Reconciling the theory and reality of shared decision-making: A "matching" approach to practitioner leadership

When Bad News Comes Through the Portal: Strengthening Trust and Guiding Patients When They Receive Bad Results Before Their Clinicians

Communication in oncology was challenging long before the emergence of the US 21st Century Cures Act. Before 2021, a growing body of evidence had demonstrated the benefits of patients' access to and review of the clinical notes in their charts (open notes); however, studies examining the benefits of immediate access to test results were scarce until the implementation of the Cures Act's Information Blocking Rule. Individuals grappling with cancer today now possess immediate access to their laboratory results, imaging scans, diagnostic tests, and progress notes as mandated by law. To many clinicians, the implementation of the Cures Act felt sudden and presented new challenges and concerns for oncologists surrounding patients' potential emotional reactions to medical notes or lack of control over the careful delivery of potentially life-changing information. Despite data that show most patients want immediate access to information in their records before it is communicated directly by a health care professional, surveys of oncologists showed trepidation. In this chapter, perspectives from a patient with cancer, an oncologist, and a cancer psychiatrist (in that order) are shared to illuminate the adjustments made in clinician-patient communication amid the era of nearly instantaneous results within the electronic health record.

The factors involved in surgical decision-making in younger women diagnosed with breast cancer in Aotearoa New Zealand: A qualitative analysis

Women diagnosed with breast cancer must make important surgical decisions. The decision-making process for younger women is complex, with this group more likely to have an advanced diagnosis and life-stage considerations that can impact on treatment. This study investigated the decision-making process of women aged <50 years who had undergone breast cancer surgery within the preceding 12 months in Aotearoa New Zealand. Twelve women participated in semi-structured qualitative interviews to explore the factors that influenced treatment decisions. Thematic analysis resulted in three themes. Fear was the main concept identified as the primary influence on initial decision-making. Good quality shared decision-making between patient and clinician was found to provide essential support during the diagnosis to treatment period. In addition, women expressed a need for multi-modal presentation of medical information and more material reflecting younger women. These findings inform provision for younger women making surgical decisions when diagnosed with breast cancer.

Women's autonomy for managing labour pain in a relational context: An interpretive description study

AIM

To describe how women perceived relational autonomy for decision-making during childbirth pain and illuminate influencing factors.

BACKGROUND

Most women report challenging pain during birth. Circumstances can affect their ability to engage in pain management decisions.

DESIGN

We used an interpretative description approach to conduct this study.

METHOD

A purposive sample of ten women who reported pain during childbirth participated in semi-structured interviews. The study was conducted between July 2019 and November 2020 and reported according to the COREQ checklist.

RESULTS

Circumstances during childbirth, such as women's expectations and relationships, influenced their efforts to engage in relational autonomy. Care providers dealt with the unpredictability of childbirth and challenges with pain management using decision-making practices that could disrupt women's expectations, undermine women's trust, demonstrate disrespect for women and rely on inadequate communication. Women who felt dependent on others were less likely to participate in decision-making. When care providers' perceptions about pain differed from women's reports of pain, participants became distressed because care providers did not acknowledge their subjective pain experiences.

CONCLUSIONS

Women regarded their relationships and communication with care providers as foundational to relational autonomy in decision-making about pain management during childbirth.

RELEVANCE TO CLINICAL PRACTICE

Study findings can support care providers' considerations of the complexity of childbirth pain and factors affecting women's relational autonomy in decision-making about pain. In particular, the findings highlight the importance of women's expectations and care providers' recognition of women's experiences of pain.

PATIENT OR PUBLIC CONTRIBUTION

Women who shared their stories of childbirth pain contributed to the data collected. The chief nursing officers in the data collection setting facilitated the recruitment and data collection.

An insight into patients’ perspectives on barriers affecting participation in shared decision making among patients with diabetes mellitus in Malawi

Background

Patient participation in decision making is a basic tenet for a patient centred care experience and, has potential to improve care experiences and responsiveness in chronic diseases such as Diabetes Mellitus (DM). However, documented experiences show that patient participation in decisions making is wanting. As Malawi strives to institutionalise patient centred care delivery, it is important to examine patients’ experiences and perceptions to identify barriers affecting their participation in shared decision making because this may provide evidence supporting strategies in implementation of the institutionalisation.

