Patient autonomy in chronic care: solving a paradox

Clinician communication strategies to navigate differences of opinion with patients

OBJECTIVE

We investigated communication strategies clinicians reported using to navigate differences of opinion with patients regarding medical decisions.

METHODS

Twenty physicians of various specialties participated in semi-structured interviews regarding their strategies for maintaining mutual respect when disagreeing with a patient. Reflexive thematic analysis was applied. Enrollment concluded upon theme saturation.

RESULTS

In an attempt to limit disagreements, physicians learned to gauge patient values, often deferring to clinicians being the expert on medicine and patients being the expert on themselves. Physicians noticed that disagreements were reinforced by prioritizing educational approaches. Strengthening the relationship by validating patient emotions was seen as a more effective strategy. Clinicians found it difficult to weigh relative potential for benefit to the relationship and feelings of moral distress in capitulating to patient preferences they disagreed with.

CONCLUSION

Physicians recognized the value of moving from educational to relationship building strategies to help limit and navigate disagreements. Key strategies include prioritizing gauging the patient's values and validating their emotions.

PRACTICE IMPLICATIONS

Anticipating disagreement, training clinicians to limit teaching, and instead prioritize a strong relationship to maintain trust and collaboration has the potential to improve patient health, with more limited resource use, and better experiences of care.

An Individualized Recovery Task Checklist Which Served as an Educational Instrument in a Critically Ill and Intubated COVID-19 Patient

This case involves a patient with severe COVID-19 pneumonia and massive pulmonary embolism requiring mechanical ventilation. His clinical course was complicated by delirium likely triggered by his critical illness and failed initial extubation, isolation from family, and escalating fear and desperation. In hopeful preparation for subsequent successful extubation, a unique approach was taken to decrease the risk of panic, delirium, and decompensation leading to reintubation. As a means of orienting him to his treatment pathway and to provide encouragement for continued recovery, an impromptu patient-directed checklist was constructed. The recovery checklist, written in simplified language, outlined the stages of severe illness that the patient had overcome after his emergent intubation. The list also outlined the tasks he needed to complete prior to hospital discharge. Unexpectedly, the checklist received a great deal of engagement from both the patient and medical team and played an important role in this patient’s successful recovery and rehabilitation.

Ethics codes and medical decision making

OBJECTIVE

The objective of this study is to analyze guidance about medical decision making contained in ethics codes. The primary question we address is which of the main decision-making models - informed decision making (IDM), shared decision making (SDM), or paternalism - is promoted by these codes.

METHODS

We manually searched codes of medical ethics for guidance on medical decision making. Our analysis focused on the major international code, the World Medical Association International Code of Medical Ethics (ICME), and national codes of the US, Canada, Australia, New Zealand, the UK, Ireland, Germany, France and Norway.

RESULTS

The ICME does not promote any specific model of medical decision making. 10 of the 11 analyzed national codes contain guidance about IDM, while only four refer to SDM. Some codes contain articles which are imprecise with regard to the question of medical decision making.

CONCLUSIONS

All of the analyzed national codes should be updated or amended. In particular, given the great importance of SDM in medicine, codes which do not contain relevant guidance should be updated.

PRACTICE IMPLICATIONS

Relevant amendments introduced to ethics codes could contribute to promoting of adequate standards of medical decision making (especially those regarding SDM) among doctors.

Personalization of Conversational Agent-Patient Interaction Styles for Chronic Disease Management: Two Consecutive Cross-sectional Questionnaire Studies

Background

Conversational agents (CAs) for chronic disease management are receiving increasing attention in academia and the industry. However, long-term adherence to CAs is still a challenge and needs to be explored. Personalization of CAs has the potential to improve long-term adherence and, with it, user satisfaction, task efficiency, perceived benefits, and intended behavior change. Research on personalized CAs has already addressed different aspects, such as personalized recommendations and anthropomorphic cues. However, detailed information on interaction styles between patients and CAs in the role of medical health care professionals is scant. Such interaction styles play essential roles for patient satisfaction, treatment adherence, and outcome, as has been shown for physician-patient interactions. Currently, it is not clear (1) whether chronically ill patients prefer a CA with a paternalistic, informative, interpretive, or deliberative interaction style, and (2) which factors influence these preferences.

Objective

We aimed to investigate the preferences of chronically ill patients for CA-delivered interaction styles.

Methods

We conducted two studies. The first study included a paper-based approach and explored the preferences of chronic obstructive pulmonary disease (COPD) patients for paternalistic, informative, interpretive, and deliberative CA-delivered interaction styles. Based on these results, a second study assessed the effects of the paternalistic and deliberative interaction styles on the relationship quality between the CA and patients via hierarchical multiple linear regression analyses in an online experiment with COPD patients. Patients’ sociodemographic and disease-specific characteristics served as moderator variables.

