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Rodenbach RA, Thordardottir T, Brauer M, Hall AC, Ward E, Smith CB, Campbell TC. Balancing risks and rewards: How hematologists discuss uncertainty in allogeneic hematopoietic cell transplantation outcomes. PATIENT EDUCATION AND COUNSELING 2024; 123:108177. [PMID: 38341898 PMCID: PMC10997451 DOI: 10.1016/j.pec.2024.108177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 01/11/2024] [Accepted: 01/26/2024] [Indexed: 02/13/2024]
Abstract
OBJECTIVE Allogeneic hematopoietic cell transplant (alloHCT) offers many patients with blood cancers a chance of cure but carries risks. We characterized how hematologists discuss the high-risk, high-reward concept of alloHCT. METHODS Qualitative analysis of video-recorded virtual encounters of hematologists who routinely perform alloHCT with actors portraying an older man recently diagnosed with high-risk myelodysplastic syndrome. RESULTS Hematologists (n = 37) were a median age of 44 years, 65% male, and 68% white. They frequently used "teeter-totter" language that juxtaposed alloHCT's risks and rewards in a dynamic, quickly alternating fashion and communicated uncertainty in transplant outcomes. This dialogue oscillated between encouragement about alloHCT's potential for cure and caution about its risks and occurred within single speech turns and in exchanges between hematologist and patient. Fewer hematologists outlined their big-picture stance on transplant's risks and benefits early in the conversation. Meanwhile, hematologists varied in how they counseled patients to manage transplant-related uncertainty and consider treatment decision making. CONCLUSION Hematologists use "teeter-totter" language to express hope and concern, confidence and uncertainty, and encouragement and caution about the high-risk, high-reward nature of alloHCT. PRACTICE IMPLICATIONS Teeter-totter language may help frame big-picture content about alloHCT's risks and benefits that is essential for patient education and decision making.
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Affiliation(s)
| | | | - Markus Brauer
- University of Wisconsin Department of Psychology, Madison, WI, USA
| | - Aric C Hall
- University of Wisconsin Carbone Cancer Center, Madison, WI, USA
| | - Earlise Ward
- University of Wisconsin Carbone Cancer Center, Madison, WI, USA; University of Wisconsin School of Medicine and Public Health, Department of Family Medicine and Community Health, Madison, WI, USA
| | | | - Toby C Campbell
- University of Wisconsin Carbone Cancer Center, Madison, WI, USA
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Rodenbach RA, Thordardottir T, Brauer M, Hall AC, Ward E, Smith CB, Campbell TC. Communication Strategies of Transplant Hematologists in High-Risk Decision-Making Conversations. JCO Oncol Pract 2024; 20:538-548. [PMID: 38241601 DOI: 10.1200/op.23.00574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/06/2023] [Accepted: 12/08/2023] [Indexed: 01/21/2024] Open
Abstract
PURPOSE Shared decision making (SDM) is essential to empower patients with blood cancers to make goal-concordant decisions about allogeneic hematopoietic cell transplantation. This study characterizes communication strategies used by hematologists to discuss treatment options and facilitate SDM with patients in this high-risk, high-reward setting. METHODS AND MATERIALS We recruited US hematologists who routinely perform allogeneic hematopoietic cell transplant through email. Participants conducted up to an hour-long video-recorded encounter with an actor portraying a 67-year-old man with recently diagnosed high-risk myelodysplastic syndrome. We transcribed and qualitatively analyzed video-recorded data. RESULTS The mean age of participants (N = 37) was 44 years, 65% male, and 68% White. Many hematologists included similar key points in this initial consultation, although varied in how much detail they provided. Their discussion of treatment options included transplant and chemotherapy and less commonly supportive care or clinical trials. They often emphasized transplant's potential for cure, discussed transplant chronologically from pretransplant considerations through the post-transplant course, and outlined risks, complications, and major outcomes. Hematologists referred to several elements that formed the basis of treatment decision making. The strength of their treatment recommendations ranged from strong recommendations for transplant or chemotherapy to deferrals pending more information. Hematologists also varied in the extent to which they indicated the decision was physician-driven, patient-led, or shared. CONCLUSION The transplant decision-making discussion is complex. Identification of similar content areas used by hematologists can be used as the basis for a communication tool to help hematologists discuss allogeneic hematopoietic cell transplant with patients.
