team talk (61.6 %). Considerably less often option talk (4.3 %) and decision talk (12.8 %) were documented. SDM elements were more frequently documented in patients with lower comorbidity scores and patients with a relatively high number of consultations. Decision talk was more frequently documented in referred patients.

CONCLUSION

Patients' and significant others' needs, goals, and wishes on diagnostic testing for dementia are often documented in EPRs.

PRACTICE IMPLICATIONS

Limited documentation of option and decision talk stresses the need for future SDM interventions to facilitate timely dementia diagnosis.

Existential Needs in Mental Health - Who Cares? A Mixed Methods Study in Norway

Mental health care that is open to patients' existential needs requires well-trained professionals who work in teams and use an open conceptualization of spirituality, religion and other meaning-making domains. Using a mixed methods approach, this article explores how professionals (n = 262) in secular Norway perceive obstacles and opportunities in existential care. The results show correlations between age group, personal religiosity, terminology and perceived expertise. Commitment is high, but collaboration with chaplains and team training are neglected.

Exploring patient ideas, concerns, and expectations in surgeon-patient consultations

OBJECTIVES

This study explores patient perspectives (ideas, concerns, and expectations) in surgeon-patient consultations.

METHODS

We examined 54 video-recorded consultations using applied conversation analysis. Consultations took place from 2012 to 2017 in an Australian metropolitan hospital clinic centre and involved seven surgeons across six specialties.

RESULTS

Patient perspectives emerged in less than one third of consultations. We describe the initiation of and response to potential perspectives sequences, demonstrating how patients and surgeons co-construct these sequences when they do occur.

CONCLUSIONS

Findings suggest a need for greater attention to supporting patient agency through explicit pursuit of patient perspectives. The implications extend to the Calgary-Cambridge Guide, suggesting that it may benefit from a focus on active pursuit and appropriate responsiveness to patient perspectives.

PRACTICE IMPLICATIONS

This study highlights the need for surgeons to actively engage with the patient perspective offered in consultations, emphasising the importance of respect for the patient's knowledge and expectations to improve patient satisfaction and healthcare outcomes.

What value structure underlies shared decision making? A qualitative synthesis of models of shared decision making

OBJECTIVE

To construct the underlying value structure of shared decision making (SDM) models.

METHOD

We included previously identified SDM models (n = 40) and 15 additional ones. Using a thematic analysis, we coded the data using Schwartz's value theory to define values in SDM and to investigate value relations.

RESULTS

We identified and defined eight values and developed three themes based on their relations: shared control, a safe and supportive environment, and decisions tailored to patients. We constructed a value structure based on the value relations and themes: the interplay of healthcare professionals' (HCPs) and patients' skills [Achievement], support for a patient [Benevolence], and a good relationship between HCP and patient [Security] all facilitate patients' autonomy [Self-Direction]. These values enable a more balanced relationship between HCP and patient and tailored decision making [Universalism].

CONCLUSION

SDM can be realized by an interplay of values. The values Benevolence and Security deserve more explicit attention, and may especially increase vulnerable patients' Self-Direction.

PRACTICE IMPLICATIONS

This value structure enables a comparison of values underlying SDM with those of specific populations, facilitating the incorporation of patients' values into treatment decision making. It may also inform the development of SDM measures, interventions, education programs, and HCPs when practicing.

Fostering relational autonomy in end-of-life care: a procedural approach and three-dimensional decision-making model

Respect for patient autonomy is paramount in resolving ethical tensions in end-of-life care. The concept of relational autonomy has contributed to this debate; however, scholars often use this concept in a fragmented manner. This leads to partial answers on ascertaining patients' true wishes, meaningfully engaging patients' significant others, balancing interests among patients and significant others, and determining clinicians' obligations to change patients' unconventional convictions to enhance patient autonomy. A satisfactory solution based on relational autonomy must incorporate patients' competence (apart from decisional capacity), authenticity (their true desires or beliefs) and the involvement level of their significant others. To that end, we argue that John Christman's procedural approach to relational autonomy provides critical insights, such as the diachronic or socio-historical personhood, sustained critical reflection and his recent explication of the nature of asymmetrical relationships and helpful interlocutors. This study reviews Christman's account, proposes minor modifications and advocates for an integrated three-dimensional model for medical decision-making. Clarifying the relationship among the three elements promotes an ethical framework with a coherent understanding of relational autonomy. This model not only provides a descriptive and normative framework for end-of-life care practice but also reconsiders the nature of the clinician-patient relationship and its normative implications. We further present a case study to illustrate the merits of our proposed model. Altogether, our proposal will help navigate complex medical decision-making, foster trust and negotiate shared values between patients and their significant others, particularly in end-of-life care.

Preference-based patient participation in intermediate care: Translation, validation and piloting of the 4Ps in Norway

INTRODUCTION

The implementation and evaluation of patient participation to obtain high-quality transitional care for older people is an international priority. Intermediate care (IC) services are regarded as an important part of the patient's pathway from the specialist to the primary care levels, bridging the gap between the hospital and the home. Patients may experience varying capacities and conditions for patient participation. Yet, few tools for evaluating patients' preferences for patient participation within IC services are at hand. Accordingly, further knowledge is needed to understand and scaffold processes for patient participation in IC. Therefore, the aim of this project was to translate, validate and pilot test the Patient Preferences for Patient Participation (the 4Ps) with patients in IC services in Norway.

METHODS

This project comprised two phases: (1) a careful translation and cultural adaptation process, followed by a content validity trial among 15 patients and staff in Norwegian IC and (2) a cross-sectional survey of the instrument with 60 patients admitted to IC.

RESULTS

The translation between Swedish and Norwegian required no conceptual or contextual adaptations. The subsequent cross-sectional study, designed as a dialogue between the patients and staff, revealed that only 50% of the participants received a sufficient level of patient participation based on their preferences, mostly indicating that patients were receiving less-than-preferred conditions for engaging in their health and healthcare issues.

CONCLUSION

The 4Ps instrument was deemed suitable for measuring patient participation based on patient preferences in the IC context and was feasible for both healthcare professionals and patients to complete in an interview when arriving at and leaving services. This may support person-centred communication and collaboration, calling for further research on what facilitates patient participation and the implementation of person-centred services for patients in IC.

