Impact of patient acuity on preference for information and autonomy in decision making

Stroke survivor views on ambulance redirection as a strategy to increase access to thrombectomy in England

Introduction

Intravenous thrombolysis and mechanical thrombectomy are effective time-sensitive treatments for selected cases of acute ischaemic stroke. While thrombolysis is widely available, thrombectomy can only be provided at facilities with the necessary equipment and interventionists. Suitable patients admitted to other hospitals require secondary transfer, causing delays to treatment. Pre-hospital ambulance redirection to thrombectomy facilities may improve access but treatment eligibility cannot be confirmed pre-hospital. Some redirected patients would travel further and be displaced without receiving thrombectomy. This study aimed to elicit stroke survivor and carer/relative views about the possible consequences of introducing a conceptual, idealised ambulance redirection pathway.

Methods

Focus groups were undertaken using a topic guide describing four hypothetical ambulance redirection scenarios and their possible consequences: earlier treatment with thrombectomy; delayed diagnosis of non-stroke 'mimic' conditions; delayed thrombolysis treatment; and delayed diagnosis of haemorrhagic stroke. Meetings were audio recorded, transcribed verbatim and data analysed thematically using emergent coding.

Results

Fifteen stroke survivors and carers/relatives participated in three focus groups. There was wide acceptance of possible low-risk consequences of ambulance redirection, including extended travel time, being further from home and experiencing longer hospital stays. Participants were more uncertain about higher-risk consequences, including delays in diagnosis/treatment for patients unsuitable for thrombectomy, but remained positive about ambulance redirection overall. Participants rationalised acceptance of higher-risk consequences by recognising that redirected patients would still access appropriate treatment, even if delayed. In addition, acceptance of ambulance redirection would be increased if there were robust clinical evidence showing net benefit over secondary transfer pathways.

Conclusions

Participant views were generally supportive of ambulance redirection to facilitate access to thrombectomy. Further research is needed to demonstrate overall benefit in an NHS context.

Perceptions of Singaporeans towards informed consent: a cross-sectional survey

INTRODUCTION

In a patient-centric health system, it is essential to know patients' views about informed consent. The objective of this study was to understand the perceptions of the local population regarding informed consent.

METHODS

Spanning 6 weeks from January 2016 to March 2016, a cross-sectional survey of adults attending the General Surgery outpatient clinics at Tan Tock Seng Hospital was conducted. Sociodemographic data, lifestyle- and health-related information, perception and purpose of consent forms, and decision-making preferences were studied.

RESULTS

A total of 445 adults participated in the survey. Most participants were aged below 40 years ( n = 265, 60.1%), female ( n = 309, 70.1%) and degree holders ( n = 196, 44.4%). Also, 56.9% of participants wanted to know every possible risk, while 28.3% wanted to know the common and serious risks. On multivariate analysis, age (61-74 years: odds ratio [OR] 11.1, 95% confidence interval [CI] 2.2-56.1, P = 0.004; age >75 years: OR 22.2, 95% CI 1.8-279.1, P = 0.017) was a predictor of not wanting to know any risks. Age also predicted risk of disclosure for death (age 61-74 years: OR 13.4, 95% CI 4.2-42.6, P < 0.001; age >75 years: OR 32.0, 95% CI 4.5-228.0, P = 0.001). Most participants (48.1%) preferred making shared decisions with doctors, and an important predictor was employment status (OR 4.8, 95% CI 1.9-12.2, P = 0.001).

CONCLUSION

Sociodemographic factors and educational level influence decision-making, and therefore, the informed consent process should be tailored for each patient.

Experiences with information provision and preferences for decision making of patients with acute stroke

OBJECTIVE

The aim of this study was to gain insight into experiences of patients with acute stroke regarding information provision and their preferred involvement in decision-making processes during the initial period of hospitalisation.

METHODS

A sequential explanatory design was used in two independent cohorts of patients with stroke, starting with a survey after discharge from hospital (cohort 1) followed by observations and structured interviews during hospitalisation (cohort 2). Quantitative data were analysed descriptively.

RESULTS

In total, 72 patients participated in this study (52 in cohort 1 and 20 in cohort 2). During hospitalisation, the majority of the patients were educated about acute stroke and their treatment. Approximately half of the patients preferred to have an active role in the decision-making process, whereas only 21% reported to be actively involved. In cohort 2, 60% of the patients considered themselves capable to carefully consider treatment options.

CONCLUSIONS

Active involvement in the acute decision-making process is preferred by approximately half of the patients with acute stroke and most of them consider themselves capable of doing so. However, they experience a limited degree of actual involvement.