Aim

The study sought to describe perspectives about barriers to participation in shared decision making among patients with DM in Malawi.

Methods

This was an exploratory qualitative study. We targeted patients attending DM clinics in four public health facilities in southern Malawi from September to December 2019. We used In-Depth Interviews and Focus Group Discussions. Data was managed using Nvivo version 11 software and analysed using Content Analysis.

Results

The study highlights the values, perceptions and benefits of shared decision making. Furthermore, patients’ narratives expose the struggles and vulnerabilities in their attempts to engage their providers towards shared decision making.

Conclusion

Interactional power imbalances, insufficient dialogue and patients’ own restrictive attitudes towards engagement with their providers thwarts SDM in clinical encounters. To make SDM a reality, transforming medical education that emphasizes on the value of good patient-provider relationship and providers’ attitudes to regard patients as active partners may be a good starting point. Additionally, strategies that empower and change patients’ perceptions about SDM require investment.

Validation of the Novel Interprofessional Shared Decision-Making Questionnaire to Facilitate Multidisciplinary Team Building in Patient-Centered Care

To support patients in making complex and difficult decisions, it is necessary to form a team that comprises different specialists, the patient, and family members who have detailed information about the latter. Shared decision-making (SDM) is the foundation of patient-centered care; however, its structure in the context of multidisciplinary teams remains unclear. This cross-sectional study aimed to validate the novel interprofessional SDM measure ("Group's SDM measure"). We used data of 175 participants who attended SDM Workshops for Advance Care Planning. The Group's SDM measure included 10 Japanese items that could be used by small groups of multidisciplinary professionals, and the responses were rated using a 6-point Likert scale. The index exhibited a single-factor structure and high goodness of fit with residual correlation via factor analysis. We calculated Cronbach's α (α = 0.948) and McDonald's ω (ω = 0.948) and verified high internal consistency. The Group's SDM measure can be used when evaluating the SDM process where multidisciplinary professionals are involved. We hope that in the future, it will lead to the promotion of interprofessional SDM through training with the use of this measure.

Supporting Health and Medical Decision Making: Findings and Insights from Fuzzy-Trace Theory

HIGHLIGHTS

Fuzzy-trace theory (FTT) supports practical approaches to improving health and medicine.FTT differs in important respects from other theories of decision making, which has implications for how to help patients, providers, and health communicators.Gist mental representations emphasize categorical distinctions, reflect understanding in context, and help cue values relevant to health and patient care.Understanding the science behind theory is crucial for evidence-based medicine.

Stakeholder involvement in care transition planning for older adults and the factors guiding their decision-making: a scoping review

OBJECTIVE

To synthesise the existing literature on care transition planning from the perspectives of older adults, caregivers and health professionals and to identify the factors that may influence these stakeholders' transition decision-making processes.

DESIGN

A scoping review guided by Arksey and O'Malley's six-step framework. A comprehensive search strategy was conducted on 7 January 2021 to identify articles in five databases (MEDLINE, Embase, CINAHL Plus, PsycINFO and AgeLine). Records were included when they described care transition planning in an institutional setting from the perspectives of the care triad (older adults, caregivers and health professionals). No date or study design restrictions were imposed.

SETTING

This review explored care transitions involving older adults from an institutional care setting to any other institutional or non-institutional care setting. Institutional care settings include communal facilities where individuals dwell for short or extended periods of time and have access to healthcare services.

PARTICIPANTS

Older adults (aged 65 or older), caregivers and health professionals.

RESULTS

39 records were included. Stakeholder involvement in transition planning varied across the studies. Transition decisions were largely made by health professionals, with limited or unclear involvement from older adults and caregivers. Seven factors appeared to guide transition planning across the stakeholder groups: (a) institutional priorities and requirements; (b) resources; (c) knowledge; (d) risk; (e) group structure and dynamic; (f) health and support needs; and (g) personality preferences and beliefs. Factors were described at microlevels, mesolevels and macrolevels.

