Whose health is it? Views about decision-making and information-seeking from people with HIV infection and their professional carers

Ugandan Study Participants Experience Electronic Monitoring of Antiretroviral Therapy Adherence as Welcomed Pressure to Adhere

Many new technologies monitor patients' and study participants' medical adherence. Some have cautioned that these devices transgress personal autonomy and ethics. But do they? This qualitative study explored how Ugandan study participants perceive the effect of electronic monitoring of their adherence to antiretroviral therapy (ART) on their freedoms to be non-adherent and pursue other activities that monitoring may inadvertently expose. Between August 2014 and June 2015, we interviewed 60 Ugandans living with HIV and enrolled in the Uganda AIDS Rural Treatment Outcomes (UARTO) study, a longitudinal, observational study involving electronic adherence monitors (EAMs) to assess ART adherence. We also interviewed 6 UARTO research assistants. Both direct and indirect content analysis were used to interpret interview transcripts. We found that monitoring created a sense of pressure to adhere to ART, which some participants described as "forcing" them to adhere. However, even participants who felt that monitoring forced them to take medications perceived using the EAM as conducive to their fundamental goal of high ART adherence. Overall, even if monitoring may have limited participants' effective freedom to be non-adherent, participants welcomed any such effect. No participant rejected the EAM on the grounds that it would limit that effective freedom. Reports that monitoring altered behaviors unrelated to pill-taking were rare. Researchers should continue to be vigilant about the ways in which behavioral health monitoring affects autonomy, but should also recognize that even autonomy-limiting monitoring strategies may enable participants to achieve their own goals.

Aligning Mental Health Treatments with the Developmental Stage and Needs of Late Adolescents and Young Adults

Transitional age youth (TAY) are in a discrete developmental stage, different from both adolescents and mature adults. Serious mental illness can result in their delayed psychosocial development and morbidity. Systemic, provider, and individual barriers result in poor access to care for these youth, potentially impeding their transition to mature adulthood. Current strategies for TAY treatment include patient centered care, vocational and educational support, and shared decision making. There is a paucity of evidence-based practices to effectively treat this population or provide practice guidelines. The research required to do so should be a priority.

Patient preferences for shared decisions: a systematic review

OBJECTIVES

Empirical literature on patient decision role preferences regarding treatment and screening was reviewed to summarize patients' role preferences across measures, time and patient population.

METHODS

Five databases were searched from January 1980 to December 2007 (1980-2007 Ovid MEDLINE, Cochrane Database of Systematic Reviews, PsychInfo, Web of Science and PubMed (2005-2007)). Eligible studies measured patient decision role preferences, described measures, presented findings as percentages or mean scores and were published in English from any country. Studies were compared by patient population, time of publication, and measure.

RESULTS

115 studies were eligible. The majority of patients preferred sharing decisions with physicians in 63% of the studies. A time trend appeared. The majority of respondents preferred sharing decision roles in 71% of the studies from 2000 and later, compared to 50% of studies before 2000. Measures themselves, in addition to patient population, influenced the preferred decision roles reported.

CONCLUSION

Findings appear to vary with the measure of preferred decision making used, time of the publication and characteristics of the population.

PRACTICE IMPLICATIONS

The role preference measure itself must be considered when interpreting patient responses to a measure or question about a patient's preference for decision roles.

A critical analysis of health promotion and 'empowerment' in the context of palliative family care-giving

Traditionally viewed as in opposition to palliative care, newer ideas about 'health-promoting palliative care' increasingly infuse the practices and philosophies of healthcare professionals, often invoking ideals of empowerment and participation in care and decision-making. The general tendency is to assume that empowerment, participation, and self-care are universally beneficial for and welcomed by all individuals. But does this assumption hold for everyone, and do we fully understand the implications of health-promoting palliative care for family caregivers in particular? In this study, we draw on existing literature to highlight potential challenges arising from the application of 'family empowerment' strategies in palliative home-care nursing practice. In particular, there is a risk that empowerment may be operationalized as transferring technical and medical-care tasks to family caregivers at home. Yet, for some family caregivers, a sense of security and support, as well as trust in professionals, may be equally if not more important than empowerment. Relational and role concerns may also at times take precedence over a desire for empowerment. The potential implications of 'family empowerment' are explored in this regard. 'Family empowerment' approaches need to be accompanied by a strong understanding of how to best support individual palliative family caregivers.

