Role in decision making among congestive heart failure patients and its association with patient outcomes: a baseline analysis of the SCOPAH study

Decision-making involvement and onset of cognitive impairment in community-dwelling older care recipients: a 2-year longitudinal study

BACKGROUND

The decision-making of older adults and people with dementia is attracting more attention among healthcare professionals. While cognitive impairment has been examined as a factor related to decision-making, it can also be assumed that involvement in decision-making leads to the maintenance of cognitive function. This study examined the association of the decision-making process with the onset of cognitive impairment.

METHODS

We analyzed data from a 2-year longitudinal panel survey of community-dwelling care recipients aged ≥65 years in Japan. The sample included 406 participants who responded to both baseline and follow-up surveys, were cognitively intact at baseline, and had no missing cognitive impairment data regarding onset at follow-up. The status of decision-making involvement was assessed using a single item and classified into four categories: 'very involved,' 'less involved,' 'unclear about desired care,' and 'having no one to share the decision.'

RESULTS

Among the participants (women, 65.0%; ≥75 years old: 68.2%), the incidence of cognitive impairment during the follow-up was 26.6%. Multivariable logistic regression showed that, compared with highly involved participants, those who lacked clarity about desired care were more likely to develop an onset of cognitive impairment (odds ratio: 5.49; 95% confidence interval: 1.63-18.54; P = 0.006).

CONCLUSION

Even among cognitively intact care recipients, those who are not able to formulate their desired care may be at risk of cognitive decline. Therefore, support for the decision-making process, not limited to the final decision, is essential to improving the prognosis of community-dwelling care recipients.

Perspectives on self-management of individuals living with chronic illnesses: A qualitative study in the Asian context

Living with a chronic illness requires individuals to perform a critical role in self-managing their illness to improve their quality of life and prevent disease-related complications. To our knowledge, no studies have explored how individuals perceive managing their illness in daily living within the Asian context. This exploratory-descriptive qualitative study aimed to explore the individuals' perspectives regarding self-managing their life with a chronic illness within the Asian context. Individual interviews were conducted with 15 adults living with chronic illness, from three teaching hospitals in Pakistan. An iterative process was followed for data collection and analysis. The analysis identified self-management as complex and situation-driven with variable roles for individuals, namely follower, selective follower, self-permitting role, and active role. Three interrelated elements were found to be influencing these roles: the components of self-management; individuals' relationship with agencies (significant people and power); and their inner drives. Individuals keep moving between these four self-management roles to avoid disharmony and reciprocate the efforts of their significant others. The interdependent community structure, which is a reality in Asian society, was reflected in our data. With this in view, a great deal of authority was given to family relationships and healthcare professionals (HCPs). This study found a lack of collaborative partnership role between individuals and HCPs. The findings and a suggested conceptual figure can facilitate redefining the individuals' and professionals' roles in the healthcare system to promote collaborative partnership and improve individuals' experience of living with a chronic illness within the Asian context. Members of the research team have extensive experience in research around chronic illness management, and self-management (support) from the Western context. The researcher did not need the patient or public contribution in this preliminary exploratory study from the Asian context.

A Prospective Cohort Study of Medical Decision-Making Roles and Their Associations with Patient Characteristics and Patient-Reported Outcomes among Patients with Heart Failure

OBJECTIVE

Among patients with heart failure (HF), we examined 1) the evolution of patient involvement in decision making over 2 y, 2) the association of patient characteristics with decision-making roles, and 3) the association of decision-making roles with distress, spiritual well-being, and quality of physician communication.

METHODS

We administered the survey every 4 mo over 24 mo to patients with New York Heart Association class 3/4 symptoms recruited from inpatient clinics. The decision-making roles were categorized as no patient involvement, physician/family-led, joint (with family and/or physicians), patient-led, or patient-alone decision making. The associations between patient characteristics and decision-making roles were assessed using a mixed-effects ordered logistic regression, whereas those between patient outcomes and decision-making roles were investigated using mixed-effects linear regressions.