PATIENT OR PUBLIC CONTRIBUTION

First, the current paper is part of the IPIC study (i.e., the implementation of patient participation in IC). Influenced by a James Lind Alliance process, the study addresses research uncertainties identified by patients, next of kin, staff and researchers in the cocreation process. Second, cognitive interviewing was conducted with 15 representatives of the target population: seven patients receiving IC services, one home-dwelling previous IC patient (altogether four women and four men, most of them 80 years or older) and seven healthcare staff working in IC services. The interviews determined the relevance, comprehensiveness and clarity of the 4Ps. Finally, 60 patients admitted to IC took part in the cross-sectional study.

Potential Adverse Outcomes of Shared Decision Making about Palliative Cancer Treatment: A Secondary Analysis of a Randomized Trial

BACKGROUND

While shared decision making (SDM) is advocated for ethical reasons and beneficial outcomes, SDM might also negatively affect patients with incurable cancer. The current study explored whether SDM, and an oncologist training in SDM, are associated with adverse outcomes (i.e., patient anxiety, tension, helplessness/hopelessness, decisional uncertainty, and reduced fighting spirit).

DESIGN

A secondary analysis of a randomized clinical trial investigating the effects of SDM interventions in the context of advanced cancer. The relations between observed SDM (OPTION12), specific SDM elements (4SDM), oncologist SDM training, and adverse outcomes were analyzed. We modeled adverse outcomes as a multivariate phenomenon, followed by univariate regressions if significant.

RESULTS

In total, 194 patients consulted by 31 oncologists were included. In a multivariate analysis, observed SDM and adverse outcomes were significantly related. More specifically, more observed SDM in the consultation was related to patients reporting more tension (P = 0.002) and more decisional uncertainty (P = 0.004) at 1 wk after the consultation. The SDM element "informing about the options" was especially found to be related to adverse outcomes, specifically to more helplessness/hopelessness (P = 0.002) and more tension (P = 0.016) at 1 wk after the consultation. Whether the patient consulted an oncologist who had received SDM training or not was not significantly related to adverse outcomes. No relations with long-term adverse outcomes were found.

CONCLUSIONS

It is important for oncologists to realize that for some patients, SDM may temporarily be associated with negative emotions. Further research is needed to untangle which, when, and how adverse outcomes might occur and whether and how burden may be minimized for patients.

HIGHLIGHTS

Observed shared decision making was related to more tension and uncertainty postconsultation in advanced cancer patientsHowever, training oncologists in SDM did not affect adverse outcomes.Further research is needed to untangle which, when, and how adverse outcomes might occur and how burden may be minimized.

Communication, Cognition and Competency Development in Healthcare: A Model for Integrating Cognitive Ethnography and Communication Skills Training in Clinical Interventions

OBJECTIVES

The aim of this study was to conduct and evaluate the Blended Learning communication skills training program. The key objective was to investigate (i) how clinical intervention studies can be designed to include cognitive, organizational, and interactive processes, and (ii) how researchers and practitioners could work with integrated methods to support the desired change.

METHODS

The method combined design and implementation of a 12-week Blended Learning communication skills training program based on the Calgary-Cambridge Guide. The training was implemented in a patient clinic at a Danish university hospital and targeted all healthcare professionals at the clinic. Cognitive ethnography was used to document and evaluate healthcare professionals' implementation and individual competency development, and support the design of in-situ simulation training scenarios.

RESULTS

Thirteen participants completed the program. The synergy within the teams, as well as the opportunities for participants to coordinate, share, discuss, and reflect on the received knowledge with a colleague or on-site researcher, affected learning positively. The knowledge transfer process was affected by negative feedback loops, such as time shortages, issues with concept development and transfer, disjuncture between the expectations of participants and instructors of the overall course structure, as well as participant insecurity and a gradual loss of motivation and compliance.

CONCLUSION

We propose a novel 3-step model for clinical interventions based on our findings and literature review. This model will effectively support the implementation of educational interventions in health care by narrowing the theory-practice gap. It will also stimulate desired change in individual behavior and organizational culture over time. Furthermore, it will work for the benefit of the clinic and may be more suitable for the implementation of communication projects than, for example, randomized setups.

Lost in the loop - a qualitative study on patient experiences of care in standardized cancer patient pathways

BACKGROUND

The Norwegian health authorities introduced standardized cancer patient pathways (CPPs) in 2015, aiming to reduce practice variations across hospitals and regions, and improve the continuity, coordination and overall quality of the health care service provided to cancer patients. There has been few studies investigating this change, and that have looked into the organisational and economic benefits of standardized pathways, however the element of care and the patient perspective has been especially neglected. This study explored the care element in cancer patient pathways through an in-depth study of patient experiences.

METHODS

The patients were enrolled approximately three years after the introduction of standardized CPPs in Norway. Through a qualitative design with in-depth interviews, a total of 21 interviews were conducted with seven patients between 2018 and 2020. The first interview took place after the diagnosis was established and before treatment, the second interview during treatment, and the final interview approximately one year after the completion of active treatment. The empirical catchment area was eastern Norway. Data were analysed using a theoretical thematic analysis.

RESULTS

This study sheds light on the complex challenges patients' faces, while navigating CPPs, including the need for better transition support, improved coordination and continuity in care, and a more holistic approach that encompasses emotional well-being and family support. Three overarching themes were identified: [1] Navigating CPPs: patient care and transition challenges, [2] Fragmented cancer care: challenges in coordination and continuity [3] Unmet needs and overlooked opportunities in CPPs.

CONCLUSIONS

Patients experience that cancer patient pathways offer good medical treatment, but that the care element deserves more attention. Current CPPs are trapped in a logic of choice, preventing room for the element of care to receive the attention it requires for the patient to truly experience holistic person-centred care and continuous, well-coordinated services. Based in our study we argue there is a need to look into the missed opportunities for using the CPPs as points of departure for more holistic collaborative models for cancer care.

'The way you talk, do I have a choice?' Patient narratives of medication decision-making during hospitalization

OBJECTIVE

Based on the principle of the autonomy of the patient, shared decision-making (SDM) is the ideal approach in clinical encounters. In SDM, patients and healthcare professionals (HCPs) share knowledge and power when faced with the task of making decisions. However, patients are often not involved in the decision-making process. In this study, we explore medication decision-making during hospitalization and how power in the specific patient-HCP relationship is articulated, as analysed by Foucauldian theory.

