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Harris KW, Schweiberger K, Kavanaugh-McHugh A, Arnold RM, Merlin J, Chang JC, Kasparian NA. An Observational Study of Dialogue about Uncertainty in Clinician-Family Counseling Conversations Following Prenatal Diagnosis of Complex Congenital Heart Disease. PEC INNOVATION 2024; 4:100265. [PMID: 38404930 PMCID: PMC10883822 DOI: 10.1016/j.pecinn.2024.100265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 11/29/2023] [Accepted: 02/12/2024] [Indexed: 02/27/2024]
Abstract
Objective Families who receive a prenatal diagnosis of complex congenital heart disease (cCHD) often experience severe psychological distress and identify uncertainty as a key source of that distress. This study examined clinician-family conversations during initial fetal cardiology consultations to identify the topics of uncertainty discussed. Methods In this observational, qualitative study, initial fetal cardiology consultations were audio-recorded, transcribed verbatim, and coded by two independent coders. A codebook was inductively and deductively developed and applied. This content analysis focused on uncertainty-related codes and associated themes. Results During 19 consultations including five clinicians, 13 different cardiac diagnoses were discussed (seven with high mortality risk). Median consultation length was 37 min (IQR: 26-51), with only 11% of words spoken by families. On average, 51% of total words spoken focused on uncertainty in relation to cardiac diagnosis, etiology, comorbidities, prognosis, childbirth, therapeutics, and logistics. Family-initiated discussion on uncertainty largely focused on childbirth and pregnancy and postpartum logistics. Conclusions Half of dialogue within initial fetal cardiology encounters discussed uncertainty surrounding prenatally diagnosed cCHD. Parent and clinician perspectives should be gathered on the essential content and optimal delivery of uncertainty-related topics. Innovation This study is conceptually and methodologically innovative as one of the first to examine audio-recorded dialogue between fetal cardiology clinicians and families.
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Affiliation(s)
- Kelly W. Harris
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kelsey Schweiberger
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ann Kavanaugh-McHugh
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert M. Arnold
- Department of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jessica Merlin
- Department of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Judy C. Chang
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nadine A. Kasparian
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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2
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Edmonds J. Uncertainty in Maternity Care. J Obstet Gynecol Neonatal Nurs 2024:S0884-2175(24)00226-0. [PMID: 38885937 DOI: 10.1016/j.jogn.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024] Open
Abstract
The Editor in Chief reflects on uncertainty in maternity care.
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3
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Ellard H, Clarke A, Wynn S, Pichini A, Lewis C. Written communication of whole genome sequencing results in the NHS Genomic Medicine Service: a multi-centre service evaluation. Eur J Hum Genet 2024:10.1038/s41431-024-01636-5. [PMID: 38806663 DOI: 10.1038/s41431-024-01636-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 05/07/2024] [Accepted: 05/13/2024] [Indexed: 05/30/2024] Open
Abstract
Whole genome sequencing (WGS) is being used in diagnostic testing for certain clinical indications within the NHS Genomic Medicine Service (GMS) in England. Letter writing is an integral part of delivering results. However, no national guidelines for writing results from WGS exist. This multi-centre service evaluation used mixed methods to understand the content and readability of letters returning diagnostic, variant of uncertain significance (VUS), and no-finding results to paediatric rare disease patients. Eight Regional Genetics Services (response rate 47%) in England provided a total of 37 letters returning diagnostic (n = 13), VUS (n = 10), and no-finding (n = 14) results. Diagnostic and VUS results were usually delivered during an appointment; no-finding results were typically delivered by letter only. Letters were diverse in which content topics they covered and level of detail. No-finding letters (14/14) explained the result but were less likely to cover other topics. Diagnostic letters discussed the result (13/13), the condition (13/13), clinical genetics follow-up (13/13), clinical management (10/13), and adapting to the result (9/13). VUS letters explained the result (10/10), diagnostic uncertainty (10/10), and clinical genetics follow-up (10/10). Uncertainty was a common component of letters (33/37), irrespective of the result. Reanalysis or review after one or more years was suggested in 6/13 diagnostic, 7/10 VUS, and 6/14 no-finding letters. The mean reading level of letters corresponded to 15-17 years. Understanding how WGS results are conveyed to families during appointments, as well as how families interpret that information, is needed to provide a more comprehensive overview of results communication and inform best practices.
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Affiliation(s)
- Holly Ellard
- School of Medicine, Cardiff University, Cardiff, Wales, UK.
- Population, Policy and Practice Department, UCL Great Ormond Street Institute of Child Health, London, UK.
| | - Angus Clarke
- Division of Cancer & Genetics, School of Medicine, Cardiff University, Cardiff, Wales, UK
| | - Sarah Wynn
- Unique, Rare Chromosome Support Group, Oxted, Surrey, UK
| | | | - Celine Lewis
- School of Medicine, Cardiff University, Cardiff, Wales, UK
- Population, Policy and Practice Department, UCL Great Ormond Street Institute of Child Health, London, UK
- NHS North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Vromans RD, van de Ven CCM, Willems SJW, Krahmer EJ, Swerts MGJ. It is, uh, very likely? The impact of prosodic uncertainty cues on the perception and interpretation of spoken verbal probability phrases. RISK ANALYSIS : AN OFFICIAL PUBLICATION OF THE SOCIETY FOR RISK ANALYSIS 2024. [PMID: 38742599 DOI: 10.1111/risa.14319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/23/2024] [Accepted: 04/25/2024] [Indexed: 05/16/2024]
Abstract
People typically use verbal probability phrases when discussing risks ("It is likely that this treatment will work"), both in written and spoken communication. When speakers are uncertain about risks, they can nonverbally signal this uncertainty by using prosodic cues, such as a rising, question-like intonation or a filled pause ("uh"). We experimentally studied the effects of these two prosodic cues on the listener's perceived speaker certainty and numerical interpretation of spoken verbal probability phrases. Participants (N = 115) listened to various verbal probability phrases that were uttered with a rising or falling global intonation and with or without a filled pause before the probability phrase. For each phrase, they gave a point estimate of their numerical interpretation in percentages and indicated how certain they thought the speaker was about the correctness of the probability phrase. Speakers were perceived as least certain when the verbal probability phrases were spoken with both prosodic uncertainty cues. Interpretation of verbal probability phrases varied widely across participants, especially when rising intonation was produced by the speaker. Overall, high probability phrases (e.g., "very likely") were estimated as lower (and low probability phrases, such as "unlikely," as higher) when they were uttered with a rising intonation. The effects of filled pauses were less pronounced, as were the uncertainty effects for medium probability phrases (e.g., "probable"). These results stress the importance of nonverbal communication when verbally communicating risks and probabilities to people, for example, in the context of doctor-patient communication.