CONCLUSIONS

This review explored stakeholder involvement in transition planning and identified seven factors that appear to influence transition decision-making. These factors may be useful in advancing the delivery of person and family-centred care by determining how individual-level, group-level and system-level values guide decision-making. Further research is needed to understand how various stakeholder groups balance these factors during transition planning in different health contexts.

'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.

Clinical reasoning as midwifery: A Socratic model for shared decision making in person-centred care

Shared decision making has become the standard of care, yet there remains no consensus about how it should be conducted. Most accounts are concerned with threats to patient autonomy, and they address the dangers of a power imbalance by foregrounding the patient as a person whose complex preferences it is the practitioner's task to support. Other corrective models fear that this level of mutuality risks abdicating the practitioner's responsibilities as an expert, and they address that concern by recovering a nuanced but genuinely directive clinical role. Cribb and Entwistle helpfully categorize models of shared decision making as 'narrower' and 'broader' and praise the latter's 'open-ended and fully dialogical ways of relating'. However, they stop short of providing a philosophical account of how that dialogue works. In this paper, a nurse-midwife and a philosopher collaborate to argue that the Socratic model of dialogue offers a solution to the practitioner-patient dilemma. In the Theaetetus, Socrates compares dialogical reasoning to 'midwifery with all its standard features'. By means of a three-way analogy, elements of midwifery practice are used to illuminate features of Socrates' claim that his dialogue is like midwifery; those features are then translated into an approach to shared decision making as the 'midwifery of good thinking' which both midwives and physicians would do well to adopt. A key concept that emerges is the need for practitioners to make a risk-confidence assessment of the particular content of any decision to appropriately modulate their role in the practice of shared decision making.

Discussions on Present Japanese Psychocultural-Social Tendencies as Obstacles to Clinical Shared Decision-Making in Japan

In Japan, where a prominent gap exists in what is considered a patient’s best interest between the medical and patient sides, appropriate decision-making can be difficult to achieve. In Japanese clinical settings, decision-making is considered an act of choice-making from multiple potential options. With many ethical dilemmas still remaining, establishing an appropriate decision-making process is an urgent task in modern Japanese healthcare. This paper examines ethical issues related to shared decision-making (SDM) in clinical settings in modern Japan from the psychocultural-social perspective and discusses the ideal decision-making process in present Japan. Specifically, we discuss how five psychocultural-social tendencies – “surmise (Sontaku),” “self-restraint (Jishuku),” “air (atmosphere or mood, Kuuki),” “peer pressure (or tuning pressure, Docho-Atsuryoku),” and “community (Seken)”—which have often been referred to as characteristics of present-day Japanese people, may affect the ideal practice of SDM in Japanese clinical settings. We conclude that health care professionals must be aware of the possible adverse effects of the above Japanese psychocultural-social tendencies on the implementation of SDM and attempt to promote autonomous decision-making, thereby allowing patients to make treatment choices that sufficiently reflect their individual and personal views of life, experiences, goals, preferences, and values.

Qualitative Examination of Shared Decision-Making in Canada's Largest Health System: More Work to be Done : Shared Decision-Making-More Work to be Done

Background: Shared Decision-Making (SDM) is an inclusive approach where patients and providers work in partnership to make health care decisions that are grounded in clinical best practice and align with patient preferences and values. Despite a growing recognition that SDM can lead to improved outcomes and reductions in unnecessary health investigations, tensions exist between patient agency and a historically paternalistic model of health care. As an evolving ideology, the Research Team sought to better understand the current state, challenges, and implementation opportunities of SDM practices across the health system. Methods: This study used a cross-sectional quality improvement design utilizing semistructured interviews to gather information from focus group participants. Five open-ended, qualitative questions were used to generate discussion on the perceptions of SDM and its role in clinical appropriateness in a variety of clinical contexts in our health system. A total of 12 focus groups (n = 95 participants) representative of patients and families, leaders, physicians, and frontline clinicians were engaged in the study. Results: Through a consensus-based approach, study results identified 4 recommendations based on 4 themes: Time, Communication, System Design, and Clinical Appropriateness. Conclusion: There are no easy solutions to the challenges of enabling SDM; however, success will be dependent upon recognizing the importance of patient agency, while maintaining an inclusive and continuous stakeholder engagement with both patients and providers. Implementation of the 4 recommendations at the organizational level highlighted in this study can serve as a road map for other health care institutions and will require a gradual approach to transform the general principles of SDM into tangible solutions to meet the emerging needs at both the local and system level.