METHODS

A qualitative case study, comprising observations of patient-HCP encounters at an internal medicines ward at a university hospital in Norway, followed by semi-structured interviews. The narratives (n = 4 patients) were selected from a larger study (n = 15 patients). The rationale behind the choice of these patients was to include diverse and rich accounts. The four patients in their 40s-70s were included close to the day of presumed discharge.

RESULTS

The narratives provide an insight into the patients as persons, their perspectives, including what mattered to them during their hospitalization, especially in relation to medications. Overall, SDM was not observed in this study. Even though all the participants actively tried to keep their autonomous capacity and to resist the HCPs' use of power, they were not able to change the established dynamics. Moreover, they were not allowed an equal voice to those of HCPs and thus not to escape the system's objectification and subjectification of them.

CONCLUSION

There is a need for HCPs to get more familiarized with SDM. The healthcare system and the individual HCP need to make more room for dialogue with the patients about their preferences. A part of this is also how health care systems are structured and scheduled, thus, it is important to empower patients and HCPs alike.

Protecting Personhood: A Classic Grounded Theory

The importance of perceiving and considering patients as healthcare partners has been increasingly promoted. Healthcare systems around the world are now highly interested in patient engagement, participation, collaboration, and partnership. Healthcare professionals are advised that patients, as autonomous beings, should be active in and responsible for a portion of their own care. The study presented here focused on patients' perceptions of interprofessional collaboration. It was conducted using the classic grounded theory methodology. The theory of protecting personhood emerged as the core concept of hospitalized patients, cared for by interprofessional healthcare teams. This theory encapsulates the process hospitalized patients go through to find balance in their sense of self, oscillating between personhood and patienthood in the unfamiliar hospital environment. The process consists of four stages: the stage of introspection, during which hospitalized patients become aware of their self as a person and as a patient; the stage of preservation, when patients find a balance between the sense of personhood and patienthood; the stage of rupture, wherein patients experience an imbalance between their sense of personhood and patienthood; and the stage of reconciliation, in which personhood is restored. The theory of protecting personhood offers insights into a better understanding of hospitalized patients' experiences and strategies, revealing the importance of relationships, and the driving force of empowerment. This study is about patients' perspectives of interprofessional healthcare teams. A grounded theory process allowed the emergence of patients' concerns and expectations, leading to a substantive theory grounded in the patients' data.

"The challenge is the complexity" - A qualitative study about decision-making in advanced lung cancer treatment

INTRODUCTION

The value of shared decision-making and decision aids (DA) has been well documented yet remain difficult to integrate into clinical practice. We wanted to investigate needs and challenges regarding decision-making about advanced lung cancer treatment after first-line therapy, focusing on DA applicability.

METHODS

Qualitative data from separate, semi-structured focus groups with patients/relatives and healthcare professionals were analysed using systematic text condensation. 12 patients with incurable lung cancer, seven relatives, 12 nurses and 18 doctors were recruited from four different hospitals in Norway.

RESULTS

The participants described the following needs and challenges affecting treatment decisions: 1) Continuity of clinician-patient-relationships as a basic framework for decision-making; 2) barriers to information exchange; 3) negotiation of autonomy; and 4) assessment of uncertainty and how to deal with it. Some clinicians feared DA would steal valuable time and disrupt consultations, arguing that such tools could not incorporate the complexity and uncertainty of decision-making. Patients and relatives reported a need for more information and the possibility both to decline or continue burdensome therapy. Participants welcomed interventions supporting information exchange, like communicative techniques and organizational changes ensuring continuity and more time for dialogue. Doctors called for tools decreasing uncertainty about treatment tolerance and futile therapy.

CONCLUSION

Our study suggests it is difficult to develop an applicable DA for advanced lung cancer after first-line therapy that meets the composite requirements of stakeholders. Comprehensive decision support interventions are needed to address organizational structures, communication training including scientific and existential uncertainty, and assessment of frailty and treatment toxicity.

Regaining Autonomy in a Holding Environment: Patients' Perspectives on the Existential Communication with Physicians When Suffering from a Severe, Chronic Illness: A Qualitative Nordic Study

Patients experience existential themes as pivotal in their lives, in order to be able to live with a severe, chronic illness; however, physicians report a hesitative approach to existential communication. The current study investigated Nordic patients' experiences of existential communication with their physicians related to the treatment of multiple sclerosis or chronic pain. Semi-structured interviews with 23 patients were analyzed following Interpretative Phenomenological Analysis. Physicians focusing on medical aspects at the expense of psychological and existential aspects of being ill was experienced by patients as challenging their treatment and well-being. For making a shared decision with the physician on their treatment, patients needed a transition from being dependent to being autonomous. A holding environment and existential communication about transitional objects such as relationships with something bigger than themselves, as nature or religion, supported this autonomy. The analysis showed that existential communication not only supported patients in developing and regaining autonomy but also functioned as a moderator for illness-related distress, as a prevention of withdrawal from treatment, and as significant for patients in relation to living with chronic illness. Further education in existential communication is desirable, to support physicians integrating existential dimensions in consultations and shared decision-making with patients suffering from a severe, chronic illness.

A blended learning for general practitioners and nurses on skills to support shared decision-making with patients about palliative cancer treatment: A one-group pre-posttest study

OBJECTIVE

To evaluate a newly developed blended learning programme for general practitioners (GPs) and nurses in supporting shared decision making (SDM) about palliative cancer treatment in a simulated setting.

METHODS

In a pre-posttest study, healthcare professionals (HCPs) participated in the blended learning (i.e. e-learning and (online) training session). HCPs filled out surveys (T0 (baseline), T1 (after e-learning) and T2 (after full blended learning)) and engaged in simulated consultations at T0 and T2. The primary outcome was observed SDM support (Triple-S; DSAT-10 for validation). Secondary outcomes included satisfaction, knowledge about and attitude towards SDM support. Repeated measures General Linear Models were conducted.

RESULTS

33 HCPs (17 GPs and 16 nurses) participated. SDM support significantly improved after training (Triple-S; medium effect). Observers' overall rating of SDM support (medium effect) as well as HCPs' knowledge (large effect) and beliefs about their capabilities (medium effect) improved after training. There was no difference in decision support skills (DSAT-10), HCPs' other clinical behavioural intentions and satisfaction. HCPs evaluated the training positively.