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Affiliation(s)
- Ruben D Vromans
- Department of Communication and Cognition, Tilburg School of Humanities and Digital Sciences, Tilburg University, Tilburg, The Netherlands
| | - Charlot C M van de Ven
- Department of Communication and Cognition, Tilburg School of Humanities and Digital Sciences, Tilburg University, Tilburg, The Netherlands
| | - Sanne J W Willems
- Methodology & Statistics, Institute of Psychology, Social and Behavioural Sciences, Leiden University, Leiden, The Netherlands
| | - Emiel J Krahmer
- Department of Communication and Cognition, Tilburg School of Humanities and Digital Sciences, Tilburg University, Tilburg, The Netherlands
| | - Marc G J Swerts
- Department of Communication and Cognition, Tilburg School of Humanities and Digital Sciences, Tilburg University, Tilburg, The Netherlands
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van der Velden NCA, Smets EMA, van Vliet LM, Brom L, van Laarhoven HWM, Henselmans I. Effects of prognostic communication strategies on emotions, coping, and appreciation of consultations: An experimental study in advanced cancer. Palliat Support Care 2024:1-13. [PMID: 38533613 DOI: 10.1017/s1478951524000403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
OBJECTIVES We aimed to investigate effects of prognostic communication strategies on emotions, coping, and appreciation of consultations in advanced cancer. METHODS For this experimental study, we created 8 videos of a scripted oncological consultation, only varying in prognostic communication strategies. Disease-naive individuals (n = 1036) completed surveys before and after watching 1 video, while imagining being the depicted cancer patient. We investigated effects of the type of disclosure (prognostic disclosure vs. communication of unpredictability vs. non-disclosure) and content of disclosure (standard vs. standard and best-case vs. standard, best- and worst-case survival scenarios; numerical vs. word-based estimates) on emotions, coping, and appreciation of consultations. Moderating effects of individual characteristics were tested. RESULTS Participants generally reported more satisfaction (p < .001) after prognostic disclosure versus communication of unpredictability and less uncertainty (p = .042), more satisfaction (p = .005), and more desirability (p = .016) regarding prognostic information after numerical versus word-based estimates. Effects of different survival scenarios were absent. Prognostic communication strategies lacked effects on emotions and coping. Significant moderators included prognostic information preference and uncertainty tolerance. SIGNIFICANCE OF RESULTS In an experimental setting, prognostic disclosure does not cause more negative emotions than non-disclosure and numerical estimates are more strongly appreciated than words. Oncologists' worries about harming patients should not preclude disclosing (precise) prognostic information, yet sensitivity to individual preferences and characteristics remains pivotal.
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Affiliation(s)
- Naomi C A van der Velden
- Department of Medical Psychology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Quality of Care, Amsterdam Public Health, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Quality of Care, Amsterdam Public Health, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Liesbeth M van Vliet
- Department of Health, Medical and Neuropsychology, University of Leiden, Leiden, The Netherlands
| | - Linda Brom
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
- Netherlands Association for Palliative Care (PZNL), Utrecht, The Netherlands
| | - Hanneke W M van Laarhoven
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Inge Henselmans
- Department of Medical Psychology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Quality of Care, Amsterdam Public Health, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
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Cox C, Hatfield T, Fritz Z. How and why do doctors communicate diagnostic uncertainty: An experimental vignette study. Health Expect 2024; 27:e13957. [PMID: 38828702 PMCID: PMC10774830 DOI: 10.1111/hex.13957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/14/2023] [Accepted: 12/16/2023] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Diagnostic uncertainty is common, but its communication to patients is under-explored. This study aimed to (1) characterise variation in doctors' communication of diagnostic uncertainty and (2) explore why variation occurred. METHODS Four written vignettes of clinical scenarios involving diagnostic uncertainty were developed. Doctors were recruited from five hospitals until theoretical saturation was reached (n = 36). Participants read vignettes in a randomised order, and were asked to discuss the diagnosis/plan with an online interviewer, as they would with a 'typical patient'. Semi-structured interviews explored reasons for communication choices. Interview transcripts were coded; quantitative and qualitative (thematic) analyses were undertaken. RESULTS There was marked variation in doctors' communication: in their discussion about differential diagnoses, their reference to the level of uncertainty in diagnoses/investigations and their acknowledgement of diagnostic uncertainty when safety-netting. Implicit expressions of uncertainty were more common than explicit. Participants expressed both different communication goals (including reducing patient anxiety, building trust, empowering patients and protecting against diagnostic errors) and different perspectives on how to achieve these goals. Training in diagnostic uncertainty communication is rare, but many felt it would be useful. CONCLUSIONS Significant variation in diagnostic uncertainty communication exists, even in a controlled setting. Differing communication goals-often grounded in conflicting ethical principles, for example, respect for autonomy versus nonmaleficence-and differing ideas on how to prioritise and achieve them may underlie this. The variation in communication behaviours observed has important implications for patient safety and health inequalities. Patient-focused research is required to guide practice. PATIENT OR PUBLIC CONTRIBUTION In the design stage of the study, two patient and public involvement groups (consisting of members of the public of a range of ages and backgrounds) were consulted to gain an understanding of patient perspectives on the concept of communicating diagnostic uncertainty. Their feedback informed the formulations of the research questions and the choice of vignettes used.
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Affiliation(s)
- Caitríona Cox
- The Healthcare Improvement Studies (THIS) InstituteUniversity of CambridgeCambridgeUK
| | - Thea Hatfield
- The Healthcare Improvement Studies (THIS) InstituteUniversity of CambridgeCambridgeUK
| | - Zoë Fritz
- The Healthcare Improvement Studies (THIS) InstituteUniversity of CambridgeCambridgeUK
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7
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van der Schoot V, van der Meer E, Hillen MA, Yntema HG, Brunner HG, Oerlemans AJM. Exploring uncertainties regarding unsolicited findings in genetic testing. PATIENT EDUCATION AND COUNSELING 2024; 119:108064. [PMID: 37976670 DOI: 10.1016/j.pec.2023.108064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/16/2023] [Accepted: 11/08/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES Non-normative uncertainty (uncertainty about empirical facts) and normative uncertainty (uncertainty about moral values or beliefs) regarding unsolicited findings (UFs) might play an important role in clinical genetics. Identifying normative uncertainty is of special interest since it might guide towards novel directions for counseling practice. This study aims to gain insight into the role of non-normative and normative uncertainty regarding UFs, as expressed by counselees and counselors. METHODS We performed a secondary qualitative analysis of interviews with counselees (n = 20) and counselors (n = 20) who had been confronted with UFs. Following a deductive approach, we used Han et al.'s existing theoretical framework of uncertainty, in which we additionally incorporated normative uncertainty. RESULTS Major issues of non-normative uncertainty were practical and personal for counselees, whilst counselors' uncertainty pertained mainly to scientific issues. Normative uncertainty was a major theme throughout the interviews. We encountered the moral conflicts of autonomy vs. beneficence and non-maleficence and of autonomy vs. truthfulness. CONCLUSION Non-normative uncertainty regarding UFs highlights the need to gain more insight in their penetrance and clinical utility. This study suggests moral conflicts are a major source of feelings of uncertainty in clinical genetics. PRACTICE IMPLICATIONS Exploring counselees' non-normative uncertainties and normative conflicts seems a prerequisite to optimize genetic counseling.