Teaching Shared Decision Making to Undergraduate Medical Students

Despite the wide endorsement of shared decision making (SDM), its integration into clinical practice has been slow. In this paper, we suggest that this integration may be promoted by teaching SDM not only to residents and practicing physicians, but also to undergraduate medical students. The proposed teaching approach assumes that SDM requires effective doctor-patient communication; that such communication requires empathy; and that the doctor's empathy requires an ability to identify the patient's concerns. Therefore, we suggest shifting the focus of teaching SDM from how to convey health-related information to patients, to how to gain an insight into their concerns. In addition, we suggest subdividing SDM training into smaller, sequentially taught units, in order to help learners to elucidate the patient's preferred role in decisions about her/his care, match the patient's preferred involvement in these decisions, present choices, discuss uncertainty, and encourage patients to obtain a second opinion.

The conceptualisation of patient-centred care: A case study of diabetes management in public facilities in southern Malawi

BACKGROUND

Patient-centred care (PCC) is one of the pillars of Malawi's quality of care policy initiatives. The role of PCC in facilitating quality service delivery is well documented, and its importance may heighten in chronic disease management. Yet, PCC conceptualisation is known to be context specific.

AIM

The study aimed to understand the conceptualisation of PCC amongst patients, healthcare providers (HCP) and policy makers in Diabetes Mellitus (DM) management.

SETTING

This study was conducted in DM clinics in Southern Malawi.

METHODS

Our qualitative exploratory research study design used in-depth and focus group interviews. We interviewed patients with DM, HCPs and policy makers. The study used framework analysis guided by Mead and Bower's work.

RESULTS

Patient-centred care conceptualisations from groups of participants showed convergence. However, they differed in emphasis in some elements. The prominent themes emerging from the participants' conceptualisation of PCC included the following: meeting individual needs, goals and expectations, accessing medication, supporting relationship building, patient involvement, information sharing, holistic care, timeliness and being realistic.

CONCLUSION

Patient-centred care conceptualisation in Malawi goes beyond the patient-HCP relational framework to include the technical aspects of care. Contrary to the global view, accessing medication and timeliness are major elements in PCC conceptualisation in Malawi. Whilst PCC conceptualisation is contextual, meeting expectations and needs of patients is fundamental.

Nursing practice in the promotion of the elderly's autonomy

OBJECTIVE

To describe the meaning attributed by specialist nurses to the promotion of the elderly's autonomy.

METHOD

This is a phenomenological study, according to Giorgi's method, which uses semi-structured interviews. Eighteen specialist nurses participated, recruited using convenience sampling, in two hospitals in the northern region of Portugal, between March and December 2018.

RESULTS

Five themes emerged: use of instruments; use of theoretical framework; nursing diagnoses; prescription of interventions; nursing records.

CONCLUSION

Specialist nurses use instruments that essentially promote the elderly's physical capacity, within the scope of autonomy. The information systems used to record the diagnoses and prescriptions for interventions do not reflect the intervention for the person's autonomy. Autonomy in a multidimensional way is not very well developed, despite the recognition of its importance for the elderly's quality of life and dignity.

Influencers of the Decision to Undergo Contralateral Prophylactic Mastectomy among Women with Unilateral Breast Cancer

Simple Summary

In this survey study, we examined survey responses from 397 women with stage 0 to III unilateral breast cancer and found that partners, physicians, and the media were significant relative to the patient’s own influence in their decision to undergo a CPM. The findings of this study may inform policy by highlighting the need for educational aids, programs, or tools that help women with unilateral breast cancer make informed, evidence-based decisions regarding CPM efficacy.