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Affiliation(s)
- Rachel A Rodenbach
- University of Wisconsin Carbone Cancer Center, Madison, WI
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | | | - Markus Brauer
- University of Wisconsin Department of Psychology, Madison, WI
| | - Aric C Hall
- University of Wisconsin Carbone Cancer Center, Madison, WI
| | - Earlise Ward
- University of Wisconsin Carbone Cancer Center, Madison, WI
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Fisher KA, Tan ASL, Matlock DD, Saver B, Mazor KM, Pieterse AH. Keeping the patient in the center: Common challenges in the practice of shared decision making. PATIENT EDUCATION AND COUNSELING 2018; 101:2195-2201. [PMID: 30144968 PMCID: PMC6376968 DOI: 10.1016/j.pec.2018.08.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/03/2018] [Accepted: 08/05/2018] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To examine situations where shared decision making (SDM) in practice does not achieve the goal of a patient-centered decision. METHODS We explore circumstances in which elements necessary to realize SDM - patient readiness to participate and understanding of the decision - are not present. We consider the influence of contextual factors on decision making. RESULTS Patients' preference and readiness for participation in SDM are influenced by multiple interacting factors including the patient's comprehension of the decision, their emotional state, the strength of their relationship with the clinician, and the nature of the decision. Uncertainty often inherent in information can lead to misconceptions and ill-formed opinions that impair patients' understanding. In combination with cognitive biases, these factors may result in decisions that are incongruent with patients' preferences. The impact of suboptimal understanding on decision making may be augmented by the context. CONCLUSIONS There are circumstances in which basic elements required for SDM are not present and therefore the clinician may not achieve the goal of a patient-centered decision. PRACTICE IMPLICATIONS A flexible and tailored approach that draws on the full continuum of decision making models and communication strategies is required to achieve the goal of a patient-centered decision.
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Affiliation(s)
- Kimberly A Fisher
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA; Meyers Primary Care Institute, A joint Endeavor Between the University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA.
| | - Andy S L Tan
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Daniel D Matlock
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA; VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO, USA
| | - Barry Saver
- Swedish Family Medicine Residency Cherry Hill, Seattle, WA, USA; Department of Family and Community Medicine, University of Massachusetts, Worcester, MA, USA
| | - Kathleen M Mazor
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA; Meyers Primary Care Institute, A joint Endeavor Between the University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA
| | - Arwen H Pieterse
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
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Abstract
The shift away from paternalistic decision-making and toward patient-centered, shared decision-making has stemmed from the recognition that in order to practice medicine ethically, health care professionals must take seriously the values and preferences of their patients. At the same time, there is growing recognition that minor and seemingly irrelevant features of how choices are presented can substantially influence the decisions people make. Behavioral economists have identified striking ways in which trivial differences in the presentation of options can powerfully and predictably affect people's choices. Choice-affecting features of the decision environment that do not restrict the range of choices or significantly alter the incentives have come to be known as "nudges." Although some have criticized conscious efforts to influence choice, we believe that clinical nudges may often be morally justified. The most straightforward justification for nudge interventions is that they help people bypass their cognitive limitations-for example, the tendency to choose the first option presented even when that option is not the best for them-thereby allowing people to make choices that best align with their rational preferences or deeply held values. However, we argue that this justification is problematic. We argue that, if physicians wish to use nudges to shape their patients' choices, the justification for doing so must appeal to an ethical and professional standard, not to patients' preferences. We demonstrate how a standard with which clinicians and bioethicists already are quite familiar-the best-interest standard-offers a robust justification for the use of nudges.