PRACTICE IMPLICATIONS

Physicians can facilitate patient engagement by explicitly emphasising when a decision has to be made in which the patient's opinion is important.

Self-rated worry is associated with hospital admission in out-of-hours telephone triage - a prospective cohort study

Objective

Telephone triage manages patient flow in acute care, but a lack of visual cues and vague descriptions of symptoms challenges clinical decision making. We aim to investigate the association between the caller’s subjective perception of illness severity expressed as “degree-of-worry” (DOW) and hospital admissions within 48 h.

Design and setting

A prospective cohort study was performed from January 24th to February 9th, 2017 at the Medical Helpline 1813 (MH1813) in Copenhagen, Denmark. The MH1813 is a primary care out-of-hours service.

Participants

Of 38,787 calls received at the MH1813, 11,338 met the inclusion criteria (caller being patient or close friend/relative and agreement to participate). Participants rated their DOW on a 5-point scale (1 = minimum worry, 5 = maximum worry) before talking to a call handler.

Main outcome measure

Information on hospitalization within 48 h after the call, was obtained from the Danish National Patient Register. The association was assessed using logistic regression in three models: 1) crude, 2) age-and-gender adjusted and 3) age, gender, co-morbidity, reason for calling and caller status adjusted.

Results

A total of 581 participants (5.1%) were admitted to the hospital, of whom 170 (11.3%) presented with a maximum DOW, with a crude odds ratio (OR) for hospitalization of 6.1 (95% confidence interval (CI) 3.9 to 9.6) compared to minimum DOW. Estimates showed dose-response relationship between DOW and hospitalization. In the fully adjusted model, the ORs decreased to 3.1 (95%CI 2.0 to 5.0) for DOW = 5, 3.2 (2.0 to 5.0) for DOW = 4, 1.6 (1.0 to 2.6) for DOW = 3 and 0.8 (0.5 to 1.4) for DOW = 2 compared to minimum DOW.

Conclusion

Patients’ self-assessment of illness severity as DOW was associated with subsequent hospital admission. Further, it may be beneficial in supporting clinical decision making in telephone triage. Finally, it might be useful as a measure to facilitate patient participation in the triage process.

Validity of the French version of the Autonomy Preference Index and its adaptation for patients with advanced cancer

BACKGROUND

While patient-centered care is recommended as a key dimension for quality improvement, in case of serious illness, patients may have different expectations regarding information and participation in medical decision-making. In oncology, anticipation of disease worsening remains difficult, especially when patient's preferences towards prognosis medical information are unclear. Valid tools to explore patients' preferences could help targeting end-of-life discussions, which have been shown to decrease aggressiveness of end-of-life care. Our aim was to establish the validity and reliability of the French version of the Autonomy Preference Index (API) among patients with incurable cancer and in primary care setting. Three supplementary items were specifically developed to evaluate preparedness to anticipate disease deterioration among patients with incurable cancer.

METHODS

The psychometric properties of the API translated into French were assessed among patients consecutively recruited from January to March 2017 in the waiting rooms of 19 general practitioners (N = 391) and in an oncology (N = 187) clinic in Paris. Relationships between the newly-developed items and the API subscale scores were studied.

RESULTS

A three correlated factors confirmatory model (two factors related to decision-making and a factor related to information-seeking preferences) showed an acceptable fit on the whole sample and no measurement invariance issue was found across settings, age, sex and educational level. Internal consistency and test-retest reliability were acceptable for the information-seeking and decision-making subscales. One of the newly-developed items on patients' ability to anticipate a decision on the use of artificial respiration if a sudden deterioration of their illness occurred was not related to the API subscale scores.

CONCLUSION

The French version of the API was found valid and reliable for use in general practice and oncology settings. The additional items on patient preparedness to anticipate disease deterioration can be of interest to ensure that patient values guide all end-of-life clinical decisions.

A patient's decision aid for vascular access placement in the emergency department

BACKGROUND

Vascular access device placement is one of the most routinely performed procedures in the emergency department. Despite its high usage, most patients have limited knowledge about vascular access device placement. Patient decision aids have been utilized heavily in non-emergency department settings to provide basic clinical information regarding a patient's medical care options. In this study, we investigated whether exposure to a patient decision aid on vascular access devices and patients' experiences with vascular access devices would influence their vascular access device preference during an acute care episode.