Decision-making role preferences among patients with HIV: associations with patient and provider characteristics and communication behaviors

BACKGROUND

A preference for shared decision-making among patients with HIV has been associated with better health outcomes. One possible explanation for this association is that patients who prefer a more active role in decision-making are more engaged in the communication process during encounters with their providers. Little is known, however, about patient and provider characteristics or communication behaviors associated with patient decision-making preferences in HIV settings.

OBJECTIVE

We examined patient and provider characteristics and patient-provider communication behaviors associated with the decision-making role preferences of patients with HIV.

DESIGN

Cross-sectional analysis of patient and provider questionnaires and audio recorded clinical encounters from four sites.

PARTICIPANTS

A total of 45 providers and 434 of their patients with HIV.

MEASURES

Patients were asked how they prefer to be involved in the decision-making process (doctor makes all/most decisions, patients and doctors share decisions, or patients make decisions alone). Measures of provider and patient communication behaviors were coded from audio recordings using the Roter Interaction Analysis System.

MAIN RESULTS

Overall, 72% of patients preferred to share decisions with their provider, 23% wanted their provider to make decisions, and 5% wanted to make decisions themselves. Compared to patients who preferred to share decisions with their provider, patients who preferred their provider make decisions were less likely to be above the age of 60 (ARR 0.09, 95% CI 0.01-0.89) and perceive high quality provider communication about decision-making (ARR 0.41, 95% CI 0.23-0.73), and more likely to have depressive symptoms (ARR 1.92, 95% CI 1.07-3.44). There was no significant association between patient preferences and measures of provider or patient communication behavior.

CONCLUSION

Observed measures of patient and provider communication behavior were similar across all patient decision-making role preferences, indicating that it may be difficult for providers to determine these preferences based solely on communication behavior. Engaging patients in open discussion about decision-making preferences may be a more effective approach.

Information disclosure to terminally ill patients and their relatives: self-reported practice of Belgian clinical specialists and general practitioners

Objective of this study is to examine physicians' practices regarding information disclosure to terminally ill patients and to their relatives, without informing the patient. A questionnaire had been sent to a random sample of 3014 Belgian physicians from different specialties frequently involved in end-of-life care. Responses were analysed using weighted percentages, Chi-square, Mann-Whitney U-tests and a multivariate ordinal logistic regression. Response rate was 58%. Both clinical specialists and general practitioners (GPs) discuss most topics related to terminal illness with their patients except end-of-life hastening options, spirituality, life expectancy and options to withhold/withdraw life-sustaining treatment. The topics which most physicians always discuss with relatives without informing the patient are the aim of treatment, palliative care and incurability. There is a significant difference between clinical specialists and GPs. Clinical specialists and GPs discuss most end-of-life topics with the patient but omit important issues such as end-of-life hastening options and life-expectancy.

Views of treatment decision making from adolescents with chronic illnesses and their parents: a pilot study

OBJECTIVE

Shared decision making may increase satisfaction with health care and improve outcomes, but little is known about adolescents' decision-making preferences. The primary purpose of this study is to describe the decision-making preferences of adolescents with chronic illnesses and their parents, and the extent to which they agree.

DESIGN

Survey.

SETTING AND PARTICIPANTS

Participants were 82 adolescents seen at one of four paediatric chronic illness subspecialty clinics and 62 of their parents.

MAIN VARIABLES

Predictor variables include sociodemographics, health parameters, risk behaviour, and physical and cognitive development. The main outcome variable is preferences for decision-making style.