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Affiliation(s)
- Scott D. Halpern
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia PA, 19146
- Center for Health Incentives and Behavioral Economics (CHIBE), Leonard Davis Institute of Health Economics, University of Pennsylvania
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
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Saver BG, Mazor KM, Luckmann R, Cutrona SL, Hayes M, Gorodetsky T, Esparza N, Bacigalupe G. Persuasive Interventions for Controversial Cancer Screening Recommendations: Testing a Novel Approach to Help Patients Make Evidence-Based Decisions. Ann Fam Med 2017; 15:48-55. [PMID: 28376460 PMCID: PMC5217843 DOI: 10.1370/afm.1996] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 07/19/2016] [Accepted: 08/09/2016] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We wanted to evaluate novel decision aids designed to help patients trust and accept the controversial, evidence-based, US Preventive Services Task Force recommendations about prostate cancer screening (from 2012) and mammography screening for women aged 40 to 49 years (from 2009). METHODS We created recorded vignettes of physician-patient discussions about prostate cancer screening and mammography, accompanied by illustrative slides, based on principles derived from preceding qualitative work and behavioral science literature. We conducted a randomized crossover study with repeated measures with 27 men aged 50 to 74 years and 35 women aged 40 to 49 years. All participants saw a video intervention and a more traditional, paper-based decision aid intervention in random order. At entry and after seeing each intervention, they were surveyed about screening intentions, perceptions of benefits and harm, and decisional conflict. RESULTS Changes in screening intentions were analyzed without regard to order of intervention after an initial analyses showed no evidence of an order effect. At baseline, 69% of men and 86% of women reported wanting screening, with 31% and 6%, respectively, unsure. Mean change on a 3-point, yes, unsure, no scale was -0.93 (P = <.001) for men and -0.50 (P = <.001) for women after seeing the video interventions vs 0.0 and -0.06 (P = .75) after seeing the print interventions. At the study end, 33% of men and 49% of women wanted screening, and 11% and 20%, respectively, were unsure. CONCLUSIONS Our novel, persuasive video interventions significantly changed the screening intentions of substantial proportions of viewers. Our approach needs further testing but may provide a model for helping patients to consider and accept evidence-based, counterintuitive recommendations.
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Affiliation(s)
- Barry G Saver
- University of Massachusetts Medical School, Worcester, Massachusetts
- Meyers Primary Care Research Institute, Worcester, Massachusetts
- Swedish Family Medicine Residency Cherry Hill, Seattle, Washington
| | - Kathleen M Mazor
- University of Massachusetts Medical School, Worcester, Massachusetts
- Meyers Primary Care Research Institute, Worcester, Massachusetts
| | - Roger Luckmann
- University of Massachusetts Medical School, Worcester, Massachusetts
| | - Sarah L Cutrona
- University of Massachusetts Medical School, Worcester, Massachusetts
- Meyers Primary Care Research Institute, Worcester, Massachusetts
- Veterans Health Administration, HSRD COIN Edith Nourse Rogers Memorial Hospitalo, Bedford, Massachusetts
| | - Marcela Hayes
- University of Massachusetts Medical School, Worcester, Massachusetts
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Reach G. Patient education, nudge, and manipulation: defining the ethical conditions of the person-centered model of care. Patient Prefer Adherence 2016; 10:459-68. [PMID: 27103791 PMCID: PMC4829190 DOI: 10.2147/ppa.s99627] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Patient education (PE) is expected to help patients with a chronic disease to manage their lives and give them the possibility of adopting, in an appropriate manner, beneficial changes in health behaviors that are prescribed by their physicians. It is aimed at delineating, agreeing on, and implementing a patient's personal action plan and is therefore an essential constituent of the person-centered model of care. The aim of this article is to examine the idea that PE may sometimes be a manipulation that is organized for the good of patients in a paternalistic framework. Theoretically, PE differs from manipulation by addressing the reflective intelligence of patients in full light and helping them make autonomous choices. In this article, we examined some analogies between PE and nudge (ie, techniques used to push people to make good choices by organizing their environment). This analysis suggests that PE is not always as transparent and reflective as it is supposed to be and that unmasking these issues may be useful for improving the ethical quality of educational practice that must be performed in a framework of a trusting patient-doctor relationship. Under this condition, PE may sometimes represent a form of persuasion without being accused of patient deception and manipulation: trust is therefore the core of the person-centered model of care.