Abstract

(1) Background: The relatively high rate of contralateral prophylactic mastectomy (CPM) among women with early stage unilateral breast cancer (BC) has raised concerns. We sought to assess the influence of partners, physicians, and the media on the decision of women with unilateral BC to undergo CPM and identify clinicopathological variables associated with the decision to undergo CPM. (2) Patients and Methods: Women with stage 0 to III unilateral BC who underwent CPM between January 2010 and December 2017. Patients were surveyed regarding factors influencing their self-determined decision to undergo CPM. Partner, physician, and media influence factors were modeled by logistic regressions with adjustments for a family history of breast cancer and pathological stage. (3) Results: 397 (29.6%) patients completed the survey and were included in the study. Partners, physicians, and the media significantly influenced patients’ decision to undergo CPM. The logistic regression models showed that, compared to self-determination alone, overall influence on the CPM decision was significantly higher for physicians (p = 0.0006) and significantly lower for partners and the media (p < 0.0001 for both). Fifty-nine percent of patients’ decisions were influenced by physicians, 28% were influenced by partners, and only 17% were influenced by the media. The model also showed that patients with a family history of BC had significantly higher odds of being influenced by a partner than did those without a family history of BC (p = 0.015). (4) Conclusions: Compared to self-determination, physicians had a greater influence and partners and the media had a lower influence on the decision of women with unilateral BC to undergo CPM. Strong family history was significantly associated with a patient’s decision to undergo CPM.

Interventions to facilitate shared decision-making using decision aids with patients in Primary Health Care: A systematic review

BACKGROUND

Shared decision making (SDM) is a process within the physician-patient relationship applicable to any clinical action, whether diagnostic, therapeutic, or preventive in nature. It has been defined as a process of mutual respect and participation between the doctor and the patient. The aim of this study is to determine the effectiveness of decision aids (DA) in primary care based on changes in adherence to treatments, knowledge, and awareness of the disease, conflict with decisions, and patients' and health professionals' satisfaction with the intervention.

METHODS

A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted in Medline, CINAHL, Embase, the Cochrane Central Register of Controlled Trials, and the NHS Economic Evaluation Database. The inclusion criteria were randomized clinical trials as study design; use of SDM with DA as an intervention; primary care as clinical context; written in English, Spanish, and Portuguese; and published between January 2007 and January 2019. The risk of bias of the included studies in this review was assessed according to the Cochrane Collaboration's tool.

RESULTS

Twenty four studies were selected out of the 201 references initially identified. With the use of DA, the use of antibiotics was reduced in cases of acute respiratory infection and decisional conflict was decreased when dealing with the treatment choice for atrial fibrillation and osteoporosis. The rate of determination of prostate-specific antigen (PSA) in the prostate cancer screening decreased and colorectal cancer screening increased. Both professionals and patients increased their knowledge about depression, type 2 diabetes, and the perception of risk of acute myocardial infarction at 10 years without statins and with statins. The satisfaction was greater with the use of DA in choosing the treatment for depression, in cardiovascular risk management, in the treatment of low back pain, and in the use of statin therapy in diabetes. Blinding of outcomes assessment was the most common bias.

CONCLUSIONS

DA used in primary care are effective to reduce decisional conflict and improve knowledge on the disease and treatment options, awareness of risk, and satisfaction with the decisions made. More studies are needed to assess the impact of shared decision making in primary care.

Why women chose unassisted home birth in Malaysia: a qualitative study

BACKGROUND

Incidences of unassisted home birthing practices have been increasing in Malaysia despite the accessibility to safe and affordable child birthing facilities. We aimed to explore the reasons for women to make such decisions.

METHODS

Twelve women participated in in-depth interviews. They were recruited using a snowballing approach. The interviews were supported by a topic guide which was developed based on the Theory of Planned Behaviour and previous literature. The interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis.

RESULTS

Women in this study described a range of birthing experiences and personal beliefs as to why they chose unassisted home birth. Four themes emerged from the interviews; i) preferred birthing experience, ii) birth is a natural process, iii) expressing autonomy and iv) faith. Such decision to birth at home unassisted was firm and steadfast despite the possible risks and complications that can occur. Giving birth is perceived to occur naturally regardless of assistance, and unassisted home birth provides the preferred environment which health facilities in Malaysia may lack. They believed that they were in control of the birth processes apart from fulfilling the spiritual beliefs.