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Affiliation(s)
- Vyne van der Schoot
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Eline van der Meer
- IQ healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marij A Hillen
- Department of Medical Psychology, University of Amsterdam, Amsterdam, the Netherlands
| | - Helger G Yntema
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands; Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Han G Brunner
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands; Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, the Netherlands; GROW School for Development and Oncology, Maastricht University Maastricht, and the MHeNS School for Neuroscience, University of Maastricht, Maastricht, the Netherlands
| | - Anke J M Oerlemans
- IQ healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
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8
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Rao V, Linsky S, Knobf MT. Perspectives of Patients With Relapsed and Refractory Acute Myeloid Leukemia and High-Risk Myelodysplastic Syndrome on Patient-Clinician Communication About Prognosis and the Future. Palliat Med Rep 2024; 5:53-62. [PMID: 38249836 PMCID: PMC10797310 DOI: 10.1089/pmr.2023.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2023] [Indexed: 01/23/2024] Open
Abstract
Background Patients with acute myeloid leukemia (AML) and high-risk myelodysplastic syndrome (MDS) experience unpredictable disease trajectories and high prognostic uncertainty, which serve as barriers to patient-clinician communication about prognosis and their values and preferences for the future in the event of worsening health. Little is known about patients' day-to-day lived experiences and how this shapes their willingness to engage in such conversations. Objectives To explore participant perspectives on living with their illness and patient-clinician communication about prognosis and the future. Design This is a qualitative study using semi-structured interviews. Setting/Subjects Patients with relapsed and refractory (R/R) AML and high-risk MDS from a northeastern U.S. cancer center. Data Collection Interviews were transcribed verbatim and thematic analysis was used to generate findings. Results Of the 14 participants, the mean age was 66 years, 79% were men, 93% were White, married, and had AML. The overarching theme that describes the experience was "Taking One Day at a Time" in a Fog of Uncertainty. Uncertainty was a universal perception related to the challenges for clinicians to predict prognosis. To cope with uncertainty, most participants tried to focus on the present and maintain normality in everyday life. Participants valued encouragement and positivity in patient-clinician communication, however, the majority were not ready to discuss prognosis and the future in the event of worsening health. Of note, 7 of 14 participants died within three months after the interview. Conclusions These data describe a unique perspective of patients with R/R AML and high-risk MDS that clinicians could use to enhance communication strategies.
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Affiliation(s)
- Vinay Rao
- Division of Palliative Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sarah Linsky
- School of Nursing, Yale University, Orange, Connecticut, USA
| | - M. Tish Knobf
- School of Nursing, Yale University, Orange, Connecticut, USA
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Simons BCR, Hillen MA, Aarts JWM, Tromp JM, de Heus E, Duijts SFA. Disentangling trust of patients with rare cancer in their healthcare professionals and the healthcare system: a qualitative interview study. J Cancer Surviv 2024:10.1007/s11764-023-01531-w. [PMID: 38225524 DOI: 10.1007/s11764-023-01531-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 12/28/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE Patients with a rare cancer face challenges, e.g., delayed diagnosis, that may affect trust in the healthcare system and the healthcare professionals (HCPs) involved. This study aimed to explore trust of patients with a rare cancer in their HCPs and the healthcare system. METHODS Semi-structured interviews were conducted with 20 purposively sampled patients with a rare cancer. The interview guide included topics related to trust, including level, development, barriers and facilitators, importance, and trust dimensions. Thematic analysis was conducted with use of Atlas.ti. RESULTS The mean age of patients was 50 years, 60% were female, and 70% were highly educated. Three themes were constructed: (1) "Confirmed expertise is a prerequisite of trust." Patients need confirmation of their HCPs' expertise, as it could not be assumed due to the rarity of their cancer; (2) "Trust depends on the adequacy of information and how it is provided." Limited information about rare cancer reduced patients' trust in health care, whereas interpersonal trust was mainly affected by how HCPs provided information; and (3) "Trust is built on properly coordinated and supportive care." Proper organization and cooperation within and between hospitals, and integration of supportive care, enhanced trust. CONCLUSION Patients with a rare cancer experience challenges that influence trust in HCPs and the healthcare system. Further research should examine trust among subgroups of patients with a rare cancer, to enable development of tailored interventions. IMPLICATIONS FOR CANCER SURVIVORS HCPs may improve trust by focusing on expertise, effective information provision, proper coordination of care, and provision of adequate supportive care.
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Affiliation(s)
- Barbara C R Simons
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (Integraal Kankercentrum Nederland, IKNL), Rijnkade 5, 3511 LC, Utrecht, The Netherlands
| | - Marij A Hillen
- Department of Medical Psychology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Johanna W M Aarts
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Gynaecological Oncology, Cancer Center Amsterdam, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - Jacqueline M Tromp
- Department of Medical Oncology, Amsterdam University Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Eline de Heus
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (Integraal Kankercentrum Nederland, IKNL), Rijnkade 5, 3511 LC, Utrecht, The Netherlands
- Department of Medical Oncology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Saskia F A Duijts
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (Integraal Kankercentrum Nederland, IKNL), Rijnkade 5, 3511 LC, Utrecht, The Netherlands.
- Department of Medical Psychology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands.
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Gans EA, Pieterse AH, Klapwijk MS, van Stiphout F, van Steenbergen IJ, Portielje JEA, de Groot JF, van Munster BC, van den Bos F. Shared decision-making with older adults with cancer: Adaptation of a model through literature review and expert opinion. Psychooncology 2024; 33:e6291. [PMID: 38282224 DOI: 10.1002/pon.6291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 12/22/2023] [Accepted: 12/27/2023] [Indexed: 01/30/2024]
Abstract
OBJECTIVE To provide a literature overview of characteristics of Shared Decision Making (SDM) with specific importance to the older adult population with cancer and to tailor an existing model of SDM in patients with cancer to the needs of older adults. METHODS A systematic search of several databases was conducted. Eligible studies described factors influencing SDM concerning cancer treatment with adults aged 65 years or above, with any type of cancer. We included qualitative or mixed-methods studies. Themes were identified and discussed in an expert panel, including a patient-representative, until consensus was reached on an adjusted model. RESULTS Overall 29 studies were included and nine themes were identified from the literature. The themes related to the importance of goal setting, need for tailored information provision, the role of significant others, uncertainty of evidence, the importance of time during and outside of consultations, the possible ill-informed preconceptions that health care professionals (HCPs) might have about older adults and the specific competencies they need to engage in the SDM process with older adults. No new themes emerged from discussion with expert panel. This study presents a visual model of SDM with older patients with cancer based on the identified themes. CONCLUSIONS Our model shows key elements that are specific to SDM with older adults. Further research needs to focus on how to educate HCPs on the competencies needed to engage in SDM with older patients, and how to implement the model into everyday practice.