CONCLUSION

Blended learning for HCPs on supporting SDM in palliative cancer care improved their skills, knowledge and confidence in simulated consultations.

PRACTICE IMPLICATIONS

These first findings are promising for evaluating interprofessional SDM in clinical practice.

Effect of communication skills training on documentation of shared decision-making for patients with life-limiting illness: An observational study in an intensive care unit

Objectives

This article aims to examine the association between a shared decision-making (SDM) clinical communication training program and documentation of SDM for patients with life-limiting illness (LLI) admitted to intensive care.

Methods

This article used a prospective, longitudinal observational study in a tertiary intensive care unit (ICU). Outcomes included the proportion of patients with SDM documented on an institutional Goals of Care Form during hospital admission, as well as characteristics, outcomes, and factors associated with an SDM admission.

Intervention

Clinical communication skills training (iValidate) and clinical support program are the intervention for this study.

Results

A total of 325 patients with LLI were admitted to the ICU and included in the study. Overall, 184 (57%) had an SDM admission, with 79% of Goals of Care Form completed by an iValidate-trained doctor. Exposure to an iValidate-trained doctor was the strongest predictor of an ICU patient with LLI having an SDM admission (odds ratio: 22.72, 95% confidence interval: 11.91-43.54, p < 0.0001). A higher proportion of patients with an SDM admission selected high-dependency unit-level care (29% vs. 12%, p < 0.001) and ward-based care (36% vs. 5%, p < 0.0001), with no difference in the proportion of patients choosing intensive care or palliative care. The proportion of patients with no deterioration plan was higher in the non-SDM admission cohort (59% vs. 0%, p < 0.0001).

Conclusions

Clinical communication training that explicitly teaches identification of patient values is associated with improved documentation of SDM for critically ill patients with LLI. Understanding the relationship between improved SDM and patient, family, and clinical outcomes requires appropriately designed high-quality trials randomised at the patient or cluster level.

Blended online learning for oncologists to improve skills in shared decision making about palliative chemotherapy: a pre-posttest evaluation

PURPOSE

To improve shared decision making (SDM) with advanced cancer patients, communication skills training for oncologists is needed. The purpose was to examine the effects of a blended online learning (i.e. e-learning and online training session) for oncologists about SDM in palliative oncological care and to compare this blended format with a more extensive, fully in-person face-to-face training format.

METHODS

A one-group pre-posttest design was adopted. Before (T0) and after (T2) training, participants conducted simulated consultations (SPAs) and surveys; after the e-learning (T1), an additional survey was filled out. The primary outcome was observed SDM (OPTION12 and 4SDM). Secondary outcomes included observed SDM per stage, SPA duration and decision made as well as oncologists' self-reported knowledge, clinical behavioural intentions, satisfaction with the communication and evaluation of the training. Additionally, outcomes of the blended learning were compared with those of the face-to-face training cohort. Analyses were conducted in SPSS by linear mixed models.

RESULTS

Oncologists (n = 17) showed significantly higher SDM scores after the blended online learning. The individual stages of SDM and the number of times the decision was postponed as well as oncologists' beliefs about capabilities, knowledge and satisfaction increased after the blended learning. Consultation duration was unchanged. The training was evaluated as satisfactory. When compared with the face-to-face training, the blended learning effects were smaller.

CONCLUSION

Blended online SDM training for oncologists was effective. However, the effects were smaller compared to face-to-face training. The availability of different training formats provides opportunities for tailoring training to the wishes and needs of learners.

The factors affecting implementing shared decision-making in clinical trials: a cross-sectional survey of clinical research coordinators' perceptions in Japan

BACKGROUND

The shared decision-making model has been proposed as the ideal treatment decision-making process in medical encounters. However, the decision to participate in clinical trials rarely involves shared decision-making. In this study, we investigated the perceptions of Japanese clinical research coordinators who routinely support the informed consent process.

METHODS

This study aimed to (1) identify clinical research coordinators' perceptions of the current status of shared decision-making implementation and its influencing factors, and (2) obtain suggestions to enhance the shared decision-making process in clinical trials. A cross-sectional survey was conducted using a web questionnaire based on the Theory of Planned behaviour. Invitations were sent to 1087 Japanese medical institutions, and responses from the participants were captured via the web. The shared decision-making process in clinical trials was defined according to the Shared Decision-Making Questionnaire for Doctors. The effect of the attitudes toward shared decision-making, clinical research coordinators' subjective norms towards its implementation, perceived barriers to autonomous decision-making, and the number of difficult steps in the shared decision-making process on the shared decision-making current status as the shared decision-making intention was assessed by multiple regression analysis.

RESULTS

In total, 373 clinical research coordinators responded to the questionnaire. Many believed that they were already implementing shared decision-making. Attitudes toward shared decision-making (t = 3.400, p < .001), clinical research coordinators' subjective norms towards its implementation (t = 2.239, p = .026), perceived barriers to autonomous decision-making (t = 3.957, p < .001), and the number of difficult steps in the shared decision-making process (t = 3.317, p = .001) were found to significantly influence current status (Adjusted R2 = .123). However, results on perceived barriers to autonomous decision-making and the number of difficult steps in the shared decision-making process indicate a lack of knowledge of shared decision-making and decision-support skills among clinical research coordinators.

CONCLUSIONS

Clinical research coordinators might positively perceive shared decision-making based on normative beliefs without sufficient knowledge of it. Therefore, providing appropriate training on shared decision-making to clinical research coordinators and increasing awareness among stakeholders could enable its improvement.

TRIAL REGISTRATION

Not applicable.

Improving shared decision-making for prosthetic care: A qualitative needs assessment of prosthetists and new lower-limb prosthesis users

BACKGROUND

Prosthesis design is complex and multiple appropriate options exist for any individual with lower-limb amputation. However, there is insufficient evidence for guiding decision-making. Shared decision-making (SDM) offers an opportunity to incorporate patient-specific values and preferences where evidence is lacking for prosthesis design decisions. To develop resources to facilitate SDM, and consistent with the International Patient Decision Aid Standards, it is necessary to identify the decisional needs of prosthetists and prosthesis users for prosthesis design decisions.

OBJECTIVES

To assess the needs of prosthetists and new prosthesis users for SDM about the first prosthesis design.