Results

Study 1 with 117 COPD patients revealed a preference for the deliberative (50/117) and informative (34/117) interaction styles across demographic characteristics. All patients who preferred the paternalistic style over the other interaction styles had more severe COPD (three patients, Global Initiative for Chronic Obstructive Lung Disease class 3 or 4). In Study 2 with 123 newly recruited COPD patients, younger participants and participants with a less recent COPD diagnosis scored higher on interaction-related outcomes when interacting with a CA that delivered the deliberative interaction style (interaction between age and CA type: relationship quality: b=−0.77, 95% CI −1.37 to −0.18; intention to continue interaction: b=−0.49, 95% CI −0.97 to −0.01; working alliance attachment bond: b=−0.65, 95% CI −1.26 to −0.04; working alliance goal agreement: b=−0.59, 95% CI −1.18 to −0.01; interaction between recency of COPD diagnosis and CA type: working alliance goal agreement: b=0.57, 95% CI 0.01 to 1.13).

Conclusions

Our results indicate that age and a patient’s personal disease experience inform which CA interaction style the patient should be paired with to achieve increased interaction-related outcomes with the CA. These results allow the design of personalized health care CAs with the goal to increase long-term adherence to health-promoting behavior.

Key Factors Associated with Adherence to Physical Exercise in Patients with Chronic Diseases and Older Adults: An Umbrella Review

Physical inactivity is a major concern and poor adherence to exercise programs is often reported. The aim of this paper was to systematically review published reviews on the study of adherence to physical exercise in chronic patients and older adults and to identify those adherence-related key factors more frequently suggested by reviews for that population. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Results were classified considering the target population and participants' characteristics to identify the most repeated factors obtained for each condition. Fifty-five articles were finally included. Fourteen key factors were identified as relevant to increase adherence to physical exercise by at least ten reviews: (a) characteristics of the exercise program, (b) involvement of professionals from different disciplines, (c) supervision, (d) technology, (e) initial exploration of participant's characteristics, barriers, and facilitators, (f) participants education, adequate expectations and knowledge about risks and benefits, (g) enjoyment and absence of unpleasant experiences, (h) integration in daily living, (i) social support and relatedness, (j) communication and feedback, (k) available progress information and monitoring, (l) self-efficacy and competence, (m) participant's active role and (n) goal setting. Therefore, adherence to physical exercise is affected by several variables that can be controlled and modified by researchers and professionals.

Deliberative and Paternalistic Interaction Styles for Conversational Agents in Digital Health: Procedure and Validation Through a Web-Based Experiment

Background

Recent years have witnessed a constant increase in the number of people with chronic conditions requiring ongoing medical support in their everyday lives. However, global health systems are not adequately equipped for this extraordinarily time-consuming and cost-intensive development. Here, conversational agents (CAs) can offer easily scalable and ubiquitous support. Moreover, different aspects of CAs have not yet been sufficiently investigated to fully exploit their potential. One such trait is the interaction style between patients and CAs. In human-to-human settings, the interaction style is an imperative part of the interaction between patients and physicians. Patient-physician interaction is recognized as a critical success factor for patient satisfaction, treatment adherence, and subsequent treatment outcomes. However, so far, it remains effectively unknown how different interaction styles can be implemented into CA interactions and whether these styles are recognizable by users.

Objective

The objective of this study was to develop an approach to reproducibly induce 2 specific interaction styles into CA-patient dialogs and subsequently test and validate them in a chronic health care context.

Methods

On the basis of the Roter Interaction Analysis System and iterative evaluations by scientific experts and medical health care professionals, we identified 10 communication components that characterize the 2 developed interaction styles: deliberative and paternalistic interaction styles. These communication components were used to develop 2 CA variations, each representing one of the 2 interaction styles. We assessed them in a web-based between-subject experiment. The participants were asked to put themselves in the position of a patient with chronic obstructive pulmonary disease. These participants were randomly assigned to interact with one of the 2 CAs and subsequently asked to identify the respective interaction style. Chi-square test was used to assess the correct identification of the CA-patient interaction style.

Results

A total of 88 individuals (42/88, 48% female; mean age 31.5 years, SD 10.1 years) fulfilled the inclusion criteria and participated in the web-based experiment. The participants in both the paternalistic and deliberative conditions correctly identified the underlying interaction styles of the CAs in more than 80% of the assessments (X²_1,88=38.2; P<.001; phi coefficient r_φ=0.68). The validation of the procedure was hence successful.