RESULTS AND CONCLUSIONS

When collapsed into three response categories, nearly equal percentages of adolescents (37%) and parents (36%) preferred shared decision making. Overall, the largest proportion of adolescents (46%) and parents (53%) preferred passive decision making compared to active or shared decision making. Across five response choices, 33% of pairs agreed. Agreement was slight and not significant. Improved general health perceptions (OR=0.76, 95% CI=0.59-0.99) and improved behaviour (OR=0.75, 95% CI=0.56-0.99) were significantly associated with parents' preferences for less active decision making. Older age was significantly associated with agreement (OR 1.58, 95% CI=1.09-2.30) between parents and adolescents. The paucity of significant predictor variables may indicate physicians need to inquire directly about patient and parent preferences.

Patient involvement in patient safety: what factors influence patient participation and engagement?

BACKGROUND

Patients can play an important role in improving patient safety by becoming actively involved in their health care. However, there is a paucity of empirical data on the extent to which patients take on such a role. In order to encourage patient participation in patient safety we first need to assess the full range of factors that may be implicated in such involvement.

OBJECTIVE

To delineate factors that could affect the participation of the patient in quality and safety issues in their health care.

METHOD

Literature review of patient involvement in health care, drawing from direct evidence (specifically from the safety context) and indirect evidence (extrapolated from treatment decision-making research and the wider patient involvement in health care literature); synthesis and conceptual framework developed, illustrating the known and putative factors that could affect the participation of the patient in safety issues in their health care.

MAIN RESULTS

Five categories of factors emerged that could affect patient involvement in safety: patient-related (e.g. patients' demographic characteristics), illness-related (e.g. illness severity), health-care professional-related (e.g. health care professionals' knowledge and beliefs), health care setting-related (e.g. primary or secondary care), and task-related (e.g. whether the required patient safety behaviour challenges clinicians' clinical abilities).

CONCLUSION

The potential for engaging patients in patient safety is considerable but further research is needed to examine the influences on patient involvement, the limits and the possible dangers. Patients can act as 'safety buffers' during their care but the responsibility for their safety must remain with the health care professionals.

Instruments for evaluating shared medical decision making: a structured literature review

The author conducted a structured literature review of instruments for evaluating shared medical decision making. She included relevant instruments that were generalizable beyond specific situations and had been formally evaluated and organized them by domains of values or preferences, information and communication in decision making, and other aspects of decision making. For values or preferences, the author identified 11 instruments, mostly on preferences for roles and information. For information and communication, she found a systematic review of instruments for observational assessment of decision making, 3 additional observational instruments, and 3 questionnaires. For other aspects of decision making, the author identified 3 instruments in domains such as decision self-efficacy and 4 multidimensional instruments. Although instrument development tended to cluster in several areas and there were clear gaps in the literature, the diversity of instruments demonstrates the broad range of constructs involved in assessing shared decision making.

Patients' preference for involvement in medical decision making: a narrative review

OBJECTIVE

This review aimed to clarify present knowledge about the factors which influence patients' preference for involvement in medical decision making.

METHODS

A thorough search of the literature was carried out to identify quantitative and qualitative studies investigating the factors which influence patients' preference for involvement in decision making. All studies were rigorously critically appraised.

RESULTS

Patients' preferences are influenced by: demographic variables (with younger, better educated patients and women being quite consistently found to prefer a more active role in decision making), their experience of illness and medical care, their diagnosis and health status, the type of decision they need to make, the amount of knowledge they have acquired about their condition, their attitude towards involvement, and the interactions and relationships they experience with health professionals. Their preferences are likely to develop over time as they gain experience and may change at different stages of their illness.

CONCLUSION

While patients' preferences for involvement in decision making are variable and the process of developing them likely to be highly complex, this review has identified a number of influences on patients' preference for involvement in medical decision making, some of which are consistent across studies.

PRACTICE IMPLICATIONS

By identifying the factors which might influence patients' preference for involvement, health professionals may be more sensitive to individual patients' preferences and provide better patient-centred care.

Not all patients want to participate in decision making. A national study of public preferences

BACKGROUND

The Institute of Medicine calls for physicians to engage patients in making clinical decisions, but not every patient may want the same level of participation.

OBJECTIVES

1) To assess public preferences for participation in decision making in a representative sample of the U.S. population. 2) To understand how demographic variables and health status influence people's preferences for participation in decision making.