STUDY DESIGN

Qualitative descriptive design.

METHODS

Six focus groups were conducted with 38 prosthetists. Individual semistructured interviews were conducted with 17 new prosthesis users. Transcripts were analyzed using directed content analysis, with codes defined a priori using existing frameworks for SDM: the Three Talk Model for SDM and the Ottawa Decision Support Framework.

RESULTS

Four main themes were identified among prosthetists and prosthesis users: acknowledging complexity in communication, clarifying values, recognizing the role of experience to inform preferences , and understanding the prosthetic journey .

CONCLUSIONS

Resources that support SDM for the first prosthesis design should consider methods for identifying individual communication needs, support with clarifying values, and resources such as experience for achieving informed preferences, within the context of the overall course of rehabilitation and recovery following lower-limb amputation. The themes identified in this work can inform SDM to promote collaborative discussion between prosthetists and new prosthesis users when making prosthesis design decisions.

Sharing decision-making between the older person and the nurse: A scoping review

BACKGROUND

Sharing decision-making is globally recognised as an important concept in healthcare research, policy, education and practice which enhances person-centred care. However, it is becoming increasingly evident shared decision-making has not been successfully translated into everyday healthcare practice. Sharing decision-making has strong links with person-centred practice. Core to person-centredness and shared decision making, is the need to recognise that as we age, greater reliance is placed on emotion and life experience to inform decision making processes. With the world's ageing population, older persons facing more complex decisions and transitions of care, it is more important than ever it is understood how shared decision-making occurs.

OBJECTIVES

This scoping literature review aims to find out how sharing decision making between nurses and older persons in healthcare settings is understood and presented in published literature.

METHODS

This scoping review utilised the Arksey and O'Malley methodological framework, advanced by Levac et al. Electronic databases and grey literature were searched, returning 362 records which were examined against defined inclusion criteria. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).

RESULTS

Twenty-two records met inclusion criteria for the review. Results indicate while shared decision-making is included in research, education and policy literature, it has not been effectively translated to inform practice and the relationship between a nurse and an older person. The records lack definitions of shared decision-making and theoretical or philosophical underpinnings. There is also no consideration of emotion and life experience in decision-making and how nurses 'do' shared decision-making with older persons.

CONCLUSIONS

The findings demonstrate sharing decision-making between nurses and older persons is not well understood in the literature, and therefore is not translated into nursing practice. Further research is needed.

Exploring sustainable care pathways - a scoping review

BACKGROUND

Patients with mental health problems experience numerous transitions into and out of hospital.

AIM

The review studies assessing clinical care pathways between psychiatric hospitalization and community health services.

METHODS

We used publications between 2009-2020 to allow a broad scoping review of the published research. Sixteen review-articles were identified, 12 primary studies were chosen, both on care pathways in the transition between psychiatric hospital and community.

RESULTS

Organizational issues: Systems and procedures to ensure clear responsibilities and transparency at each stage of the pathways of care.

RESOURCES

Information-technology in objectively improving patient outcome. Information/documentation: Providing patients with adequate structured information and documented plans at the appropriate time. Patient/families: Continuous collaborative decision-making. Clinical care and teamwork: Collaboration between mental health and other professionals to guarantee that planned activities meet patient need.

ETHICAL ISSUES

Respectful communication and patient-centred, non-humiliating care.

CONCLUSIONS

System and procedures ensure clear responsibilities and transparency. Information technology support decision-making and referral and objectively improve patient outcomes in care pathways. Collaboration between mental health and other professionals guarantee that planned activities meet patients' needs along with regular meetings sharing key information. Around-the-clock ambulant-teams important to transition success. Informed-shared decision-making between parties, support patient participation and respectful communication.

Patient Trust in Physicians Matters-Understanding the Role of a Mobile Patient Education System and Patient-Physician Communication in Improving Patient Adherence Behavior: Field Study

BACKGROUND

The ultimate goal of any prescribed medical therapy is to achieve desired outcomes of patient care. However, patient nonadherence has long been a major problem detrimental to patient health and, thus, is a concern for all health care providers. Moreover, nonadherence is extremely costly for global medical systems because of unnecessary complications and expenses. Traditional patient education programs often serve as an intervention tool to increase patients' self-care awareness, disease knowledge, and motivation to change patient behaviors for better adherence. Patient trust in physicians, patient-physician relationships, and quality of communication have also been identified as critical factors influencing patient adherence. However, little is known about how mobile patient education technologies help foster patient adherence.

OBJECTIVE

This study aimed to empirically investigate whether and how a mobile patient education system (MPES) juxtaposed with patient trust can increase patient adherence to prescribed medical therapies.

METHODS

This study was conducted based on a field survey of 125 patients in multiple states in the United States who have used an innovative mobile health care system for their health care education and information seeking. Partial least squares techniques were used to analyze the collected data.

RESULTS

The results revealed that patient-physician communication and the use of an MPES significantly increase patients' trust in their physicians. Furthermore, patient trust has a prominent effect on patient attitude toward treatment adherence, which in turn influences patients' behavioral intention and actual adherence behavior. Based on the theory of planned behavior, the results also indicated that behavioral intention, response efficacy, and self-efficacy positively influenced patients' actual treatment adherence behavior, whereas descriptive norms and subjective norms do not play a role in this process.

CONCLUSIONS

Our study is one of the first that examines the relationship between patients who actively use an MPES and their trust in their physicians. This study contributes to this context by enriching the trust literature, addressing the call to identify key patient-centered technology determinants of trust, advancing the understanding of patient adherence mechanisms, adding a new explanation of the influence of education mechanisms delivered via mobile devices on patient adherence, and confirming that the theory of planned behavior holds in this patient adherence context.

Qualitatively exploring the impact of a relationship-centered communication skills training program in improving patient perceptions of care

Objective

To explore qualitative patient experience comments before and after a relationship-centered communication skills training to understand patient experience, program impact, and opportunities for improvement.

Methods

Qualitative patient experience evaluation data was captured from January 2016 to December 2018 for 483 health care clinicians who participated in the skills training. A random sampling of available open-ended patient comments (N = 33,223) were selected pre-training (n = 668) and post-training (n = 566). Comments were coded for valence (negative/neutral/positive), generality versus specificity, and based on 12 communication behaviors reflective of training objectives.

