The Framing Dilemma: Quantitative Information, Shared Decision Making, and Nudging

Information and communication priorities of patients and healthcare professionals in shared decision making regarding adjuvant systemic breast cancer treatment: A survey study

PURPOSE

To assess information and communication priorities of patients and healthcare professionals in Shared Decision Making about adjuvant systemic treatment of primary breast cancer and identify key decision-relevant information accordingly.

METHODS

Patients (N = 122) and professionals working with breast cancer patients (N = 118), of whom 38 were nurse practitioners and 32 nurses, were recruited using convenience sampling, and surveyed about information/communication aspects key to decision-making, using ranking assignments. We further posed a simple open question, questions about receiving population-based statistics versus personalized statistics concerning treatment outcomes, and their attitude and experience concerning Shared Decision Making. Data were analyzed using descriptive analysis and a qualitative analysis.

RESULTS

Both patients and professionals prioritized information about treatment outcomes (i.e., survival, recurrence) as key decision-relevant information for patients. Patients prioritized information about relatively severe treatment side-effects and late effects (e.g., blood clot, stroke), whilst professionals prioritized information about effects that occur relatively often (e.g., hair loss, fatigue). Patients specifically wanted to know if the benefit of treatment is worth the negative impact. Both groups prioritized personalized statistics over population-based statistics.

CONCLUSIONS

Some differences between patients and professionals were found in information and communication priorities, specifically related to the different side-effects. It seems worthwhile to precisely address these side-effects in Shared Decision Making concerning adjuvant systemic treatment. Furthermore, it seems important to deliberate together on the question if expected benefit of treatment is worth the potential negative impact for the individual patient.

Algorithms in medical decision-making and in everyday life: what's the difference?

Algorithms are a ubiquitous part of modern life. Despite being a component of medicine since early efforts to deploy computers in medicine, clinicians' resistance to using decision support and use algorithms to address cognitive biases has been limited. This resistance is not just limited to the use of algorithmic clinical decision support, but also evidence and stochastic reasoning and the implications of the forcing function of the electronic medical record. Physician resistance to algorithmic support in clinical decision making is in stark contrast to their general acceptance of algorithmic support in other aspects of life.

Communication of benefits and harms in shared decision making with patients with limited health literacy: A systematic review of risk communication strategies

OBJECTIVES

Risk communication (RC), as part of shared decision making, is challenging with people with limited health literacy (LHL). We aim to provide an overview of strategies to communicate benefits and harms of diagnostic and treatment options to this group.

METHODS

We systematically searched PubMed, Embase, Cinahl and PsycInfo. We included 28 studies on RC in informed/shared decision making without restriction to a health setting or condition and using a broad conceptualization of health literacy. Two researchers independently selected studies and one researcher performed data extraction. We descriptively compared findings for people with LHL towards recommendations for RC.

RESULTS

Health literacy levels varied in the included studies. Most studies used experimental designs, primarily on visual RC. Findings show verbal RC alone should be avoided. Framing of risk information influences risk perception (less risky when positively framed, riskier when negatively framed). Most studies recommended the use of icon arrays. Graph literacy should be considered when using visual RC.

CONCLUSIONS

The limited available evidence suggests that recommended RC strategies seem mainly to be valid for people with LHL, but more research is required.

PRACTICE IMPLICATIONS

More qualitative research involving people with LHL is needed to gain further in-depth insights into optimal RC strategies.

PROTOCOL REGISTRATION

PROSPERO ID 275022.

A case for preference-sensitive decision timelines to aid shared decision-making in intensive care: need and possible application

In the intensive care unit, it can be challenging to determine which interventions align with the patients' preferences since patients are often incapacitated and other sources, such as advance directives and surrogate input, are integral. Managing treatment decisions in this context requires a process of shared decision-making and a keen awareness of the preference-sensitive instances over the course of treatment. The present paper examines the need for the development of preference-sensitive decision timelines, and, taking aneurysmal subarachnoid hemorrhage as a use case, proposes a model of one such timeline to illustrate their potential form and value. First, the paper draws on an overview of relevant literature to demonstrate the need for better guidance to (a) aid clinicians in determining when to elicit patient preference, (b) support the drafting of advance directives, and (c) prepare surrogates for their role representing the will of an incapacitated patient in clinical decision-making. This first section emphasizes that highlighting when patient (or surrogate) input is necessary can contribute valuably to shared decision-making, especially in the context of intensive care, and can support advance care planning. As an illustration, the paper offers a model preference-sensitive decision timeline-whose generation was informed by existing guidelines and a series of interviews with patients, surrogates, and neuro-intensive care clinicians-for a use case of aneurysmal subarachnoid hemorrhage. In the last section, the paper offers reflections on how such timelines could be integrated into digital tools to aid shared decision-making.