RESULTS

Of the 557 patients invited, 251 participated in the study. The most common roles in decision making at baseline assessment were "no involvement" (27.53%) and "patient-alone decision making" (25.10%). The proportions of different decision-making roles did not change over 2 y (P = 0.37). Older age (odds ratio [OR] = 0.97; P = 0.003) and being married (OR = 0.63; P = 0.035) were associated with lower involvement in decision making. Chinese ethnicity (OR = 1.91; P = 0.003), higher education (OR = 1.87; P = 0.003), awareness of terminal condition (OR = 2.00; P < 0.001), and adequate self-care confidence (OR = 1.74; P < 0.001) were associated with greater involvement. Compared with no patient involvement, joint (β = -0.58; P = 0.026) and patient-led (β = -0.59; P = 0.014) decision making were associated with lower distress, while family/physician-led (β = 4.37; P = 0.001), joint (β = 3.86; P < 0.001), patient-led (β = 3.46; P < 0.001), and patient-alone (β = 3.99; P < 0.001) decision making were associated with better spiritual well-being.

CONCLUSION

A substantial proportion of patients was not involved in decision making. Patients should be encouraged to participate in decision making since it is associated with lower distress and better spiritual well-being.

HIGHLIGHTS

The level of involvement in medical decision making did not change over time among patients with heart failure. A substantial proportion of patients were not involved in decision making throughout the 24-mo study period.Patients' involvement in decision making varied by age, ethnicity, education level, marital status, awareness of the terminal condition, and confidence in self-care.Compared with no patient involvement in decision making, joint and patient-led decision making were associated with lower distress, and any level of patient involvement in decision making was associated with better spiritual well-being.

Shared Decision-Making and Cardiovascular Health: A Scientific Statement From the American Heart Association

Shared decision-making is increasingly embraced in health care and recommended in cardiovascular guidelines. Patient involvement in health care decisions, patient-clinician communication, and models of patient-centered care are critical to improve health outcomes and to promote equity, but formal models and evaluation in cardiovascular care are nascent. Shared decision-making promotes equity by involving clinicians and patients, sharing the best available evidence, and recognizing the needs, values, and experiences of individuals and their families when faced with the task of making decisions. Broad endorsement of shared decision-making as a critical component of high-quality, value-based care has raised our awareness, although uptake in clinical practice remains suboptimal for a range of patient, clinician, and system issues. Strategies effective in promoting shared decision-making include educating clinicians on communication techniques, engaging multidisciplinary medical teams, incorporating trained decision coaches, and using tools (ie, patient decision aids) at appropriate literacy and numeracy levels to support patients in their cardiovascular decisions. This scientific statement shines a light on the limited but growing body of evidence of the impact of shared decision-making on cardiovascular outcomes and the potential of shared decision-making as a driver of health equity so that everyone has just opportunities. Multilevel solutions must align to address challenges in policies and reimbursement, system-level leadership and infrastructure, clinician training, access to decision aids, and patient engagement to fully support patients and clinicians to engage in the shared decision-making process and to drive equity and improvement in cardiovascular outcomes.

Complexity of implementing a nationwide advance care planning program: results from a qualitative evaluation

BACKGROUND

We evaluated Singapore's national advance care planning (ACP) program to understand challenges to its implementation within multiple clinical settings.

METHODS

We conducted focus group discussions (FGDs) with a purposive sample of health care professionals (HCPs) involved in ACP program delivery within acute care hospitals, primary care clinics and nursing homes. FGDs were stratified into three categories based on HCPs' role within the ACP framework-leaders versus facilitators and advocates versus nursing home heads. Using NVivo 11, we analysed data using thematic analysis and Conceptual Framework for Implementation Research.

RESULTS

A total of 107 HCPs from 25 organisations participated in 22 FGDs. Findings revealed wide variation in ACP implementation among organisations and identified 12 themes organized within four domains-outer setting (lack of public awareness, shortcomings in inter-organisational partnerships, performance driven policies), inner setting (lack of commitment from organisational leadership, paucity of dedicated resources, absence of an institution-wide ACP culture, lack of physician engagement), characteristics of HCPs (language barriers) and process (inadequate training, complexity of conversations and documentations, challenges to retrieving ACP documents, absence of comprehensive monitoring and evaluation).

CONCLUSION

ACP program implementation is complex and faces multiple health care system challenges. To integrate ACP within routine clinical care, ACP processes should be simplified, training framework be strengthened, physicians be engaged and an ACP supportive culture be created within and outside organisations. Findings will be used to guide ACP implementation within the country and globally.

Preferred Role in Health Care Decision Making Over Time in Patients With Heart Failure: My Decision or My Doctor's Decision?

BACKGROUND

Understanding patients' preferred role in decision making can improve patient-centered care. This study aimed to determine change and the predictors of change in preferred decision-making roles over time in patients with heart failure.