Results

No significant difference was found in the valence of comments, or generality versus specificity of comments before and after the training. A significant decrease was present in perceived clinician concern. "Confidence in care provider" was the communication skill most frequently identified in comments both pre- and post-training.

Conclusion

Perceptions of interactions largely remained the same following training. Key relationship-centered communication skills require further attention in future training efforts. Measurements of patient satisfaction and engagement may not adequately represent patient experience.

Innovation

This study identified areas for improvement in the training program and offers a model for utilizing patient experience qualitative data in understanding communication training impact.

Physicians' responses to advanced cancer patients' existential concerns: A video-based analysis

OBJECTIVE

In a recent study, we explored what kind of existential concerns patients with advanced cancer disclose during a routine hospital consultation and how they communicate such concerns. The current study builds on these results, investigating how the physicians responded to those concerns.

METHODS

We analyzed video-recorded hospital consultations involving adult patients with advanced cancer. The study has a qualitative and exploratory design, using procedures from microanalysis of face-to-face-dialogue.

RESULTS

We identified 185 immediate physician-responses to the 127 patient existential utterances we had previously identified. The responses demonstrated three approaches: giving the patient control over the content, providing support, and taking control over the content. The latter was by far the most common, through which the physicians habitually kept the discussion around biomedical aspects and rarely pursued the patients' existential concerns.

CONCLUSIONS

Although the physicians, to some extent, allowed the patients to talk freely about their concerns, they systematically failed to acknowledge and address the patients' existential concerns.

PRACTICE IMPLICATIONS

Physicians should be attentive to their possible habit of steering the agenda towards biomedical topics, hence, avoiding patients' existential concerns. Initiatives cultivating behavior enhancing person-centered and existential communication should be implemented in clinical practice and medical training.

Confucian Familism and Shared Decision Making in End-of-Life Care for Patients with Advanced Cancers

Shared decision-making (SDM) has been institutionally recognized as clinically effective by many Western healthcare systems. Nevertheless, it appears culturally unattractive in China, a country that adheres to Confucian familism which strongly prefers collective family decisions. This study examined this conflict and assessed the influence of Confucian familism on SDM in end-of-life (EOL) care for advanced cancer patients. Between August and November 2018, 188 EOL advanced-cancer patients were randomly recruited from 640 cancer hospital medical records at a Tertiary A-level hospital in Shandong province. Eventually, 164 (87.23%) sample patients were included in the statistical analysis after the non-responsive cases (4.79%) and missing value (7.98%) were removed. SDM was measured through SDM-Q-9, and the patient's siblings were used as indicators of Confucian Familism. Of the 164 patients, the mean SDM score was 38/100; 47.6% were thoroughly unfamiliar with their treatment plans and fell outside the decision-making procedure. Each patient had four siblings on average. Ceteris paribus, more siblings led to lower SDM. Moreover, being 56-65 years old and open-minded were associated with higher SDM, while higher satisfaction of the quality of EOL care yielded lower SDM. In conclusion, Confucian familism weakened patient-clinician SDM in EOL care for advanced cancer patients.

Men's experiences of receiving a prostate cancer diagnosis after opportunistic screening-A qualitative descriptive secondary analysis

BACKGROUND

Prostate cancer is one of the most common types of cancer in men and could occur without symptoms. Screening has been debated but remains controversial and, in most countries, organized population-based screening does not exist. The aim of this study was to describe men's experiences of receiving a prostate cancer diagnosis after opportunistic screening.

METHODS

This study is a secondary analysis from interviews with 17 men (aged 56-80 years) who had undergone curative treatment for prostate cancer. Data were collected in an urban region of Sweden through interviews conducted face to face or by telephone. An inductive content analysis was used with Consolidated criteria for Reporting Qualitative research as a reporting checklist.

RESULTS

Two main categories were identified. Screening is a lifesaver enclosed by ethical dilemmas reflects how men considered screening as a lifesaving test. Testing was surrounded by injustice and an eagerness to encourage other men to undergo screening. Facing challenges during diagnosis reflects the men's experiences of being in an unknown field yet expected to engage in decision-making concerning appropriate treatment. Receiving the diagnosis rendered mixed emotions about having a cancer disease, that the treatment could cause lifelong symptom distress and the men described being hesitant to talk about their diagnosis.

CONCLUSIONS

The findings highlight men's opinions about screening and that the lack of routine screening represents injustice. The men considered this as an ethical question of lifesaving justice, while stakeholders may argue that screening could lead to unnecessary suffering and overtreatment. Men do not always talk openly about their diagnosis, linked to the fact that it concerns intimate areas. It is important to balance the information in relation to shared decision-making regarding treatment. Health care professionals have an ethical responsibility to support and coach the patient in their decision.

PATIENT OR PUBLIC CONTRIBUTION

This study was based on interviews with men who had experienced a diagnosis of prostate cancer.

"I'm not the doctor; I'm just the patient": Patient agency and shared decision-making in naturally occurring primary care consultations

OBJECTIVES

To explore interactional processes in which clinical decisions are made in situ during medical consultations, particularly the ways in which patients show agency in decision-making processes by proposing and opposing actions, and which normative dimensions and role-expectations their engagement entail.

METHODS

Narrative analysis of verbatim transcripts of 22 naturally occurring consultations, sourced from a corpus of 212 consultations between general practitioners and patients in England. After thematically coding the whole dataset, we selected 22 consultations with particularly engaged patients for in-depth analysis.

RESULTS

Patients oppose further actions more often than they propose actions, and they oppose more directly than they propose. When they explain why they propose and oppose something, they reveal their values. Patients' role-performance changes throughout the consultations.

CONCLUSION

Assertive patients claim - and probably also achieve - most influence when they oppose actions directly and elaborate why. Patients display ambiguous role-expectations. In final concluding stages of decision-making processes, patients usually defer to GPs' authority.

PRACTICE IMPLICATIONS

Clinicians should be attentive to the ways in which patients want to engage in decision-making throughout the whole consultation, with awareness of normative dimensions of both process and content, and the ways in which patient's actions are constrained by their institutional position.

"Eh - What type of cells are these - flourishing in the liver?" Cancer patients' disclosure of existential concerns in routine hospital consultations

OBJECTIVE

Advanced cancer poses a threat to all aspects of being, potentially causing existential suffering. We explore what kind of existential concerns patients with advanced cancer disclose during a routine hospital consultation, and how they communicate such concerns.