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Affiliation(s)
- Emma A Gans
- University Center of Geriatric Medicine, University Medical Center Groningen, Groningen, The Netherlands
- Knowledge Institute of the Dutch Association of Medical Specialists, Utrecht, The Netherlands
| | - Arwen H Pieterse
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Maartje S Klapwijk
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Feikje van Stiphout
- Department of Geriatric Internal Medicine, Meander Medical Center, Amersfoort, The Netherlands
| | - Irma J van Steenbergen
- Department of Gerontology and Geriatrics, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Janke F de Groot
- Knowledge Institute of the Dutch Association of Medical Specialists, Utrecht, The Netherlands
| | - Barbara C van Munster
- University Center of Geriatric Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Frederiek van den Bos
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
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Myronenko A, van der Velde P, Derksen SMJC, Peerdeman KJ. How should uncertainty about upcoming painful procedures be communicated? An experimental study into highly uncertain pain predictions. PATIENT EDUCATION AND COUNSELING 2024; 118:108008. [PMID: 37871353 DOI: 10.1016/j.pec.2023.108008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 09/29/2023] [Accepted: 10/05/2023] [Indexed: 10/25/2023]
Abstract
OBJECTIVE Uncertainty is unavoidable in the context of painful medical procedures. It is important to investigate the impact of different ways of communicating uncertainty on upcoming pain. METHODS In our exploratory study, healthy participants (n = 30) were repeatedly presented with three highly uncertain pain predictions communicated by a hypothetical doctor. A direct statement of high uncertainty ("I don't know") was compared to more indirect predictions (social prediction: "It varies widely among people"; range prediction: "… not painful at all to very highly painful"), followed by individually calibrated electrical stimuli of non-, moderately, or very highly painful intensity. RESULTS The direct expression of uncertainty led to the most intense pain sensation (for moderately painful stimuli only), lowest and most certain pain expectations, lowest trust in the hypothetical doctor, and lowest feeling of being well-informed, especially as compared to the social prediction. No differential effects on anxiety were observed. CONCLUSIONS Expressing high uncertainty indirectly, with reference to the common experiences of others, may be beneficial for optimizing pain experiences and enhancing patients' trust in a medical professional. PRACTICE IMPLICATIONS Our findings inform on how high uncertainty about upcoming pain may impact patient and health outcomes, pointing to some advantages of indirect communication.
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Affiliation(s)
- Anastasiia Myronenko
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands
| | - Pien van der Velde
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands
| | - Suzanne M J C Derksen
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands
| | - Kaya J Peerdeman
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands; Leiden Institute for Brain and Cognition, Leiden University, Leiden, the Netherlands.
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12
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Cifra CL, Custer JW, Smith CM, Smith KA, Bagdure DN, Bloxham J, Goldhar E, Gorga SM, Hoppe EM, Miller CD, Pizzo M, Ramesh S, Riffe J, Robb K, Simone SL, Stoll HD, Tumulty JA, Wall SE, Wolfe KK, Wendt L, Eyck PT, Landrigan CP, Dawson JD, Reisinger HS, Singh H, Herwaldt LA. Prevalence and Characteristics of Diagnostic Error in Pediatric Critical Care: A Multicenter Study. Crit Care Med 2023; 51:1492-1501. [PMID: 37246919 PMCID: PMC10615661 DOI: 10.1097/ccm.0000000000005942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVES Effective interventions to prevent diagnostic error among critically ill children should be informed by diagnostic error prevalence and etiologies. We aimed to determine the prevalence and characteristics of diagnostic errors and identify factors associated with error in patients admitted to the PICU. DESIGN Multicenter retrospective cohort study using structured medical record review by trained clinicians using the Revised Safer Dx instrument to identify diagnostic error (defined as missed opportunities in diagnosis). Cases with potential errors were further reviewed by four pediatric intensivists who made final consensus determinations of diagnostic error occurrence. Demographic, clinical, clinician, and encounter data were also collected. SETTING Four academic tertiary-referral PICUs. PATIENTS Eight hundred eighty-two randomly selected patients 0-18 years old who were nonelectively admitted to participating PICUs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 882 patient admissions, 13 (1.5%) had a diagnostic error up to 7 days after PICU admission. Infections (46%) and respiratory conditions (23%) were the most common missed diagnoses. One diagnostic error caused harm with a prolonged hospital stay. Common missed diagnostic opportunities included failure to consider the diagnosis despite a suggestive history (69%) and failure to broaden diagnostic testing (69%). Unadjusted analysis identified more diagnostic errors in patients with atypical presentations (23.1% vs 3.6%, p = 0.011), neurologic chief complaints (46.2% vs 18.8%, p = 0.024), admitting intensivists greater than or equal to 45 years old (92.3% vs 65.1%, p = 0.042), admitting intensivists with more service weeks/year (mean 12.8 vs 10.9 wk, p = 0.031), and diagnostic uncertainty on admission (77% vs 25.1%, p < 0.001). Generalized linear mixed models determined that atypical presentation (odds ratio [OR] 4.58; 95% CI, 0.94-17.1) and diagnostic uncertainty on admission (OR 9.67; 95% CI, 2.86-44.0) were significantly associated with diagnostic error. CONCLUSIONS Among critically ill children, 1.5% had a diagnostic error up to 7 days after PICU admission. Diagnostic errors were associated with atypical presentations and diagnostic uncertainty on admission, suggesting possible targets for intervention.