Factors facilitating shared decision making in eczema: Met and unmet needs from the patient perspective

Background

Research has shown that eczema patients prefer some degree of shared control over treatment decisions, but little is known about factors perceived to be important to facilitate shared decision making (SDM).

Objective

To determine factors eczema patients and caregivers consider to be important for SDM, and how often they experience them with their eczema healthcare provider (HCP).

Methods

A cross-sectional survey study (64 questions) was conducted, which included factors related to SDM rated by respondents on a Likert scale for importance, and how often these factors were true with their current eczema HCP.

Results

Respondents (840, response rate 62.4%) most frequently rated their health literacy and communication skills as important for SDM. Factors which indicated a strong provider-patient relationship, and HCPs who initiate treatment conversations were also deemed beneficial. Low importance was placed on concordant HCP race/ethnicity, however, of those who did rate it as important, 53/91 identified as Black (half of all Black respondents).

Limitations

A high proportion of respondents were aware of the term SDM prior to the survey.

Conclusions

SDM is more likely to be facilitated when patient education and empowerment are coupled with HCPs who initiate treatment discussions, maintain compassion resilience, and listen to patient perspectives.

Investigating and Supporting Patient and Caregiver Sensemaking in Complex Medical Decisions Using Participatory Design

Background. Patients and caregivers facing complex health decisions must make sense of unfamiliar, emotionally challenging information and experiences. For patients with hematological malignancy, bone marrow transplant (BMT) may be the best chance for a cure but has significant risk of morbidity and mortality. This study aimed to investigate and support patient and caregiver sensemaking as they consider BMT. Methods. Ten BMT patients and 5 caregivers engaged in remote participatory design (PD) workshops. Participants drew timelines of their memorable experiences leading up to BMT. Then, they used transparency paper to annotate their timelines and design improvements to this process. Results. Thematic analysis of drawings and transcripts revealed a 3-phase sensemaking process. In phase 1, participants were introduced to BMT and understood it as a possibility, not an inevitability. In phase 2, they focused on meeting prerequisites including remission and donor identification. Participants came to believe they needed transplant, consequently describing BMT not as a decision between viable options, but that transplant was their "only chance" for survival. In phase 3, participants attended an orientation detailing the extensive risks of transplant, leading to anxiety and doubt. Participants designed solutions that provided reassurance to those grappling with the life-altering impacts of transplant. Conclusions. For patients and caregivers navigating complex health decisions, sensemaking is a dynamic, ongoing process that affects expectations and emotional well-being. Interventions targeting reassurance alongside risk information can alleviate emotional impact and facilitate expectation development. The integration of PD and sensemaking methodologies enables participants to create holistic, tangible representations of experiences while empowering stakeholder engagement in intervention design. This method could be applied to other complex medical contexts to understand lived experiences and develop effective support interventions.

Highlights

Bone marrow transplant patients and caregivers experienced an evolving, emotionally challenging process of gradually understanding the transplant procedure and its risks.The solutions that participants designed centered on providing reassurance alongside risk information, suggesting future interventions could target emotional support as patients attempt to meet prerequisites and grapple with the risks of the potentially curative procedure.By viewing the challenges of complex medical decisions in terms of sensemaking and applying visual methods such as participatory design, researchers can facilitate expression of the dynamic, multifaceted, emotional components of experience and empower stakeholder involvement in intervention design.

Shared decision-making in patients with multiple sclerosis

Multiple sclerosis (MS) is a chronic and progressive neurological disorder impacting physical, cognitive, and psychosocial health. The disease course, severity, and presence of symptoms differ within and between persons over time and are unpredictable. Given the preference-sensitive nature of many key decisions to be made, and the increasing numbers of disease-modifying therapies, shared decision-making (SDM) with patients seems to be key in offering optimum care and outcomes for people suffering from MS. In this paper, we describe our perspective on how to achieve SDM in patients with MS, following key SDM-elements from established SDM-frameworks. As for deliberation in the clinical encounter, SDM communication training of professionals and feedback on their current performance are key aspects, as well as encouraging patients to participate. Concerning information for patients, it is important to provide balanced, evidence-based information about the benefits and the harms of different treatment options, including the option of surveillance only. At the same time, attention is needed for the optimal dosage of that information, given the symptoms of cognitive dysfunction and fatigue among MS-patients, and the uncertainties they have to cope with. Finally, for broader communication, a system is required that assures patient preferences are actually implemented by multidisciplinary MS-teams. As SDM is also being implemented in many countries within the context of value-based health care, we consider the systematic use of outcome information, such as patient-reported outcome measures (PROMs) and Patient Decision Aids, as an opportunity to achieve SDM.