METHODS

We analyzed thirteen video-recorded hospital consultations involving adult patients with advanced cancer. The study has a qualitative and exploratory design, using procedures from microanalysis of face-to-face-dialogue.

RESULTS

Nearly all patients disclosed how the illness experience included losses and threats of loss that are strongly associated with existential suffering, displaying uncertainty about future and insecurity about self and coping. Patients usually disclosed existential concerns uninvited, but they did so indirectly and subtly, typically hiding concerns in biomedical terms or conveying them with hesitation and very little emotion.

CONCLUSIONS

Patients may have existential concerns they want to address, but they may be uncertain whether these are issues they can discuss with the physician.

PRACTICE IMPLICATIONS

Health professionals should be attentive to underlying existential messages embedded in the patient's questions and concerns. Acknowledging these existential concerns provides an opportunity to briefly explore the patient's needs and may direct how the physician tailors information and support to promote coping, autonomy, and existential health.

Asking the right questions: towards a person-centered conception of shared decision-making regarding treatment of advanced chronic kidney disease in older patients

An increasing number of older patients have to decide on a treatment plan for advanced chronic kidney disease (CKD), involving dialysis or conservative care. Shared decision-making (SDM) is recommended as the model for decision-making in such preference-sensitive decisions. The aim of SDM is to come to decisions that are consistent with the patient’s values and preferences and made by the patient and healthcare professional working together. In clinical practice, however, SDM appears to be not yet routine and needs further implementation. A shift from a biomedical to a person-centered conception might help to make the process more shared. Shared should, therefore, be interpreted as two persons bringing two perspectives to the table, that both need to be explored during the decision-making process. Starting from the patient’s perspective will enable to determine the mutual goals of care first and, subsequently, determine the best way for achieving those goals. To perform such SDM, the healthcare professional needs to become a skilled companion, being part of the patient’s relational context, and start asking the right questions about what matters to the patient as person. In this article, we describe the need for a person-centered conception of SDM for the setting of older patients with advanced CKD.

'I Don't Like Uncertainty, I Like to Know': How and why uveal melanoma patients consent to life expectancy prognostication

BACKGROUND

Technological advances have led to cancer prognostication that is increasingly accurate but often unalterable. However, a reliable prognosis of limited life expectancy can cause psychological distress. People should carefully consider offers of prognostication, but little is known about how and why they decide on prognostication. Using uveal melanoma (UM) patients, we aimed to identify (i) how and why do people with UM decide to accept prognostication and (ii) alignment and divergence of their decision-making from conceptualizations of a 'well-considered' decision.

METHODS

UM provides a paradigm to elucidate clinical and ethical perspectives on prognostication, because prognostication is reliable but prognoses are largely nonameliorable. We used qualitative methods to examine how and why 20 UM people with UM chose prognostication. We compared findings to a template of 'well-considered' decision-making, where 'well-considered' decisions involve consideration of all likely outcomes.

RESULTS

Participants wanted prognostication to reduce future worry about uncertain life expectancy. They spontaneously spoke of hoping for a good prognosis when making their decisions, but largely did not consider the 50% possibility of a poor prognosis. When pressed, they argued that a poor outcome at least brings certainty.

CONCLUSIONS

While respecting decisions as valid expressions of participants' wishes, we are concerned that they did not explicitly consider the realistic possibility of a poor outcome and how this would affect them. Thus, it is difficult to see their decisions as 'well-considered'. We propose that nondirective preference exploration techniques could help people to consider the possibility of a poor outcome.

PATIENT OR PUBLIC CONTRIBUTION

This paper is a direct response to a patient-identified and defined problem that arose in therapeutic and conversational discourse. The research was informed by the responses of patient participants, as we used the material from interviews to dynamically shape the interview guide. Thus, participants' ideas drove the analysis and shaped the interviews to come.

Complexity in shared decision making: a qualitative analysis of clinical encounters and patient/physician interviews

Background:  Shared decision making is a complex clinical activity, for which the most effective educational interventions are unclear. Cultural Historical Activity Theory (CHAT) can be utilized as a framework to help medical educators understand and teach shared decision making. The objective of this qualitative study was to utilize CHAT to explore, through analysis of clinical encounters and interviews, patient and provider perspectives of a medical decision-making process that included use of a decision aid mobile application (app). Methods: Female patients from age 17 to 45, who sought care at a contraceptive clinic between April and June 2019, and physicians providing care in the clinic, were recruited for this study. Patients utilized the decision aid app prior to the visit. The clinical encounter and semi-structured interviews with each patient and physician were recorded. Template analysis was used to analyze the transcripts with themes including elements of activity systems within CHAT, tensions within and between activity systems, and agency. Results: In total, 21 patients and eight providers participated in the study. Evidence of CHAT elements were identified for each patient-physician dyad. In analyzing occurrences of codes across transcripts, recurring contradictions and themes emerged, such as how the app is utilized as a mediating tool and the importance of patient and physician communities.     Conclusions: Through analysis of clinical encounters and focused interviews, patient and provider perspectives provided a unique understanding of the complex process of decision-making. These findings can assist educators in developing more effective teaching strategies that may lead to enhanced patient agency, effective relational agency, and successful shared decision making.

General dental practitioners' perceptions of shared decision making: a qualitative study

Introduction As patient-centred care becomes more of the focus in healthcare, informed consent is receiving more attention in dental practice as the pinnacle principle in patient care. Shared decision making or person-centred care appears to be taking a back foot in dentistry.Aim This study aims to gain insight into the current views and perceptions of shared decision making by general dental practitioners and how it can be utilised in daily practice.Method Empirical qualitative data were collected using semi-structured interviews of nine dentists working in general practice, with an average of 30 minutes for each interview. The data were analysed using thematic analysis.Results Overall, there was a misunderstanding of what constitutes shared decision making among dental practitioners, with communication focused more on information provision rather than collaborative discussion. There were barriers which prevented full discussions with patients from occurring, some of which directly conflicted with the focus of shared decision making.Conclusion There is a need to provide more clarity of what shared decision making is and how it can facilitate person-centred care in dental practice. Dental practitioners felt that standards and guidelines were not clear; therefore, they were confused as to what was expected of them with regards to communication. More support, in the form of standardised decision-making aids, is needed to assist dental practitioners to streamline the delivery of shared decision making in primary care.