CONCLUSIONS

Women may choose unassisted home birth to express their personal views and values, at the expense of the health risks. Apart from increasing mothers' awareness of the possible complications arising from unassisted home births, urgent efforts are needed to provide better birth experiences in healthcare facilities that resonate with the mothers' beliefs and values.

Why women chose unassisted home birth in Malaysia: A qualitative study.. [DOI: 10.21203/rs.2.16973/v3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background: Incidences of unassisted home birthing practices have been increasing in Malaysia despite the accessibility to safe and affordable child birthing facilities. We aimed to explore the reasons for women to make such decisions. Methods: Twelve women participated in in-depth interviews. They were recruited using a snowballing approach. The interviews were supported by a topic guide which was developed based on the Theory of Planned Behaviour and previous literature. The interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis.Results: Women in this study described a range of birthing experiences and personal beliefs as to why they chose unassisted home birth. Four themes emerged from the interviews; i) preferred birthing experience, ii) birth is a natural process, iii) expressing autonomy and iv) faith. Such decision to birth at home unassisted was firm and steadfast despite the possible risks and complications that can occur. Giving birth is perceived to occur naturally regardless of assistance, and unassisted home birth provides the preferred environment which health facilities in Malaysia may lack. They believed that they were in control of the birth processes apart from fulfilling the spiritual beliefs.Conclusions: Women may choose unassisted home birth to express their personal views and values, at the expense of the health risks. Apart from increasing mothers' awareness of the possible complications arising from unassisted home births, urgent efforts are needed to provide better birth experiences in healthcare facilities that resonate with the mothers’ beliefs and values.

Reconciling the theory and reality of shared decision-making: A "matching" approach to practitioner leadership

Shared decision making (SDM) evolved to resolve tension between patients’ entitlement to make health‐care decisions and practitioners’ responsibility to protect patients’ interests. Implicitly assuming that patients are willing and able to make “good” decisions, SDM proponents suggest that patients and practitioners negotiate decisions. In practice, patients often do not wish to participate in decisions, or cannot make good decisions. Consequently, practitioners sometimes lead decision making, but doing so risks the paternalism that SDM is intended to avoid. We argue that practitioners should take leadership when patients cannot make good decisions, but practitioners will need to know: (a) when good decisions are not being made; and (b) how to intervene appropriately and proportionately when patients cannot make good decisions. Regarding (a), patients rarely make decisions using formal decision logic, but rely on informal propositions about risks and benefits. As propositions are idiographic and their meanings context‐dependent, normative standards of decision quality cannot be imposed. Practitioners must assess decision quality by making subjective and contextualized judgements as to the “reasonableness” of the underlying propositions. Regarding (b), matched to judgements of reasonableness, we describe levels of leadership distinguished according to how directively practitioners act; ranging from prompting patients to question unreasonable propositions or consider new propositions, to directive leadership whereby practitioners recommend options or deny requested procedures. In the context of ideas of relational autonomy, the objective of practitioner leadership is to protect patients’ autonomy by supporting good decision making, taking leadership in patients’ interests only when patients are unwilling or unable to make good decisions.

Reflections on a Health Psychology Service for Patients with Uveal Melanoma: The Challenge of Psychological Screening and Intervention When Distress is 'Normal'

We appraise the role of screening for distress as part of health psychology assessment of patients newly diagnosed with cancer. We reviewed records of consecutive patients who accepted a health psychologist’s assessment over 4 years, examining convergence and divergence of the result of screening (whether patients reached threshold as ‘cases’) with the psychologist’s clinical judgment of need for intervention. Of 261 patients, 88 (33.7%) were ‘cases’. Of these, need for psychological intervention was identified in 70 (79.5%). Of the 173 (66.3%) ‘non-cases’, need was identified in 59 (34.1%). Examination of cases where the psychologist’s judgment diverged from screening showed that ‘caseness’ can arise from distress that patients can manage themselves and, conversely, that psychological needs arise in the absence of overt distress. Formal screening may not identify need for psychological intervention. The psychologist’s role is to make expert judgments of patients’ current and future needs. Dialogue with patients should be the vehicle for assessment.