DESIGN AND PARTICIPANTS

A population-based survey of a fully representative sample of English-speaking adults was conducted in concert with the 2002 General Social Survey (N= 2,765). Respondents expressed preferences ranging from patient-directed to physician-directed styles on each of 3 aspects of decision making (seeking information, discussing options, making the final decision). Logistic regression was used to assess the relationships of demographic variables and health status to preferences.

MAIN RESULTS

Nearly all respondents (96%) preferred to be offered choices and to be asked their opinions. In contrast, half of the respondents (52%) preferred to leave final decisions to their physicians and 44% preferred to rely on physicians for medical knowledge rather than seeking out information themselves. Women, more educated, and healthier people were more likely to prefer an active role in decision making. African-American and Hispanic respondents were more likely to prefer that physicians make the decisions. Preferences for an active role increased with age up to 45 years, but then declined.

CONCLUSION

This population-based study demonstrates that people vary substantially in their preferences for participation in decision making. Physicians and health care organizations should not assume that patients wish to participate in clinical decision making, but must assess individual patient preferences and tailor care accordingly.

Decision Making in Medicine and Health Care

Decision making is central to health policy and medical practice. Because health outcomes are probabilistic, most decisions are made under conditions of uncertainty. This review considers two classes of decisions in health care: decisions made by providers on behalf of patients, and shared decisions between patients and providers. Considerable evidence suggests wide regional variation exists in services received by patients. Evidence-based guidelines that incorporate quality of life and patient preferences may help address this problem. Systematic cost-effectiveness analysis can be used to improve resource allocation decisions. Shared medical decision making seeks to engage patients and providers in a collaborative process to choose clinical options that reflect patient preferences. Although some evidence indicates patients want an active role in making decisions, other evidence suggests that some patients prefer a passive role. Decision aids hold promise for improving individual decisions, but there are still few systematic evaluations of these aids. Several directions for future research are offered.

Women's preferences for and views on decision-making for diagnostic tests

It is unclear whether the Control Preferences Scale (CPS) provides a suitable framework for eliciting women's preferences for involvement in decision-making about diagnostic tests. The aims of this study were to assess the appropriateness of the role label approach for eliciting preferences for decision-making about diagnostic tests and to elicit women's preferences for, and views about, decision-making for diagnostic tests. In-depth, face-to-face, semi-structured interviews were conducted with 37 women who had previously participated in a population-based telephone survey. Analysis of the interview transcripts revealed that qualitative questions may be a more sensitive methodology for eliciting preferences than the role label approach as exemplified by the CPS. The analysis identified a number of issues associated with decision-making for diagnostic tests, including defining what a decision is, the rationale for the preference and factors that influence the preferred role such as the perceived seriousness of the test and potential outcomes. The role label approach used to elicit preferences for involvement in decision-making may be too simplistic. It may not fully capture the complexity of women's thoughts about test decision-making, including how they define a decision and what factors affect their preference.

Medical tests: women's reported and preferred decision-making roles and preferences for information on benefits, side-effects and false results

OBJECTIVE

To determine women's preferences for and reported experience with medical test decision-making.

DESIGN

Computer-assisted telephone survey.

SETTING AND PARTICIPANTS

Six hundred and fifty-two women resident in households randomly selected from the New South Wales electronic white pages.

MAIN OUTCOME MEASURES

Reported and preferred test and treatment (for comparison) decision-making, satisfaction with and anxiety about information on false results and side-effects; and effect of anxiety on desire for such information.

RESULTS

Overall most women preferred to share test (94.6%) and treatment (91.2%) decision-making equally with their doctor, or to take a more active role, with only 5.4-8.9% reporting they wanted the doctor to make these decisions on their behalf. This pattern was consistent across all age groups. In general, women reported experiencing a decision-making role that was consistent with their preference. Women who had a usual doctor were more likely to report experiencing an active role in decision-making. More women reported receiving as much information as they wanted about the benefits of tests and treatment than about the side-effects of tests and treatment. Most women wanted information about the possibility of false test results (91.5%) and test side-effects (95.6%), but many reported the doctor never provided this information (false results = 40.0% and side-effects = 31.3%). A substantial proportion said this information would make them anxious (false results = 56.6% and side-effects = 43.1%), but reported they wanted the information anyway (false results = 77.6% and side-effects = 88.1%).