METHODS

Patients in this institutional review board-approved study were enrolled prospectively in the emergency department at a busy level 1 trauma institution. A patient decision aid on vascular access device was constructed using criteria developed by the International Patient Decision Aid Standards. All participants were exposed to the patient decision aid and were asked to complete two questionnaires, and two tests.

RESULTS

Fifty subjects (50) were enrolled prospectively in the emergency department. The mean pretest score was 17.2% (95% confidence interval, 0.54-1.18), while the mean post-test score was 72.4% (95% confidence interval, 3.15-4.09). We found that patients who were exposed to the patient decision aid preferred landmark-based peripheral intravenous lines over ultrasound-guided peripheral intravenous lines in this data set.

CONCLUSION

The result from this analysis indicated that most patients visiting the emergency department are not knowledgeable about their options related to vascular access device placement. The observed increase in the average correct responses on the post-test indicates that a patient decision aid can be an effective educational tool in the emergency department.

Patient Preferences Regarding Shared Decision Making in the Emergency Department: Findings From a Multisite Survey

OBJECTIVES

As shared decision making (SDM) has received increased attention as a method to improve the patient-centeredness of emergency department (ED) care, we sought to determine patients' desired level of involvement in medical decisions and their perceptions of potential barriers and facilitators to SDM in the ED.

METHODS

We surveyed a cross-sectional sample of adult ED patients at three academic medical centers across the United States. The survey included 32 items regarding patient involvement in medical decisions including a modified Control Preference Scale and questions about barriers and facilitators to SDM in the ED. Items were developed and refined based on prior literature and qualitative interviews with ED patients. Research assistants administered the survey in person.

RESULTS

Of 797 patients approached, 661 (83%) agreed to participate. Participants were 52% female, 45% white, and 30% Hispanic. The majority of respondents (85%-92%, depending on decision type) expressed a desire for some degree of involvement in decision making in the ED, while 8% to 15% preferred to leave decision making to their physician alone. Ninety-eight percent wanted to be involved with decisions when "something serious is going on." The majority of patients (94%) indicated that self-efficacy was not a barrier to SDM in the ED. However, most patients (55%) reported a tendency to defer to the physician's decision making during an ED visit, with about half reporting they would wait for a physician to ask them to be involved.

CONCLUSION

We found that the majority of ED patients in our large, diverse sample wanted to be involved in medical decisions, especially in the case of a "serious" medical problem, and felt that they had the ability to do so. Nevertheless, many patients were unlikely to actively seek involvement and defaulted to allowing the physician to make decisions during the ED visit. After fully explaining the consequences of a decision, clinicians should make an effort to explicitly ascertain patients' desired level of involvement in decision making.

Addressing overuse in emergency medicine: evidence of a role for greater patient engagement

Overuse of health care refers to tests, treatments, and even health care settings when used in circumstances where they are unlikely to help. Overuse is not only wasteful, it threatens patient safety by exposing patients to a greater chance of harm than benefit. It is a widespread problem and has proved resistant to change. Overuse of diagnostic testing is a particular problem in emergency medicine. Emergency physicians cite fear of missing a diagnosis, fear of law suits, and perceived patient expectations as key contributors. However, physicians' assumptions about what patients expect are often wrong, and overlook two of patients' most consistently voiced priorities: communication and empathy. Evidence indicates that patients who are more fully informed and engaged in their care often opt for less aggressive approaches. Shared decision making refers to (1) providing balanced information so that patients understand their options and the trade-offs involved, (2) encouraging them to voice their preferences and values, and (3) engaging them-to the extent appropriate or desired-in decision making. By adopting this approach to discretionary decision making, physicians are better positioned to address patients' concerns without the use of tests and treatments patients neither need nor value.

Shared Decisionmaking in the Emergency Department: A Guiding Framework for Clinicians

Shared decisionmaking has been proposed as a method to promote active engagement of patients in emergency care decisions. Despite the recent attention shared decisionmaking has received in the emergency medicine community, including being the topic of the 2016 Academic Emergency Medicine Consensus Conference, misconceptions remain in regard to the precise meaning of the term, the process, and the conditions under which it is most likely to be valuable. With the help of a patient representative and an interaction designer, we developed a simple framework to illustrate how shared decisionmaking should be approached in clinical practice. We believe it should be the preferred or default approach to decisionmaking, except in clinical situations in which 3 factors interfere. These 3 factors are lack of clinical uncertainty or equipoise, patient decisionmaking ability, and time, all of which can render shared decisionmaking infeasible. Clinical equipoise refers to scenarios in which there are 2 or more medically reasonable management options. Patient decisionmaking ability refers to a patient's capacity and willingness to participate in his or her emergency care decisions. Time refers to the acuity of the clinical situation (which may require immediate action) and the time that the clinician has to devote to the shared decisionmaking conversation. In scenarios in which there is only one medically reasonable management option, informed consent is indicated, with compassionate persuasion used as appropriate. If time or patient capacity is lacking, physician-directed decisionmaking will occur. With this framework as the foundation, we discuss the process of shared decisionmaking and how it can be used in practice. Finally, we highlight 5 common misconceptions in regard to shared decisionmaking in the ED. With an improved understanding of shared decisionmaking, this approach should be used to facilitate the provision of high-quality, patient-centered emergency care.