Correlation analysis between physicians' evaluations of doctor-patient relationship and their preferences for shared decision-making in China

Shared decision-making (SDM) is a scientific and reasonable decision-making model. However, whether physicians choose SDM is usually influenced by many factors. It is not clear whether the strained doctor-patient relationship will affect physicians' willingness to choose SDM. Through a survey by questionnaire, 304 physicians' evaluations of doctor-patient relationship (DPR) were quantified by the difficult DPR questionnaire-8. Their preferences for SDM and the reasons were also evaluated. The correlation between physicians' evaluations of DPR and their preferences for SDM were analyzed. 84.5% physicians perceived DPR as poor or strained, 53.3% physicians preferred SDM, mainly because of the influences of medical ethics and social desirability bias. Their preferences for SDM were not significantly correlated with their evaluations of DPR (P > 0.05). Physicians with different evaluations of DPR (good, poor, and strained) all had similar preferences for SDM (42.6, 56.4, and 42.9%), with no significant difference (P > 0.05). There was no correlation between physicians' evaluations of DPR and their preferences for SDM. Physicians' evaluations of poor DPR did not affect their preferences for SDM. This may be influenced by the medical ethics and social desirability bias.

Addressing Religion in Secular Healthcare: Existential Communication and the Post-Secular Negotiation

This article aims to understand why religion has proven difficult to address in secular healthcare, although existential communication is important for patients’ health and wellbeing. Two qualitative data samples exploring existential communication in secular healthcare were analyzed following Interpretative Phenomenological Analysis, leading to the development of the analytical constructs of ‘the secular’ and ‘the non-secular’. The differentiation of the secular and the non-secular as different spheres for the individual to be situated in offers a nuanced understanding of the physician–patient meeting, with implications for existential communication. We conceptualize the post-secular negotiation as the attempt to address the non-secular through secular activities in healthcare. Employment of the post-secular negotiation enables an approach to existential communication where the non-secular, including religion, can be addressed as part of the patients’ life without compromising the professional grounding in secular healthcare. The post-secular negotiation presents potential for further research, clinical practice, and for the benefit of patients.

Seeing Complexity: Cultural Historical Activity Theory (CHAT) As a Lens for Shared Decision Making

Shared decision making, a collaborative approach between patient and provider that considers the patient's values and preferences in addition to the scientific evidence, is a complex clinical activity that has not realized its full potential. Gaps in education and training have been cited as barriers to shared decision making, and evidence is inconsistent on effective educational interventions. Because individual agents with their own social and behavioral contexts co-construct a shared decision, the educational approach may need to consider the role of patient agency and sociocultural influences. To address the inherent complexity in shared decision making, the authors identified cultural historical activity theory (CHAT) as a framework for analysis. Although certainly not the only relevant theory, CHAT offers an appropriate lens through which the multivoiced nature of shared decision making can be more clearly appreciated. In this article, the authors demonstrate the application of CHAT as a lens for researchers and educators to examine the complexity of shared decision making. The fictitious case presented in this article describes the use of CHAT with a patient who experiences 2 clinical encounters; during the second, shared decision making takes place. Elements of the case are threaded through the article, demonstrating a sample analysis of the interacting activity systems of the patient and physician and highlighting inherent tensions and contradictions. The authors propose CHAT as a tool for future research around the role of agency in shared decision making and other complex topics and as a framework for design of novel instructional strategies. Although not applicable to all topics and settings, CHAT has significant potential within health professions education.

Role of GPs in shared decision making with patients about palliative cancer treatment: a qualitative study in the Netherlands

Background

GPs are well placed to enhance shared decision making (SDM) about treatment for patients with advanced cancer. However, to date, little is known about GPs’ views about their contribution to SDM.

Aim

To explore GPs’ perspectives on their role in SDM about palliative cancer treatment and the requirements they report to fulfil this role.

Design and setting

Qualitative interview study among Dutch GPs.

Method

GPs were sampled purposefully and conveniently. In-depth, semi-structured interviews were conducted, recorded, and transcribed verbatim. Transcripts were analysed by thematic analysis.

Results

Fifteen GPs took part in this study. Most of them reported practices that potentially support SDM: checking the quality of a decision, complementing SDM, and enabling SDM. Even though most of the GPs believed that decision making about systemic cancer treatment is primarily the oncologist’s responsibility, they did recognise their added value in the SDM process because of their gatekeeper position, the additional opportunity they offer patients to discuss treatment decisions, and their knowledge and experience as primary healthcare providers at the end of life. Requirements for them to support the SDM process were described as: good collaboration with oncologists; sufficient information about the disease and its treatment; time to engage in conversations about treatment; a trusting relationship with patients; and patient-centred communication.

Conclusion

GPs may support SDM by checking the quality of a decision and by complementing and enabling the SDM process to reach high-quality decisions. This conceptualisation of the GP’s supporting role in SDM may help us to understand how SDM is carried out through interprofessional collaboration and provide tools for how to adopt a role in the interprofessional SDM process.

Negotiating uncertainty in clinical encounters: A narrative exploration of naturally occurring primary care consultations

Based on a narrative analysis of 20 naturally occurring clinical consultations between general practitioners and patients in England, sourced from the One in a million data archive, we explore how they conceptualize and negotiate medical and existential uncertainty. To capture the interactional element, which is often overlooked, three consultations receive special attention. While exploring the ongoing dynamics of the moment-to-moment realization of negotiations, we relate their actions to the institutionalized positions of doctor and patient. Situating their negotiations in the sociocultural context in which their interaction is embedded reveals how consultations unfold as a result of communication between two different positions in a normatively structured system. When uncertainty prevails, both patients and GPs mainly conceptualize uncertainty indirectly. By conceptualizing uncertainty indirectly and in a depersonalized manner, GPs manage to safeguard against clinical errors without compromising their authority and credibility. Contrary to medical uncertainty, which is continuously discussed, existential uncertainty usually recedes in the background. However, as our consultations unfold it becomes evident that medical and existential dimensions of uncertainty are inextricably linked. By acknowledging that clinical uncertainty is not only an epistemic concern but also an existential one, existential aspects may usefully rise to the surface.