CONCLUSIONS

Women prefer an active role in test and treatment decision-making. Many women reported receiving inadequate information. If so, this may jeopardize informed decision-making.

Treatment decisions for breast carcinoma: patient preferences and physician perceptions

BACKGROUND

Patient autonomy and participation in treatment decision making have been encouraged in recent years. However, patients and physicians frequently disagree with regard to the patient's needs and perceptions of their illness. To the authors' knowledge to date only limited research has assessed physicians' perceptions of patients' decision-making preferences. The purpose of the current prospective study was to determine the agreement between patient decision-making preferences and physician perceptions of those preferences.

METHODS

Women with breast carcinoma who were attending their first outpatient consultation with a breast medical oncologist in a university cancer center were enrolled in the current study. At the end of the consultation, the patients were given a survey regarding their treatment decision-making preferences that included active, shared, and passive roles in decision-making and the patients' attending physicians also were given a survey regarding their perceptions of the patients' decision-making preferences.

RESULTS

Fifty-seven patients had complete data and were analyzed. Approximately 89% of these 57 patients preferred either an active or a shared role in decision making. The agreement between patients and physicians with regard to decision-making preference only occurred in 24 cases (42%). The majority of covariates such as age, education, and income were not found to be statistically significant with regard to patient preferences or to the proportion of patients and physicians who agreed on the patient's preferences.

CONCLUSIONS

Women with breast carcinoma appear to have a strong desire for involvement in making decisions regarding their treatment. However, physicians do not appear to be consistently able to predict the decision-making preferences of their patients. Enhanced agreement between patient preferences and physician expectations mostly likely will improve communication and patient satisfaction with the treatment decision-making process.

Nurses' ethical conflicts: what is really known about them?

The purpose of this article is to report what can be learned about nurses' ethical conflicts by the systematic analysis of methodologically similar studies. Five studies were identified and analysed for: (1) the character of ethical conflicts experienced; (2) similarities and differences in how the conflicts were experienced and how they were resolved; and (3) ethical conflict themes underlying four specialty areas of nursing practice (diabetes education, paediatric nurse practitioner, rehabilitation and nephrology). The predominant character of the ethical conflicts was disagreement with the quality of medical care given to patients. A significant number of ethical conflicts were experienced as 'moral distress', the resolution of which was variable, depending on the specialty area of practice. Ethical conflict themes underlying the specialty areas included: differences in the definition of adequacy of care among professionals, the institution and society; differences in the philosophical orientations of nurses, physicians and other health professionals involved in patient care; a lack of respect for the knowledge and expertise of nurses in specialty practice; and difficulty in carrying out the nurse's advocacy role for patients.

People with HIV/AIDS: who cares?

Studies have shown that some nurses, doctors and other carers have negative attitudes towards people with human immune deficiency virus/acquired immune deficiency syndrome (HIV/AIDS). Some cope by avoiding working with such patients, while others just do the best they can. But does it matter? This paper describes a review of the literature on the impact of attitudes to care and the barriers affecting the quality of care for people with HIV/AIDS by professional health care workers and other carers. Most of the reports identified were based on attitude scales, mostly unique and often unvalidated. Attitudes of health care workers based in the community, and 'house keeping' staff such as porters, receptionists, etc., have been neglected areas of research. There is also little information about the culture of organizations and the attitudes of individuals with HIV/AIDS to care. Only three references were found in which both patients' and carers' attitudes to each other were considered and none of these looked at negative feelings and their impact. There is scope therefore to investigate the attitudes of patients and carers towards each other and how this can effect the quality of care. It is anticipated that the benefits of such investigations could lead to the development of educational strategies designed to improve the quality of patient care.

Speaking up for ourselves. The evolution of consumer advocacy in health care

Forces from communities and from health care are pushing toward more consumer involvement in health care internationally. This article addresses the philosophies and rationales behind this trend and traces the history and development of consumer advocacy in health care.