Predicting the preferences for involvement in medical decision making among patients with mental disorders

BACKGROUND

The involvement of patients in medical decision making has been investigated widely in somatic diseases. However, little is known about the preferences for involvement and variables that could predict these preferences in patients with mental disorders.

OBJECTIVE

This study aims to determine what roles mentally ill patients actually want to assume when making medical decisions and to identify the variables that could predict this role, including patients' self-efficacy.

METHOD

Demographic and clinical data of 798 patients with mental disorders from three psychotherapeutic units in Germany were elicited using self-report questionnaires. Control preference was measured using the Control Preferences Scale, and patients' perceived self-efficacy was assessed using the Self-Efficacy Scale. Bivariate and multivariate regression analyses were conducted to investigate the associations between patient variables and control preference.

RESULTS

Most patients preferred a collaborative role (57.5%), followed by a semi passive (21.2%), a partly autonomous (16.2%), an autonomous (2.8%) and a fully passive (2.3%) role when making medical decisions. Age, sex, diagnosis, employment status, medical pretreatment and perceived self-efficacy were associated with the preference for involvement in the multivariate logistic model.

CONCLUSION

Our results confirm the preferences for involvement in medical decisions of mentally ill patients. We reconfirmed previous findings that older patients prefer a shared role over an autonomous role and that subjects with a high qualification prefer a more autonomous role over a shared role. The knowledge about predictors may help strengthen treatment effectiveness because matching the preferred and actual role preferences has been shown to improve clinical outcome.

Understanding Overuse of Computed Tomography for Minor Head Injury in the Emergency Department: A Triangulated Qualitative Study

BACKGROUND

Overuse of computed tomography (CT) for minor head injury continues despite developed and rigorously validated clinical decision rules like the Canadian CT Head Rule (CCHR). Adherence to this sensitive and specific rule could decrease the number of CT scans performed in minor head injury by 35%. But in practice, the CCHR has failed to reduce testing, despite its accurate performance.

OBJECTIVES

The objective was to identify nonclinical, human factors that promote or inhibit the appropriate use of CT in patients presenting to the emergency department (ED) with minor head injury.

METHODS

This was a qualitative study in three phases, each with interview guides developed by a multidisciplinary team. Subjects were recruited from patients treated and released with minor head injuries and providers in an urban academic ED and a satellite community ED. Focus groups of patients (four groups, 22 subjects total) and providers (three groups, 22 subjects total) were conducted until thematic saturation was reached. The findings from the focus groups were triangulated with a cognitive task analysis, including direct observation in the ED (>150 hours), and individual semistructured interviews using the critical decision method with four senior physician subject matter experts. These experts are recognized by their peers for their skill in safely minimizing testing while maintaining patient safety and engagement. Focus groups and interviews were audio recorded and notes were taken by two independent note takers. Notes were entered into ATLAS.ti and analyzed using the constant comparative method of grounded theory, an iterative coding process to determine themes. Data were double-coded and examined for discrepancies to establish consensus.

RESULTS

Five core domains emerged from the analysis: establishing trust, anxiety (patient and provider), constraints related to ED practice, the influence of others, and patient expectations. Key themes within these domains included patient engagement, provider confidence and experience, ability to identify and manage patient anxiety, time constraints, concussion knowledge gap, influence of health care providers, and patient expectations to get a CT.

CONCLUSIONS

Despite high-quality evidence informing use of CT in minor head injury, multiple factors influence the decision to obtain CT in practice. Identifying and disseminating approaches and designing systems that help clinicians establish trust and manage uncertainty within the ED context could optimize CT use in minor head injury.