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Affiliation(s)
- Christina L. Cifra
- Division of Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Division of Medical Critical Care, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jason W. Custer
- Division of Critical Care, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Craig M. Smith
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kristen A. Smith
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Dayanand N. Bagdure
- Department of Pediatrics, Louisiana State University Health Shreveport School of Medicine, Shreveport, Louisiana
| | - Jodi Bloxham
- University of Iowa College of Nursing, Iowa City, Iowa
| | - Emily Goldhar
- Pediatric Intensive Care Unit, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Stephen M. Gorga
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Elizabeth M. Hoppe
- Pediatric Intensive Care Unit, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Christina D. Miller
- Department of Pediatrics, Section of Critical Care, University of Colorado School of Medicine, Aurora, Colorado
| | - Max Pizzo
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
- University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Sonali Ramesh
- Department of Pediatrics, BronxCare Health System, New York, New York
| | - Joseph Riffe
- Department of Pediatrics, Family First Health, York, Pennsylvania
| | - Katharine Robb
- Division of Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Shari L. Simone
- University of Maryland School of Nursing, Baltimore, Maryland
| | | | - Jamie Ann Tumulty
- Pediatric Intensive Care Unit, University of Maryland Children’s Hospital, Baltimore, Maryland
| | - Stephanie E. Wall
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
- University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Katie K. Wolfe
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Linder Wendt
- University of Iowa Institute for Clinical and Translational Science, Iowa City, Iowa
| | - Patrick Ten Eyck
- University of Iowa Institute for Clinical and Translational Science, Iowa City, Iowa
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa
| | - Christopher P. Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey D. Dawson
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa
| | - Heather Schacht Reisinger
- University of Iowa Institute for Clinical and Translational Science, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - Loreen A. Herwaldt
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
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Hendriksen HMA, van Gils AM, van Harten AC, Hartmann T, Mangialasche F, Kamondi A, Kivipelto M, Rhodius-Meester HFM, Smets EMA, van der Flier WM, Visser LNC. Communication about diagnosis, prognosis, and prevention in the memory clinic: perspectives of European memory clinic professionals. Alzheimers Res Ther 2023; 15:131. [PMID: 37543608 PMCID: PMC10404377 DOI: 10.1186/s13195-023-01276-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/19/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND The paradigm shift towards earlier Alzheimer's disease (AD) stages and personalized medicine creates new challenges for clinician-patient communication. We conducted a survey among European memory clinic professionals to identify opinions on communication about (etiological) diagnosis, prognosis, and prevention, and inventory needs for augmenting communication skills. METHODS Memory clinic professionals (N = 160) from 21 European countries completed our online survey (59% female, 14 ± 10 years' experience, 73% working in an academic hospital). We inventoried (1) opinions on communication about (etiological) diagnosis, prognosis, and prevention using 11 statements; (2) current communication practices in response to five hypothetical cases (AD dementia, mild cognitive impairment (MCI), subjective cognitive decline (SCD), with ( +) or without ( -) abnormal AD biomarkers); and (3) needs for communication support regarding ten listed communication skills. RESULTS The majority of professionals agreed that communication on diagnosis, prognosis, and prevention should be personalized to the individual patient. In response to the hypothetical patient cases, disease stage influenced the inclination to communicate an etiological AD diagnosis: 97% would explicitly mention the presence of AD to the patient with AD dementia, 68% would do so in MCI + , and 29% in SCD + . Furthermore, 58% would explicitly rule out AD in case of MCI - when talking to patients, and 69% in case of SCD - . Almost all professionals (79-99%) indicated discussing prognosis and prevention with all patients, of which a substantial part (48-86%) would personalize their communication to patients' diagnostic test results (39-68%) or patients' anamnestic information (33-82%). The majority of clinicians (79%) would like to use online tools, training, or both to support them in communicating with patients. Topics for which professionals desired support most were: stimulating patients' understanding of information, and communicating uncertainty, dementia risk, remotely/online, and with patients not (fluently) speaking the language of the country of residence. CONCLUSIONS In a survey of European memory clinic professionals, we found a strong positive attitude towards communication with patients about (etiological) diagnosis, prognosis, and prevention, and personalization of communication to characteristics and needs of individual patients. In addition, professionals expressed a need for supporting tools and skills training to further improve their communication with patients.
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Affiliation(s)
- Heleen M A Hendriksen
- Alzheimer Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands.
- Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands.
| | - Aniek M van Gils
- Alzheimer Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands
| | - Argonde C van Harten
- Alzheimer Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands
| | - Tobias Hartmann
- Experimental Neurology, Saarland University, 66424, Homburg, Germany
- Deutsches Institut Für DemenzPrävention, Saarland University, 66424, Homburg, Germany
| | - Francesca Mangialasche
- Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital, Medical Unit Aging, Theme Inflammation and Aging, Stockholm, Sweden
| | - Anita Kamondi
- Department of Neurology, Neurology and Neurosurgery, National Institute of Mental Health, Budapest, Hungary
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Miia Kivipelto
- Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital, Medical Unit Aging, Theme Inflammation and Aging, Stockholm, Sweden
- Ageing and Epidemiology (AGE) Research Unit, School of Public Health, Imperial College London, London, UK
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Helsinki, Finland
| | - Hanneke F M Rhodius-Meester
- Alzheimer Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands
- Department of Geriatric Medicine, The Memory Clinic, Oslo University Hospital, Oslo, Norway
- Internal Medicine, Geriatric Medicine Section, Amsterdam Cardiovascular Sciences Institute, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Ellen M A Smets
- Medical Psychology, Amsterdam UMC Location AMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Quality of Care, Personalized Medicine, , Amsterdam, The Netherlands
| | - Wiesje M van der Flier
- Alzheimer Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands
- Epidemiology and Biostatistics, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Leonie N C Visser
- Alzheimer Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands
- Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Medical Psychology, Amsterdam UMC Location AMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Quality of Care, Personalized Medicine, , Amsterdam, The Netherlands
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14
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Riera R, de Oliveira Cruz Latorraca C, Padovez RCM, Pacheco RL, Romão DMM, Barreto JOM, Machado MLT, Gomes R, da Silva SF, Martimbianco ALC. Strategies for communicating scientific evidence on healthcare to managers and the population: a scoping review. Health Res Policy Syst 2023; 21:71. [PMID: 37430348 DOI: 10.1186/s12961-023-01017-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/14/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Health evidence needs to be communicated and disseminated in a manner that is clearly understood by decision-makers. As an inherent component of health knowledge translation, communicating results of scientific studies, effects of interventions and health risk estimates, in addition to understanding key concepts of clinical epidemiology and interpreting evidence, represent a set of essential instruments to reduce the gap between science and practice. The advancement of digital and social media has reshaped the concept of health communication, introducing new, direct and powerful communication platforms and gateways between researchers and the public. The objective of this scoping review was to identify strategies for communicating scientific evidence in healthcare to managers and/or population. METHODS We searched Cochrane Library, Embase®, MEDLINE® and other six electronic databases, in addition to grey literature, relevant websites from related organizations for studies, documents or reports published from 2000, addressing any strategy for communicating scientific evidence on healthcare to managers and/or population. RESULTS Our search identified 24 598 unique records, of which 80 met the inclusion criteria and addressed 78 strategies. Most strategies focused on risk and benefit communication in health, were presented by textual format and had been implemented and somehow evaluated. Among the strategies evaluated and appearing to yield some benefit are (i) risk/benefit communication: natural frequencies instead of percentages, absolute risk instead relative risk and number needed to treat, numerical instead nominal communication, mortality instead survival; negative or loss content appear to be more effective than positive or gain content; (ii) evidence synthesis: plain languages summaries to communicate the results of Cochrane reviews to the community were perceived as more reliable, easier to find and understand, and better to support decisions than the original summaries; (iii) teaching/learning: the Informed Health Choices resources seem to be effective for improving critical thinking skills. CONCLUSION Our findings contribute to both the knowledge translation process by identifying communication strategies with potential for immediate implementation and to future research by recognizing the need to evaluate the clinical and social impact of other strategies to support evidence-informed policies. Trial registration protocol is prospectively available in MedArxiv (doi.org/10.1101/2021.11.04.21265922).