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Affiliation(s)
- Gérard Reach
- Department of Endocrinology, Diabetes and Metabolic Diseases, Avicenne Hospital AP-HP, Bobigny, France
- EA 3412, Centre de Recherche en Nutrition Humaine Ile-de-France (CRNH-IDF), Paris 13 University, Sorbonne Paris Cité, Bobigny, France
- Correspondence: Gérard Reach, Department of Endocrinology, Diabetes and Metabolic Diseases, Avicenne Hospital AP-HP, 125 Rue de Stalingrad, Bobigny 93000, France, Tel +33 1 4895 5158, Fax +33 1 4895 5560, Email
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Hammami MM, Al Gaai E, Hammami S, Attala S. Exploring end of life priorities in Saudi males: usefulness of Q-methodology. BMC Palliat Care 2015; 14:66. [PMID: 26611147 PMCID: PMC4661936 DOI: 10.1186/s12904-015-0064-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 11/24/2015] [Indexed: 11/29/2022] Open
Abstract
Background Quality end-of-life care depends on understanding patients’ end-of-life choices. Individuals and cultures may hold end-of-life priorities at different hierarchy. Forced ranking rather than independent rating, and by-person factor analysis rather than averaging may reveal otherwise masked typologies. Methods We explored Saudi males’ forced-ranked, end-of-life priorities and dis-priorities. Respondents (n = 120) rank-ordered 47 opinion statements on end-of-life care following a 9-category symmetrical distribution. Statements’ scores were analyzed by averaging analysis and factor analysis (Q-methodology). Results Respondents’ mean age was 32.1 years (range, 18–65); 52 % reported average religiosity, 88 and 83 % ≥ very good health and life-quality, respectively, and 100 % ≥ high school education. Averaging analysis revealed that the extreme five end-of-life priorities were to, be at peace with God, be able to say the statement of faith, maintain dignity, resolve conflicts, and have religious death rituals respected, respectively. The extreme five dis-priorities were to, die in the hospital, not receive intensive care if in coma, die at peak of life, be informed about impending death by family/friends rather than doctor, and keep medical status confidential from family/friends, respectively. Q-methodology classified 67 % of respondents into five highly transcendent opinion types. Type-I (rituals-averse, family-caring, monitoring-coping, life-quality-concerned) and Type-V (rituals-apt, family-centered, neutral-coping, life-quantity-concerned) reported the lowest and highest religiosity, respectively. Type-II (rituals-apt, family-dependent, monitoring-coping, life-quantity-concerned) and Type-III (rituals-silent, self/family-neutral, avoidance-coping, life-quality & quantity-concerned) reported the best and worst life-quality, respectively. Type-I respondents were the oldest with the lowest general health, in contrast to Type-IV (rituals-apt, self-centered, monitoring-coping, life-quality/quantity-neutral). Of the extreme 14 priorities/dis-priorities for the five types, 29, 14, 14, 50, and 36 %, respectively, were not among the extreme 20 priorities/dis-priorities identified by averaging analysis for the entire cohort. Conclusions 1) Transcendence was the extreme end-of-life priority, and dying in the hospital was the extreme dis-priority. 2) Quality of life was conceptualized differently with less emphasize on its physiological aspects. 3) Disclosure of terminal illness to family/close friends was preferred as long it is through the patient. 4) Q-methodology identified five types of constellations of end-of-life priorities and dis-priorities that may be related to respondents’ demographics and are partially masked by averaging analysis. Electronic supplementary material The online version of this article (doi:10.1186/s12904-015-0064-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Muhammad M Hammami
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia. .,Alfaisal University College of Medicine, Riyadh, Saudi Arabia.
| | - Eman Al Gaai
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia.
| | - Safa Hammami
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia.
| | - Sahar Attala
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia.