The Role of Patient Activation in Preferences for Shared Decision Making: Results From a National Survey of U.S. Adults

Studies investigating preferences for shared decision making (SDM) have focused on associations with sociodemographic variables, with few investigations exploring patient factors. We aimed to investigate the relationship between patient activation and preferences for SDM in 6 common medical decisions among a nationally representative cross-sectional survey of American adults. Adults older than 18 were recruited online (n = 2,700) and by telephone (n = 700). Respondents completed sociodemographic assessments and the Patient Activation Measure. They were also asked whether they perceived benefit (yes/no) in SDM in 6 common medical decisions. Nearly half of the sample (45.9%) reached the highest level of activation (Level 4). Activation was associated with age (p < .001), higher income (p = .001), higher education (p = .010), better self-rated health (p < .001), and fewer chronic conditions (p = .050). The proportion of people who agreed that SDM was beneficial varied from 53.1% (deciding the necessity of a diagnostic test) to 71.8% (decisions associated with making lifestyle changes). After we controlled for participant characteristics, higher activation was associated with greater perceived benefit in SDM across 4 of the 6 decisions. Preferences for SDM varied among 6 common medical scenarios. Low patient activation is an important barrier to SDM that could be ameliorated through the development of behavioral interventions.

Emergency physician perceptions of shared decision-making

OBJECTIVES

Despite the potential benefits of shared decision-making (SDM), its integration into emergency care is challenging. Emergency physician (EP) perceptions about the frequency with which they use SDM, its potential to reduce medically unnecessary diagnostic testing, and the barriers to employing SDM in the emergency department (ED) were investigated.

METHODS

As part of a larger project examining beliefs on overtesting, questions were posed to EPs about SDM. Qualitative analysis of two multispecialty focus groups was done exploring decision-making around resource use to generate survey items. The survey was then pilot-tested and revised to focus on advanced diagnostic imaging and SDM. The final survey was administered to EPs recruited at four emergency medicine (EM) conferences and 15 ED group meetings. This report addresses responses regarding SDM.

RESULTS

A purposive sample of 478 EPs from 29 states were approached, of whom 435 (91%) completed the survey. EPs estimated that, on average, multiple reasonable management options exist in over 50% of their patients and reported employing SDM with 58% of such patients. Respondents perceived SDM as a promising solution to reduce overtesting. However, despite existing research to the contrary, respondents also commonly cited beliefs that 1) "many patients prefer that the physician decides," 2) "when offered a choice, many patients opt for more aggressive care than they need," and 3) "it is too complicated for patients to know how to choose."

CONCLUSIONS

Most surveyed EPs believe SDM is a potential high-yield solution to overtesting, but many perceive patient-related barriers to its successful implementation.

Emergency physician perceptions of medically unnecessary advanced diagnostic imaging

OBJECTIVES

The objective was to determine emergency physician (EP) perceptions regarding 1) the extent to which they order medically unnecessary advanced diagnostic imaging, 2) factors that contribute to this behavior, and 3) proposed solutions for curbing this practice.

METHODS

As part of a larger study to engage physicians in the delivery of high-value health care, two multispecialty focus groups were conducted to explore the topic of decision-making around resource utilization, after which qualitative analysis was used to generate survey questions. The survey was extensively pilot-tested and refined for emergency medicine (EM) to focus on advanced diagnostic imaging (i.e., computed tomography [CT] or magnetic resonance imaging [MRI]). The survey was then administered to a national, purposive sample of EPs and EM trainees. Simple descriptive statistics to summarize physician responses are presented.

RESULTS

In this study, 478 EPs were approached, of whom 435 (91%) completed the survey; 68% of respondents were board-certified, and roughly half worked in academic emergency departments (EDs). Over 85% of respondents believe too many diagnostic tests are ordered in their own EDs, and 97% said at least some (mean = 22%) of the advanced imaging studies they personally order are medically unnecessary. The main perceived contributors were fear of missing a low-probability diagnosis and fear of litigation. Solutions most commonly felt to be "extremely" or "very" helpful for reducing unnecessary imaging included malpractice reform (79%), increased patient involvement through education (70%) and shared decision-making (56%), feedback to physicians on test-ordering metrics (55%), and improved education of physicians on diagnostic testing (50%).

CONCLUSIONS

Overordering of advanced imaging may be a systemic problem, as many EPs believe a substantial proportion of such studies, including some they personally order, are medically unnecessary. Respondents cited multiple complex factors with several potential high-yield solutions that must be addressed simultaneously to curb overimaging.