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Affiliation(s)
- Rachel Riera
- Hospital Sírio-Libanês, Rua Barata Ribeiro, 142, 2O andar, São Paulo, SP, 01308-000, Brazil
- Universidade Federal de São Paulo (Unifesp), São Paulo, Brazil
| | - Carolina de Oliveira Cruz Latorraca
- Hospital Sírio-Libanês, Rua Barata Ribeiro, 142, 2O andar, São Paulo, SP, 01308-000, Brazil
- Universidade Federal de São Paulo (Unifesp), São Paulo, Brazil
| | | | - Rafael Leite Pacheco
- Hospital Sírio-Libanês, Rua Barata Ribeiro, 142, 2O andar, São Paulo, SP, 01308-000, Brazil.
- Universidade Federal de São Paulo (Unifesp), São Paulo, Brazil.
| | - Davi Mamblona Marques Romão
- Hospital Sírio-Libanês, Rua Barata Ribeiro, 142, 2O andar, São Paulo, SP, 01308-000, Brazil
- Instituto Veredas, São Paulo, Brazil
| | - Jorge Otávio Maia Barreto
- Hospital Sírio-Libanês, Rua Barata Ribeiro, 142, 2O andar, São Paulo, SP, 01308-000, Brazil
- Fundação Oswaldo Cruz, Brasília, Brazil
| | - Maria Lúcia Teixeira Machado
- Hospital Sírio-Libanês, Rua Barata Ribeiro, 142, 2O andar, São Paulo, SP, 01308-000, Brazil
- Universidade Federal de São Carlos, São Carlos, Brazil
| | - Romeu Gomes
- Hospital Sírio-Libanês, Rua Barata Ribeiro, 142, 2O andar, São Paulo, SP, 01308-000, Brazil
- Fundação Oswaldo Cruz, Brasília, Brazil
| | | | - Ana Luiza Cabrera Martimbianco
- Hospital Sírio-Libanês, Rua Barata Ribeiro, 142, 2O andar, São Paulo, SP, 01308-000, Brazil
- Universidade Metropolitna de Santo (Unimes), Santos, Brazil
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15
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Akkermans A, Prins S, Spijkers AS, Wagemans J, Labrie NHM, Willems DL, Schultz MJ, Cherpanath TGV, van Woensel JBM, van Heerde M, van Kaam AH, van de Loo M, Stiggelbout A, Smets EMA, de Vos MA. Argumentation in end-of-life conversations with families in Dutch intensive care units: a qualitative observational study. Intensive Care Med 2023; 49:421-433. [PMID: 37004524 PMCID: PMC10119246 DOI: 10.1007/s00134-023-07027-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/01/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE In intensive care units (ICUs), decisions about the continuation or discontinuation of life-sustaining treatment (LST) are made on a daily basis. Professional guidelines recommend an open exchange of standpoints and underlying arguments between doctors and families to arrive at the most appropriate decision. Yet, it is still largely unknown how doctors and families argue in real-life conversations. This study aimed to (1) identify which arguments doctors and families use in support of standpoints to continue or discontinue LST, (2) investigate how doctors and families structure their arguments, and (3) explore how their argumentative practices unfold during conversations. METHOD A qualitative inductive thematic analysis of 101 audio-recorded conversations between doctors and families. RESULTS Seventy-one doctors and the families of 36 patients from the neonatal, pediatric, and adult ICU (respectively, N-ICU, P-ICU, and A-ICU) of a large university-based hospital participated. In almost all conversations, doctors were the first to argue and families followed, thereby either countering the doctor's line of argumentation or substantiating it. Arguments put forward by doctors and families fell under one of ten main types. The types of arguments presented by families largely overlapped with those presented by doctors. A real exchange of arguments occurred in a minority of conversations and was generally quite brief in the sense that not all possible arguments were presented and then discussed together. CONCLUSION This study offers a detailed insight in the argumentation practices of doctors and families, which can help doctors to have a sharper eye for the arguments put forward by doctors and families and to offer room for true deliberation.
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Affiliation(s)
- Aranka Akkermans
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, North Holland, The Netherlands.
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Sanne Prins
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, North Holland, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Amber S Spijkers
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, North Holland, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Jean Wagemans
- Department of Speech Communication, Argumentation Theory, and Rhetoric, University of Amsterdam, Amsterdam, The Netherlands
| | - Nanon H M Labrie
- Department of Language, Literature and Communication, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Dick L Willems
- Department of Ethics, Law and Humanities, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Thomas G V Cherpanath
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Job B M van Woensel
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc van Heerde
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Moniek van de Loo
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anne Stiggelbout
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, North Holland, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Mirjam A de Vos
- Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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16
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Gerritse K, Martens C, Bremmer MA, Kreukels BPC, de Boer F, Molewijk BC. Sharing decisions amid uncertainties: a qualitative interview study of healthcare professionals' ethical challenges and norms regarding decision-making in gender-affirming medical care. BMC Med Ethics 2022; 23:139. [PMID: 36575401 PMCID: PMC9793857 DOI: 10.1186/s12910-022-00880-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND In gender-affirming medical care (GAMC), ethical challenges in decision-making are ubiquitous. These challenges are becoming more pressing due to exponentially increasing referrals, politico-legal contestation, and divergent normative views regarding decisional roles and models. Little is known, however, about what ethical challenges related to decision-making healthcare professionals (HCPs) themselves face in their daily work in GAMC and how these relate to, for example, the subjective nature of Gender Incongruence (GI), the multidisciplinary character of GAMC and the role HCPs play in assessing GI and eligibility for interventions. Given the relevance and urgency of these questions, we conducted a qualitative study among HCPs providing GAMC to transgender adults in the Netherlands. METHODS In this qualitative research, we conducted 11 semi-structured interviews between May 2020 and February 2021 with HCPs (six mental health professionals, two HCPs in endocrinology, two in plastic surgery, and one in nursing) working in two distinct GAMC settings. We purposively sampled for professional background and years of experience in GAMC. We analyzed our interview data using thematic analysis. As some respondents were more inclined to speak about what should or ought to be done to arrive at good or right decision-making, we identified both ethical challenges and norms. Furthermore, in our analysis, we differentiated between respondents' explicit and implicit ethical challenges and norms and ascertained the specific context in which these challenges emerged. RESULTS Respondents' ethical challenges and norms centered on (1) dividing and defining decisional roles and bounds, (2) negotiating decision-making in a (multidisciplinary) team, and (3) navigating various decision-making temporalities. These themes arose in the context of uncertainties regarding (1) GAMC's guidelines, evidence, and outcomes, as well as (2) the boundaries and assessment of GI. CONCLUSIONS This interview study provides detailed empirical insight into both the explicit and implicit ethical challenges that HCPs experience and their ethical norms regarding decision-making. It also describes how uncertainties and (implicit) normativities concerning GAMC and GI pre-structure the moral environment in which these challenges and norms manifest. We provide normative reflections and recommendations on handling these ethical challenges in a way that is sensitive to the context in which they arise.