Conclusions

We developed an approach that is tailored for a medical context to induce a paternalistic and deliberative interaction style into a written interaction between a patient and a CA. We successfully tested and validated the procedure in a web-based experiment involving 88 participants. Future research should implement and test this approach among actual patients with chronic diseases and compare the results in different medical conditions. This approach can further be used as a starting point to develop dynamic CAs that adapt their interaction styles to their users.

Implementation of home blood pressure monitoring among French GPs: A long and winding road

BACKGROUND

To explore the perception of home blood pressure monitoring (HBPM) by general practitioners (GPs) in everyday practice in order to identify facilitators and barriers to its implementation in daily practice.

METHODS

A qualitative study comprising the conduct of six focus groups between October 2016 and February 2017, gathering 41 general practitioners in primary care practice in Lorraine (North Eastern France), with thematic and comprehensive analysis.

RESULTS

The first reasons given by GPs to explain their difficulties with HBPM (Home Blood Pressure Monitoring) implementation were the usual lack of time, material and human resources. However, all of these motives masked other substantial limiting factors including insufficient knowledge regarding HBPM, poor adherence to recommendations on HBPM and fear of losing their medical authority. GPs admitted that HBPM use could enhance patient observance and decrease therapeutic inertia. Despite this observation, most GPs used HBPM only at the time of diagnosis and rarely for follow-up. One explanation for GP reluctance towards HBPM may be, along with guidelines regarding hypertension, HBPM is perceived as being a binding framework and being difficult to implement. This barrier was more predominantly observed among aging GPs than in young GPs and was less frequent when GPs practiced in multidisciplinary health centers because the logistical barrier was no longer present.

DISCUSSION

In order to improve HBPM implementation in everyday practice in France, it is necessary to focus on GP training and patient education. We must also end "medical power" in hypertension management and turn to multidisciplinary care including nurses, pharmacists and patients.

What deserves our respect? Reexamination of respect for autonomy in the context of the management of chronic conditions

The global increase in patients with chronic conditions has led to increased interest in ethical issues regarding such conditions. A basic biomedical principle-respect for autonomy-is being reexamined more critically in its clinical implications. New accounts of this basic principle are being proposed. While new accounts of respect for autonomy do underpin the design of many public programs and policies worldwide, addressing both chronic disease management and health promotion, the risk of applying such new accounts to clinical setting remain understudied. However, the application of new accounts of respect for autonomy to clinical settings could support disrespectful attitudes toward or undue interference with patients with chronic conditions. Reconsidering autonomy and respect using Kantian accounts, this paper proposes respect for persons as an alternative basic bioethical principle to respect for autonomy. Unlike the principle of respect for persons in the Belmont Report, our principle involves respecting any patient's decisions, behaviors, emotions, or life-style regardless of his or her "autonomous" capabilities. Thus, attitudes toward patients should be no different irrespective of the assessment of their decisional or executive capabilities.

Physical therapists' perceptions and experiences about barriers and facilitators of therapeutic patient-centred relationships during outpatient rehabilitation: a qualitative study

BACKGROUND

Over recent years there has been a paradigm shift towards a patient-centred biopsychosocial care model in physical therapy. This new paradigm features a growing interest in understanding the contextual factors that influence the patient's experience of disease, pain and recovery. This includes generalized consensus regarding the importance of establishing a therapeutic relationship that is centred on the patient.

OBJECTIVE

To explore physical therapists' perceptions and experiences regarding barriers and facilitators of therapeutic patient-centred relationships in outpatient rehabilitation settings.

METHODS

This is a qualitative study with four focus groups including twenty-one physical therapists. Two researchers conducted the focus groups, using a topic guide with predetermined questions. The focus group discussions were audiotaped and videotaped, transcribed verbatim and analysed thematically using a modified grounded theory approach.

RESULTS

Physical therapists perceived that the therapeutic patient-centred relationship not only depends on the personal qualities of the professional, but also on the patient's attitudes and the characteristics of the context, including the organization and team coordination.

CONCLUSIONS

Although being more linked towards the patients' contextual factors and needs than towards the practice of the profession, a therapeutic relationship is worth considering by physical therapists. Furthermore this study highlights the need for physical therapists and administrators to rethink the situation and propose strategies for improvement.

The Paradox of Waiting for Heart Transplant: Between Control and Fate

OBJECTIVES

Understanding a patient's perspective has received increased attention. Awaiting heart transplant remains a great challenge, not only for patients and their families but also for health professionals. This particular challenge has multiple aspects, the most important being the psychological one. Understanding candidates for heart transplant is vital for all caregivers. In this study, our aim was to present the individual's experience of awaiting heart transplant.