The collaborative autonomy model of medical decision-making

While the bioethical principle of beneficence originated in antiquity, the ascension of autonomy, or "self-rule," has redefined the physician-patient relationship to the extent that autonomy often dominates medical decision-making. Philosophical and social movements, medical research atrocities, consumerism, and case law have all had their influence on this paradigm shift. Consequently, the contemporary physician encounters an uncertainty in medical practice on how to resolve conflicts that arise in the pursuit of valuing both autonomy and beneficence. This is especially true in the practice of neurologic critical care where physicians may be advising comfort care measures for neurologically devastated patients while surrogates request physiologically futile interventions. This conundrum has been an important subject of the bioethics and social science literature but often this discourse is not disseminated to the clinicians confronting these issues. The purpose of this essay is to present a history of the principles of autonomy and beneficence and then present a shared medical decision-making model, collaborative autonomy, to provide guidance to neurologic critical care providers in how to resolve such dilemmas. Clinical vignettes will help illustrate the model.

Are GP patients' needs being met? Unfulfilled information needs among native-Dutch and Turkish-Dutch patients

OBJECTIVE

This study aims to assess unfulfilled information needs of native-Dutch and Turkish-Dutch general practitioner (GP) patients in the Netherlands. In addition, the relation between perceived and recorded information provision by GPs is studied.

METHODS

Unfulfilled information needs of native-Dutch (N=117) and Turkish-Dutch patients (N=74) were assessed through pre- and post-consultation questionnaires. Audiotapes of GP consultations were made to code GPs' information provision.

RESULTS

Turkish-Dutch patients experience more unfulfilled information needs than native-Dutch patients, in particular those who identify equally with Dutch and Turkish culture. Overall, perceived information provision is hardly related to recorded information provision.

CONCLUSION

GPs insufficiently provide Turkish-Dutch patients and, to a lesser extent, native-Dutch patients as well, the information they need.

PRACTICE IMPLICATIONS

GPs should be trained in giving adequate, tailored information to patients with various ethnic and cultural backgrounds.

Engaging patients in health care decisions in the emergency department through shared decision-making: a systematic review

BACKGROUND

Many decisions in the emergency department (ED) may benefit from patient involvement, even though this setting has been considered least conducive to shared decision-making (SDM).

OBJECTIVES

The objective was to conduct a systematic review to evaluate the approaches, methods, and tools used to engage patients or their surrogates in SDM in the ED.

METHODS

Five electronic databases were searched in conjunction with contacting content experts, reviewing selected bibliographies, and conducting citation searches using the Web of Knowledge database. Two reviewers independently selected eligible studies that addressed patient involvement and engagement in decision-making in the ED setting via the use of decision support interventions (DSIs), defined as decision aids or decision support designed to communicate probabilistic information on the risks and benefits of treatment options to patients as part of an SDM process. Eligible studies described and assessed at least one of the following outcomes: patient knowledge, experiences and perspectives on participating in treatment or management decisions, clinician or patient satisfaction, preference for involvement and/or degree of engagement in decision-making and treatment preferences, and clinical outcomes (e.g., rates of hospital admission/readmission, rates of medical or surgical interventions). Two reviewers extracted data on study characteristics, methodologic quality, and outcomes. The authors also assessed the extent to which SDM interventions adhered to good practice for the presentation of information on outcome probabilities (eight probability items from the International Patient Decision Aid Standards Instrument [IPDASi]) and had comprehensive development processes.

RESULTS

Five studies met inclusion criteria and were synthesized using a narrative approach. Each study was of satisfactory methodologic quality and used a DSI to engage patients or their surrogates in decision-making in the ED across four domains: 1) management options for children with small lacerations; 2) options for rehydrating children presenting with vomiting or diarrhea or both; 3) risk of bacteremia (and associated complications), tests, and treatment options for febrile children; and 4) short-term risk of acute coronary syndrome (ACS) in adults with low-risk nontraumatic chest pain. Three studies had poor IPDASi probabilities and development process scores and lacked development informed by theory or involvement of clinicians and patients in development and usability testing. Overall, DSIs were associated with improvements in patients' knowledge and satisfaction with the explanation of their care, preferences for involvement, and engagement in decision-making and demonstrated utility for eliciting patients' preferences and values about management and treatment options. Two computerized DSIs (designed to predict risk of ACS in adults presenting to the ED with chest pain) were shown to reduce health care use without evidence of harm. None of the studies reported lack of feasibility of SDM in the ED.

CONCLUSIONS

Early investigation of SDM in the ED suggests that patients may benefit from involvement in decision-making and offers no empirical evidence to suggest that SDM is not feasible. Future work is needed to develop and test additional SDM interventions in the ED and to identify contextual barriers and facilitators to implementation in practice.