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Affiliation(s)
- Karl Gerritse
- grid.509540.d0000 0004 6880 3010Department of Ethics, Law and Humanities (ELH), Amsterdam University Medical Center (UMC), Location VUmc, De Boelelaan 1089a, 1081 HV Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCenter of Expertise on Gender Dysphoria (CEGD), Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XDepartment of Psychiatry, Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands
| | - Casper Martens
- grid.509540.d0000 0004 6880 3010Department of Ethics, Law and Humanities (ELH), Amsterdam University Medical Center (UMC), Location VUmc, De Boelelaan 1089a, 1081 HV Amsterdam, The Netherlands
| | - Marijke A. Bremmer
- grid.16872.3a0000 0004 0435 165XCenter of Expertise on Gender Dysphoria (CEGD), Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XDepartment of Psychiatry, Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands
| | - Baudewijntje P. C. Kreukels
- grid.16872.3a0000 0004 0435 165XCenter of Expertise on Gender Dysphoria (CEGD), Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XDepartment of Medical Psychology, Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands
| | - Fijgje de Boer
- grid.509540.d0000 0004 6880 3010Department of Ethics, Law and Humanities (ELH), Amsterdam University Medical Center (UMC), Location VUmc, De Boelelaan 1089a, 1081 HV Amsterdam, The Netherlands
| | - Bert C. Molewijk
- grid.509540.d0000 0004 6880 3010Department of Ethics, Law and Humanities (ELH), Amsterdam University Medical Center (UMC), Location VUmc, De Boelelaan 1089a, 1081 HV Amsterdam, The Netherlands
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17
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Simonovic N, Taber JM, Scherr CL, Dean M, Hua J, Howell JL, Chaudhry BM, Wain KE, Politi MC. Uncertainty in healthcare and health decision making: Five methodological and conceptual research recommendations from an interdisciplinary team. J Behav Med 2022. [DOI: 10.1007/s10865-022-00384-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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18
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Anantapong K, Davies N, Sampson EL. Communication between the multidisciplinary team and families regarding nutrition and hydration for people with severe dementia in acute hospitals: a qualitative study. Age Ageing 2022; 51:6834151. [PMID: 36434801 PMCID: PMC9701106 DOI: 10.1093/ageing/afac230] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND When a person with severe dementia is in hospital and has eating and drinking difficulties, communication between the multidisciplinary team and families can be challenging and lead to suboptimal care. OBJECTIVE To gain in-depth understanding about the experiences, views and needs of family carers and hospital staff, regarding communication and conversations about nutrition and hydration, for hospital patients with severe dementia. DESIGN Qualitative semi-structured interview study. SETTING Acute hospital in England. METHODS From January to May 2021, semi-structured interviews were conducted with 29 family carers and hospital staff. Interviews were transcribed verbatim and analysed using reflexive thematic methods. RESULTS Four overarching themes were developed: (i) prerequisites to initiating communication about eating and drinking; (ii) communication aiming to develop agreed care plans; (iii) difficulty discussing palliative and end-of-life care; and (iv) needs of information and plans about future eating and drinking difficulties. Families tended to wait for hospital staff to initiate discussions but usually experienced frustration with delays and repeated conversations with different staff. Some staff felt unprepared to manage these conversations and found it challenging to work across the multidisciplinary team. During discharge processes, key information and care plans about eating and drinking were not regularly passed on to people involved to avoid unnecessary readmissions. CONCLUSIONS In acute hospitals, family carers and hospital staff can have disjointed communications and conversations about nutrition and hydration for persons with severe dementia. Timely reassurance, ongoing discussions and clear information sharing will support communication between those involved.
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Affiliation(s)
| | - Nathan Davies
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK,Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK,Department of Psychological Medicine, Royal London Hospital, East London NHS Foundation Trust, London, UK
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19
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How doctors manage conflicts with families of critically ill patients during conversations about end-of-life decisions in neonatal, pediatric, and adult intensive care. Intensive Care Med 2022; 48:910-922. [PMID: 35773499 PMCID: PMC9273549 DOI: 10.1007/s00134-022-06771-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/31/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Intensive care is a stressful environment in which team-family conflicts commonly occur. If managed poorly, conflicts can have negative effects on all parties involved. Previous studies mainly investigated these conflicts and their management in a retrospective way. This study aimed to prospectively explore team-family conflicts, including its main topics, complicating factors, doctors' conflict management strategies and the effect of these strategies. METHODS Conversations between doctors in the neonatal, pediatric, and adult intensive care unit of a large university-based hospital and families of critically ill patients were audio-recorded from the moment doubts arose whether treatment was still in patients' best interest. Transcripts were coded and analyzed using a qualitative deductive approach. RESULTS Team-family conflicts occurred in 29 out of 101 conversations (29%) concerning 20 out of 36 patients (56%). Conflicts mostly concerned more than one topic. We identified four complicating context- and/or family-related factors: diagnostic and prognostic uncertainty, families' strong negative emotions, limited health literacy, and burden of responsibility. Doctors used four overarching strategies to manage conflicts, namely content-oriented, process-oriented, moral and empathic strategies. Doctors mostly used content-oriented strategies, independent of the intensive care setting. They were able to effectively address conflicts in most conversations. Yet, if they did not acknowledge families' cues indicating the existence of one or more complicating factors, conflicts were likely to linger on during the conversation. CONCLUSION This study underlines the importance of doctors tailoring their communication strategies to the concrete conflict topic(s) and to the context- and family-related factors which complicate a specific conflict.