MATERIALS AND METHODS

Structured interviews and the Pictorial Representation of Illness and Self Measure, Hospital Anxiety and Depression Scale, the Illness Cognition Questionnaire, and the Illness Perception Questionnaire-Revised measurements were performed in 2 male patients (60 and 61 years old) who were on heart transplant wait list.

RESULTS

The patients expressed their concerns and perceived severe consequences of heart disease. They also demonstrated the importance of significant others and hope. The results suggest the existence of realistic cognitive pictures of the disease. The patients revealed high sense of control along with the awareness of being dependent on fate. The lack of severe anxiety and depressive symptoms along with high perceived benefits' scores suggest the existence of an adaptation process.

CONCLUSIONS

Awaiting heart transplant appears to be a multidimensional phenomenon. The paradoxic configuration of a high sense of control along with the awareness of being dependent on fate was apparent. Significant others and hope seem to be of great importance. The Pictorial Representation of Illness and Self Measure allows a better understanding of a patient's perspective and allows the patient to share personal views. The individual approach provides opportunities that go far beyond routine clinical assessment.

Contextual factors affecting autonomy for patients in Iranian hospitals: A qualitative study

BACKGROUND

Consideration of patient autonomy is an essential element in individualized, patient-centered, ethical care. Internal and external factors associated with patient autonomy are related to culture and it is not clear what they are in Iran. The aim of this study was to explore contextual factors affecting the autonomy of patients in Iranian hospitals.

MATERIALS AND METHODS

This was a qualitative study using conventional content analysis methods. Thirty-four participants (23 patients, 9 nurses, and 2 doctors) from three Iranian teaching hospitals, selected using purposive sampling, participated in semi-structured interviews. Unstructured observation and filed notes were other methods for data collection. The data were subjected to qualitative content analysis and analyzed using the MAXQDA-10 software.

RESULTS

Five categories and sixteen subcategories were identified. The five main categories related to patient autonomy were: Intrapersonal factors, physical health status, supportive family and friends, communication style, and organizational constraints.

CONCLUSIONS

In summary, this study uncovered contextual factors that the care team, managers, and planners in the health field should target in order to improve patient autonomy in Iranian hospitals.

Simplistic and complex thought in medicine: the rationale for a person-centered care model as a medical revolution

According to the concept developed by Thomas Kuhn, a scientific revolution occurs when scientists encounter a crisis due to the observation of anomalies that cannot be explained by the generally accepted paradigm within which scientific progress has thereto been made: a scientific revolution can therefore be described as a change in paradigm aimed at solving a crisis. Described herein is an application of this concept to the medical realm, starting from the reflection that during the past decades, the medical community has encountered two anomalies that, by their frequency and consequences, represent a crisis in the system, as they deeply jeopardize the efficiency of care: nonadherence of patients who do not follow the prescriptions of their doctors, and clinical inertia of doctors who do not comply with good practice guidelines. It is proposed that these phenomena are caused by a contrast between, on the one hand, the complex thought of patients and doctors that sometimes escapes rationalization, and on the other hand, the simplification imposed by the current paradigm of medicine dominated by the technical rationality of evidence-based medicine. It is suggested therefore that this crisis must provoke a change in paradigm, inventing a new model of care defined by an ability to take again into account, on an individual basis, the complex thought of patients and doctors. If this overall analysis is correct, such a person-centered care model should represent a solution to the two problems of patients' nonadherence and doctors' clinical inertia, as it tackles their cause. These considerations may have important implications for the teaching and the practice of medicine.

"The others look at you as if you are a grave": a qualitative study of subjective experiences of patients with epilepsy regarding their treatment and care in Cape Town, South Africa

BACKGROUND

Existing evidence shows that the majority of people with epilepsy in lower and middle income countries are not receiving appropriate treatment and care. Although this problem has been reported as one of the factors affecting the quality of lives of people with epilepsy, very few studies have investigated patients' perspectives and their experiences about the problem. This qualitative study explored perspectives and subjective experiences of people with epilepsy about their illness in an urban township in South Africa.

METHODS

Individual face-to-face interviews included twelve people who had epilepsy. A semi-structured interview guide which was based on Kleinman (1980) Explanatory Models Framework was used to elicit participants' perspectives and subjective experiences about their illness and its treatment. Thematic analysis method was used to analyse the data.