Emergency department triage: an ethical analysis

Background

Emergency departments across the globe follow a triage system in order to cope with overcrowding. The intention behind triage is to improve the emergency care and to prioritize cases in terms of clinical urgency.

Discussion

In emergency department triage, medical care might lead to adverse consequences like delay in providing care, compromise in privacy and confidentiality, poor physician-patient communication, failing to provide the necessary care altogether, or even having to decide whose life to save when not everyone can be saved. These consequences challenge the ethical quality of emergency care. This article provides an ethical analysis of "routine" emergency department triage. The four principles of biomedical ethics - viz. respect for autonomy, beneficence, nonmaleficence and justice provide the starting point and help us to identify the ethical challenges of emergency department triage. However, they do not offer a comprehensive ethical view. To address the ethical issues of emergency department triage from a more comprehensive ethical view, the care ethics perspective offers additional insights.

Summary

We integrate the results from the analysis using four principles of biomedical ethics into care ethics perspective on triage and propose an integrated clinically and ethically based framework of emergency department triage planning, as seen from a comprehensive ethics perspective that incorporates both the principles-based and care-oriented approach.

Can patients' preferences for involvement in decision-making regarding the use of medicines be predicted?

OBJECTIVE

The current study aimed to develop a model of patients' preferences for involvement in decision-making concerning the use of medicines for chronic conditions in the UK and test it in a large representative sample of patients with one of two clinical conditions.

METHODS

Following a structured literature review, an instrument was developed which measured the variables that had been identified as predictors of patients' preferences for involvement in decision making in previous research. Five hundred and sixteen patients with rheumatoid arthritis or type 2 diabetes were recruited from outpatient and primary care clinics and asked to complete the instrument.

RESULTS

Multivariate analysis revealed that age, social class and clinical condition were associated with preferences for involvement in decision-making concerning the use of medicines for chronic illness but gender, ethnic group, concerns about medicines, beliefs about necessity of medicines, health status, quality of life and time since diagnosis were not. In total, the fitted model explained only 14% of the variance.

CONCLUSION

This study has demonstrated that current research does not provide a basis for predicting patients' preferences for involvement in decision-making.

PRACTICE IMPLICATIONS

Building concordant relationships may depend on practitioners developing strategies to establish individuals' preferences for involvement in decision-making as part of the ongoing prescriber-patient relationship.

Medical information and surrogate designation: results of a prospective study in elderly hospitalised patients

OBJECTIVES

To determine the preferences of French elderly inpatients concerning medical information and surrogate designation in life-threatening situations.

METHODS

Intention-to-act questionnaire was completed by two geriatricians during a patient interview in the week following admission in three geriatric units in France. The participants were elderly patients (> or =70 years) with adequate cognitive performance for decision making as assessed by the Mini Mental State Examination. The impact of socio-demographic factors, level of confidence in medical care, cognitive or physical disability on surrogate designation and amount of medical information expected were measured.

MEASUREMENTS

Impact of socio-demographic factors, level of confidence in medical care, cognitive or physical disability on surrogate designation and amount of medical information expected.

RESULTS

426 consecutive elderly patients were recruited. 32.6% wanted to receive complete information about their care and 77% declared they would want to be informed if they were in a life-threatening situation. 4.5% reported they would not want any medical information. A family member was designated as surrogate by 73% of the patients. In 28%, a second surrogate was also designated, usually the family physician (22%) or a member of the hospital medical staff (10%). Polytomous logistic regression analysis was used to assess determinants of the amount of information expected and social and medical parameters. MMSE score, the presence of physical disability, a low level of confidence in medicine and the presence of children were identified as independent determinants of a high level of information expectation.

CONCLUSION

Elderly hospitalised patients expressed a strong desire to receive extensive information and were willing to designate a surrogate in a life-threatening situation. The surrogate was usually a family member alone or with another person, usually a practitioner.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

PRACTICE IMPLICATIONS

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

Information and participation preferences of dental patients

Dutch dentists have a moral and legal obligation to inform their patients and involve them in the decision-making process. It is unclear, though, to what extent patients prefer information and involvement in decision-making. Therefore, the aim of this study was to determine levels of preference for information and participation in decision-making among emergency patients (n = 96) and regular patients (n = 245). It was hypothesized that female gender, higher education, younger age, and a monitoring coping style are positively associated with higher preferences for information and participation. The results demonstrated that emergency and regular patients have high preferences for information, but that their preferences for actual involvement are significantly lower. Only weak associations were found between the antecedent variables and patients' preferences. It is concluded that, in the study of the etiology of patients' preferences for information and participation, future research should incorporate factors such as dental anxiety and seriousness of the dental condition.