METHODS AND RESULTS

During the CASA (Collaborative Care to Alleviate Symptoms and Adjust to Illness) trial, patients' preferred roles in decision making were measured using the Control Preferences Scale (range 1-5; higher = less active; n = 312) at 4 timepoints over 1 year. The effect of the CASA intervention on preferred decision-making roles was tested using generalized linear mixed models. Whether preferences changed over time in the whole population was determined using linear regression. Demographic and health-related factors were examined as predictors of change using multiple linear regression. At baseline, most participants preferred active (score 1-2, 37.2%) or collaborative (score 3, 44.9%) roles. The CASA intervention did not influence preferred decision-making roles (P > 0.1). Preferences significantly changed over 1 year (P < 0.01), becoming more active (82.1%, 84.2%, 89.0%, 90.1% active/collaborative at each timepoint). Among all models and covariates, there were no significant predictors of change (P > 0.1).

CONCLUSIONS

Patients' preferred roles in decision making change over time, but changes are not well predicted. Clinicians should frequently and directly communicate with patients about their preferred decision-making roles.

An Adaptation, Extension and Pre-Testing of an Interactive Decision Aid for Men Diagnosed with Localized Prostate Cancer in Iceland: A Mixed-Method Study

In this study an interactive decision aid (DA) for men diagnosed with localized prostate cancer was adapted, extended and pre-tested. The DA's prototype was based on a literature review and other empirically tested DAs. Semi-structured interviews with 12 men (age 65-80) diagnosed with localized prostate cancer were conducted to get feedback on content, usability, and the DA's layout. The interviews were analyzed using thematic analysis and themes were identified using deductive and inductive coding. Participants found the accessibility of the information and the explicit values clarification tool helpful. Four themes were identified: (1) usability and design, (2) content and knowledge, (3) deciding factors of decision-making, and (4) social support. Participants valued receiving extensive and realistic information on surgery/radiation therapy side effects and getting unbiased presentations of treatment options. Following the thematic analysis, the DA was revised and tested in a survey among 11 newly diagnosed prostate cancer patients (age 60-74). The participants valued the DA and found it helpful when making a treatment decision, and all reported that they would recommend it to others making a prostate cancer treatment decision. The DA is currently being tested in a randomized clinical trial (RCT). This is the first DA developed for prostate cancer patients in Iceland and if the results of the RCT show that it is more effective than standard care in assisting newly diagnosed patients with their treatment decision, the DA can be easily translated and adapted to cultures similar to Iceland such as the Nordic countries.

Experiences with health care practitioners among advanced cancer patients and their family caregivers: A longitudinal dyadic study

BACKGROUND

Assessing patient and caregiver experiences with care is central to improving care quality. The authors assessed variations in the experiences of advanced cancer patients and their caregivers with physician communication and care coordination by patient and caregiver factors.

METHODS

The authors surveyed 600 patients with a stage IV solid malignancy and 346 caregivers every 3 months for more than 2 years. Patients entered the cohort any time during their stage IV trajectory. The analytic sample was restricted to patient-caregiver dyads (n = 299). Each survey assessed patients' experiences with physician communication and care coordination; patients' symptom burden; caregivers' quality of life; and patients' and caregivers' anxiety, financial difficulties, and perceptions of treatment goals. An actor-partner interdependence framework was used for analysis.

RESULTS

Patients reported better physician communication (average marginal effect [AME], 6.04; 95% confidence interval [CI], 3.82 to 8.26) and care coordination (AME, 8.96; 95% CI, 6.94 to 10.97) than their caregivers. Patients reported worse care coordination when they (AME, -0.56; 95% CI, -1.07 to -0.05) or their caregivers (AME, -0.58; 95% CI, -0.97 to -0.19) were more anxious. Caregivers reported worse care coordination when they were anxious (AME, -1.62; 95% CI, -2.02 to -1.23) and experienced financial difficulties (AME, -2.31; 95% CI, -3.77 to -0.86). Correct understanding of the treatment goal (vs being uncertain) was associated with caregivers reporting physician communication as better (AME, 3.67; 95% CI, 0.49 to 6.86) but with patients reporting it as worse (AME, -3.29; 95% CI, -6.45 to -0.14).

CONCLUSIONS

Patients' and caregivers' reports of physician communication and care coordination vary with aspects of their own and each other's well-being and with their perceptions of treatment goals. These findings may have implications for improving patients' and caregivers' reported experiences with health care practitioners.