RESULTS

The main theme reflecting participants' verbatim accounts was about their perceived difficulties affecting their access to treatment and care during their routine clinical follow up visits. These concerned rushed consultations which focussed on seizure frequency and adherence to medication with no attention to personal concerns. They perceived that part of the problem could be that some health care practitioners were not adequately trained and lacked empathy, interest, respect and listening skills. We argue that in a health system where patients feel that they are not respected and their concerns are not listened to or are ignored, they may lack trust in the system and this may violate their right to access treatment and care.

CONCLUSIONS

The findings provide a glimpse of the extent to which the power and nature of the routine task-centred system can lead to violation of patients' health rights - especially with epilepsy which is poorly understood and stigmatized. Appropriate interventions are needed to address health system factors affecting the treatment and care of this marginalized and vulnerable group of patients.

Working Together to Promote Diabetes Control: A Practical Guide for Diabetes Health Care Providers in Establishing a Working Alliance to Achieve Self-Management Support

The quality of the "patient-carer" relationship is the foundation of self-management support and has been shown to influence treatment outcome in relation to psychological and somatic illness, including diabetes. It has long been accepted within applied psychology that the quality of the client-therapist relationship--termed the working alliance--is of central importance to treatment outcome and may account for a significant degree of the overall treatment effect. Diabetes healthcare providers have recently expressed a need for further training in communication techniques and in the psychological aspects of diabetes. Could we take a page from the psychological treatment manual on working alliance in therapy to guide the diabetes healthcare provider in their role of supporting the person with diabetes achieve and maintain better metabolic control? This paper examines the role of the working alliance in diabetes care and offers a practical guide to the diabetes healthcare provider in establishing a working alliance with the person with diabetes in managing diabetes.

"Professional Helper" or "Helping Professional?" The Patient-Physician Relationship in the Chronic Pain Setting, With Special Reference to the Current Opioid Debate

There seems to be a strong cultural expectation among patients for effective pain relief. As a result, physicians often find themselves trying to bridge the gap between the chronic pain patient's expectations and harsh biomedical reality. The typology of Emanuel and Emanuel of four models for the patient-physician relationship is used in this article as a conceptual tool to examine the possible roles of physicians in the context of chronic noncancer pain. Their typology is reconceptualized as a "pathway" along which the physician is able to walk more or less far, starting from the "information" end of the path. The other end of the pathway is "caring deliberation." I then propose that, in pain medicine today, consumerism is a powerful incentive for physicians to stay at the information end of the spectrum. Against this background, I discuss the current opioid epidemic in the United States and the need for what has been called a new medical professionalism. I conclude by challenging educators involved in pain medicine continuing professional development to not only design adequate biomedical-educational programs, but also consider issues like professionalism, personal development, critical self-reflection, and the ethics of engaging in caring deliberation with chronic pain patients.

Patient education, nudge, and manipulation: defining the ethical conditions of the person-centered model of care

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.

A structuration framework for bridging the macro-micro divide in health-care governance

BACKGROUND

Extant studies demonstrate that macro (hierarchical) and micro (relational) governance initiatives in health-care settings continue to be developed in isolation rather than interactively. Government-driven hierarchical governance endeavours that guide health-care reforms and medical practice are disconnected from micro-level physician-patient interactions being unable to account for patient preferences in the macro-level policymaking.

METHOD/OBJECTIVE

We undertake a review of the recent literature to couch our argument for a unified governance framework for bridging the macro-micro divide in medical contexts. Adopting an interdisciplinary approach to health-care delivery, we maintain that the (strong) structuration theory provides a fruitful opportunity for narrowing the gap between hierarchical and relational governance.

DISCUSSION

Emphasizing the coexistence of institutional structures and human agency, the (strong) structuration theory elucidates how macro and micro governance devices shape each other's structure via mutually reinforcing cycles of influence. Micro-level encounters between patients and physicians give rise to social structures that constitute the constraining and enabling forces through which macro-level health-care infrastructures are altered and reproduced over time. Permitting to illustrate how patients' agency can effectively emerge from complex networks of clinical trajectories, the advanced structuration framework for macro-micro governance integration avoids the extremes of paternalism and autonomy through a balanced consideration of professional judgement and patient preferences.

CONCLUSION/IMPLICATIONS

The macro-micro integration of governance efforts is a critical issue in both high-income states, where medical institutions attempt to deploy substantial realignment efforts, and developing nations, which are lagging behind due to leadership weaknesses and lower levels of governmental investment. A key priority for regulators is the identification of relevant systems to support this holistic governance by providing clinicians with needed resources for focusing on patient advocacy and installing enabling mechanisms for incorporating patients' inputs in health-care reforms and policymaking.