Self-Determination in Surgical Patients in Five European Countries

OBJECTIVE

To analyze the effects of informational support, desire for behavioral involvement in health decision-making (behavioral involvement), opportunities to make decisions, and independence on subjective health status in surgical patients. A theoretical model of self-determination was applied and tested.

METHODS

The data were collected by structured questionnaires with a sample of 1,454 surgical patients in five European countries. LISREL analyses were used to test the theoretical causal model of self-determination.

RESULTS

Patients' perceptions of informational support received from nursing professionals and their desired involvement in health decision-making affected patients' opportunities to make decisions and further their independence level, which in turn affected patients' subjective health status.

CONCLUSIONS

Understanding of factors that increase self-determination in patients can help health care professionals to promote patients' well-being.

The phenomena of participation and non-participation in health care--experiences of patients attending a nurse-led clinic for chronic heart failure

BACKGROUND

Patient participation is stressed in the health care acts of many western countries yet a common definition of the concept is lacking. The understanding of experiences of patients with chronic heart failure (CHF) who attend nurse-led specialist clinics, a form of care suggested as beneficiary to this group, may promote a better understanding of participation.

AIM

To investigate the meanings of participation and non-participation as experienced by patients living with CHF.

METHODS

Narrative interviews analysed in the phenomenological hermeneutic tradition inspired by Ricoeur where the interpretation is made in the hermeneutic circle, explaining and understanding the experienced phenomena.

FINDINGS

Participation was experienced as to "be confident", "comprehend" and "seek and maintain a sense of control". Non-participation was experienced as to "not understand", "not be in control", "lack a relationship" and "not be accountable". The findings indicate that the experiences of participation and non-participation can change over time and phases of the disease and treatment.

CONCLUSION

The study suggests an extended view on the concept of participation. Patients' experiences of participation in health care can vary and should therefore be an issue for dialogue between nurses and patients with CHF in nurse-led specialist clinics.

Patient participation during dental consultations: the influence of patients' characteristics and dentists' behavior

OBJECTIVE

This study examined the influence of the following variables on patients' information-seeking and participating behavior during emergency treatment: patients' preferences for information and participation, patients' coping style, patients' socio-demographic variables, and dentists' communicative behavior.

METHODS

The sample consisted of 83 patients receiving emergency care from 13 different dentists. Consultations were videotaped in order to assess dentists' and patients' behavior. Dentists' communicative behavior was coded by means of the Communication in Dental Settings Scale (CDSS); scores for patients' behavior included the number and nature of questions asked during the consultation, attempts to offer diagnoses, and whether or not patients made the decision to undergo treatment themselves. At home, patients filled out a questionnaire that included scales to measure their preference for information and participation and other background variables.

RESULTS

Results showed that patients' desire for information and participation, together with other variables, was not reflected in their overt behavior. Furthermore, dentists' communicative behavior was unrelated to patients' information-seeking and participating behavior.

CONCLUSIONS

Scores on the CDSS show that still there is a discrepancy between the legal prerequisites of information-giving and emergency dental practice. Therefore, dentists' information-giving behavior should be improved in order to enhance the patients' right to make informed decisions.

Information needs of patients with cancer: results from a large study in UK cancer centres

As part of a multi-centred study evaluating a communication skills training model for clinicians, we collected information preferences using an adaptation of Cassileth's Information Needs questionnaire from a heterogeneous sample of 2331 patients. Results showed that 87% (2027) wanted all possible information, both good and bad news and 98% (2203) preferred to know whether or not their illness was cancer. Cross tabulation of responses revealed no significant differences in information preferences for tumour site or treatment aims but did show an effect of age and sex. The few 58/440 (13.2%) patients who stated that in general they preferred to leave disclosure of details up to the doctor, tended to be older patients more than 70 years of age (chi square = 26.01, df = 2, P< 0.0001), although paradoxically they still wanted to know certain specific details. In comparison to men women preferred to know the specific name of the illness (chi square = 4.9, df = 1, P< 0.02) and what were all the possible treatments (chi square = 8.26, df = 1, P< 0.004). The results from this very large sample provide conclusive evidence that the vast majority of patients with cancer want a great deal of specific information concerning their illness and treatment. Failure to disclose such information on the grounds that significant numbers of patients prefer not to know is untenable.