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Kelly ML, Sulmasy DP, Weil RJ. Spontaneous intracerebral hemorrhage and the challenge of surgical decision making: a review. Neurosurg Focus 2013; 34:E1. [PMID: 23634913 DOI: 10.3171/2013.2.focus1319] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Decision making for patients with spontaneous intracerebral hemorrhage (ICH) poses several challenges. Outcomes in this patient population are generally poor, prognostication is often uncertain, and treatment strategies offer limited benefits. Studies demonstrate variability in the type and intensity of treatment offered, which is attributed to clinical uncertainty and habits of training. Research has focused on new techniques and more stringent evidence-based selection criteria to improve outcomes and produce consensus around treatment strategies for patients with ICH. Such focus, however, offers little description of how ICH treatment decisions are made and how such decisions reflect patient preferences regarding medical care. A growing body of literature suggests that the process of decision making in ICH is laden with bias, value assumptions, and subjective impressions. Factors such as geography, cognitive biases, patient perceptions, and physician characteristics can all shape decision making and the selection of treatment. Such factors often serve as a barrier to providing patient-centered medical care. In this article, the authors review how surgical decision making for patients with ICH is shaped by these decisional factors and suggest future research pathways to study decision making in ICH. Such research efforts are important for establishing quality guidelines and pay-for-performance measures that reflect the preferences of individual patients and the contextual nature of medical decision making.
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Affiliation(s)
- Michael L Kelly
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Blumenthal-Barby JS, McCullough LB, Krieger H, Coverdale J. Methods of influencing the decisions of psychiatric patients: an ethical analysis. Harv Rev Psychiatry 2013; 21:275-9. [PMID: 24651560 DOI: 10.1097/hrp.0b013e3182a75d4f] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- J S Blumenthal-Barby
- From the Center for Medical Ethics & Health Policy (Drs. Blumenthal-Barby and McCullough, and Ms. Krieger) and Department of Psychiatry (Dr. Coverdale), Baylor College of Medicine
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Blumenthal-Barby JSS. On nudging and informed consent--four key undefended premises. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2013; 13:31-33. [PMID: 23641846 DOI: 10.1080/15265161.2013.781717] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Within the black box: exploring how intensivists resolve conflict at the end-of-life. Crit Care Med 2012; 40:1339-40. [PMID: 22425829 DOI: 10.1097/ccm.0b013e3182451b76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Critical care physicians' approaches to negotiating with surrogate decision makers: a qualitative study. Crit Care Med 2012; 40:1080-7. [PMID: 22080645 DOI: 10.1097/ccm.0b013e31823c8d21] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe how critical care physicians manage conflicts with surrogates about withdrawing or withholding patients' life support. DESIGN Qualitative analysis of key informant interviews with critical care physicians during 2010. We transcribed interviews verbatim and used grounded theory to code and revise a taxonomy of themes and to identify illustrative quotes. SETTING Three academic medical centers, one academic-affiliated medical center, and four private practice groups or private hospitals in a large Midwestern city SUBJECTS Fourteen critical care physicians. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Physicians reported tailoring their approach to address specific reasons for disagreement with surrogates. Five common approaches were identified: 1) building trust; 2) educating and informing; 3) providing surrogates more time; 4) adjusting surrogate and physician roles; and 5) highlighting specific values. When mistrust was an issue, physicians endeavored to build a more trusting relationship with the surrogate before readdressing decision making. Physicians also reported correcting misunderstandings by providing targeted education, and some reported highlighting specific patient, surrogate, or physician values that they hoped would guide surrogates to agree with them. When surrogates struggled with decisionmaking roles, physicians attempted to reinforce the concept of substituted judgment. Physicians noted that some surrogates needed time to "come to terms" with the patent's illness before agreeing with physicians. Many physicians had witnessed colleagues negotiate in ways they found objectionable such as providing misleading information, injecting their own values into the negotiation or behaving unprofessionally toward surrogates. Although some physicians viewed their efforts to encourage surrogates' agreement as persuasive, others strongly denied persuading surrogates and described their actions as "guiding" or "negotiating." CONCLUSIONS Physicians reported using a tailored approach to resolve decisional conflicts about life support and attempted to change surrogates' decisions in accordance with what the physician thought was in the patients' best interests. Although physicians acknowledged their efforts to change surrogates' decisions, many physicians did not perceive these efforts as persuasive.
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