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Smits RM, Vissers E, te Pas R, Roebbers N, Feitz WFJ, van Rooij IALM, de Blaauw I, Verhaak CM. Common needs in uncommon conditions: a qualitative study to explore the need for care in pediatric patients with rare diseases. Orphanet J Rare Dis 2022; 17:153. [PMID: 35379257 PMCID: PMC8981675 DOI: 10.1186/s13023-022-02305-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/23/2022] [Indexed: 01/13/2023] Open
Abstract
Abstract
Background
Challenges faced by children diagnosed with a rare disease or complex condition and their family members are often characterized by disease-specific complexities, such as a prolonged diagnostic process, an uncertain prognosis, and the absence of curative treatment. The psychological burden of living with a rare disease or complex condition is often understudied and may present overarching concepts that shape the general experience of having been diagnosed with a rare condition. The present study examines common needs from a comprehensive perspective combining relevant aspects from the rare disease literature in a theoretical perspective from pediatric psychology, such as a family-centred, developmental and interdisciplinary approach. An exploratory study was designed among parents from children with a rare disease or complex condition in an Integrated University Children’s Hospital in the Netherlands. Semi-structured interviews were conducted with open-ended questions based around the experience of having a child diagnosed with a rare condition, such as the psychosocial impact on the child and it’s development, the impact on the family, and how provided care was experienced.
Results
Twelve interviews were analysed with a thematic content analysis to identify common needs. Eight themes followed from the analysis and uncovered the need for (1) family-focused care, (2) coping with uncertainty, (3) empathic communication, (4) practical support, (5) information, (6) psychological support, (7) interdisciplinary care, and (8) social support.
Conclusions
The results from our study provide directions for research and health care to support young patients with a rare disease or complex condition and their families. Moreover, our results demonstrated that there are overarching concepts across different rare diseases that may be optimally supported with interdisciplinary care.
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Porzsolt F, Pfuhl G, Kaplan RM, Eisemann M. Covid-19 pandemic lessons: uncritical communication of test results can induce more harm than benefit and raises questions on standardized quality criteria for communication and liability. Health Psychol Behav Med 2021; 9:818-829. [PMID: 34567838 PMCID: PMC8462930 DOI: 10.1080/21642850.2021.1979407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 09/07/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic is characterized by both health and economic risks. A 'safety loop' model postulates risk-related decisions are not based on objective and measurable risks but on the subjective perception of those risks. We here illustrate a quantification of the difference between objective and subjective risks. METHOD The objective risks (or chances) can be obtained from traditional 2 × 2 tables by calculating the positive (+LR) and negative (-LR) likelihood ratios. The subjective perception of objective risks is calculated from the same 2 × 2 tables by exchanging the X- and Y-axes. The traditional 2 × 2 table starts with the hypothesis, uses a test and a gold standard to confirm or exclude the investigated condition. The 2 × 2 table with inverted axes starts with the communication of a test result and presumes that the communication of bad news (whether right or false) will induce 'Perceived Anxiety' while good news will induce 'Perceived Safety'. Two different functions (confirmation and exclusion) of both perceptions (Perceived Anxiety and Safety) can be quantified with those calculations. RESULTS The analysis of six published tests and of one incompletely reported test on COVID-19 polymerase chain reactions (completed by four assumptions on high and low sensitivities and specificities) demonstrated that none of these tests induces 'Perceived Safety'. Eight of the ten tests confirmed the induction of 'Perceived Anxiety' with + LRs (range 3.1-5900). In two of these eight tests, a -LR (0.25 and 0.004) excluded the induction of 'Perceived Safety'. CONCLUSIONS Communication of test results caused perceived anxiety but not perceived safety in 80% of the investigated tests. Medical tests - whether true or false - generate strong psychological messages. In the case of COVID-19 tests may induce more perceived anxiety than safety. Risk communication has to balance objective and subjective risks.
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Affiliation(s)
- Franz Porzsolt
- Institute of Clinical Economics (ICE) e.V., Ulm, Germany
| | - Gerit Pfuhl
- UiT The Arctic University of Norway, Tromsø, Norway
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Medendorp NM, Stiggelbout AM, Aalfs CM, Han PKJ, Smets EMA, Hillen MA. A scoping review of practice recommendations for clinicians' communication of uncertainty. Health Expect 2021; 24:1025-1043. [PMID: 34101951 PMCID: PMC8369117 DOI: 10.1111/hex.13255] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/21/2021] [Accepted: 03/23/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Health-care providers increasingly have to discuss uncertainty with patients. Awareness of uncertainty can affect patients variably, depending on how it is communicated. To date, no overview existed for health-care professionals on how to discuss uncertainty. OBJECTIVE To generate an overview of available recommendations on how to communicate uncertainty with patients during clinical encounters. SEARCH STRATEGY A scoping review was conducted. Four databases were searched following the PRISMA-ScR statement. Independent screening by two researchers was performed of titles and abstracts, and subsequently full texts. INCLUSION CRITERIA Any (non-)empirical papers were included describing recommendations for any health-care provider on how to orally communicate uncertainty to patients. DATA EXTRACTION Data on provided recommendations and their characteristics (eg, target group and strength of evidence base) were extracted. Recommendations were narratively synthesized into a comprehensible overview for clinical practice. RESULTS Forty-seven publications were included. Recommendations were based on empirical findings in 23 publications. After narrative synthesis, 13 recommendations emerged pertaining to three overarching goals: (a) preparing for the discussion of uncertainty, (b) informing patients about uncertainty and (c) helping patients deal with uncertainty. DISCUSSION AND CONCLUSIONS A variety of recommendations on how to orally communicate uncertainty are available, but most lack an evidence base. More substantial research is needed to assess the effects of the suggested communicative approaches. Until then, health-care providers may use our overview of communication strategies as a toolbox to optimize communication about uncertainty with patients. PATIENT OR PUBLIC CONTRIBUTION Results were presented to stakeholders (physicians) to check and improve their practical applicability.
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Affiliation(s)
- Niki M. Medendorp
- Department of Medical PsychologyAmsterdam UMCAmsterdam Public HealthAmsterdamThe Netherlands
| | - Anne M. Stiggelbout
- Medical Decision MakingDepartment of Biomedical Data SciencesLeiden University Medical CenterLeidenThe Netherlands
| | - Cora M. Aalfs
- Division of Biomedical GeneticsDepartment of GeneticsUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Paul K. J. Han
- Center for Outcomes Research and EvaluationMaine Medical Center Research InstitutePortlandMEUSA
| | - Ellen M. A. Smets
- Department of Medical PsychologyAmsterdam UMCAmsterdam Public HealthAmsterdamThe Netherlands
| | - Marij A. Hillen
- Department of Medical PsychologyAmsterdam UMCAmsterdam Public HealthAmsterdamThe Netherlands
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