Can patients be given too much room to make own decisions?
Can patients be given too much room to make own decisions?
Needless pressure can result
If a patient has high blood pressure, prescribing medication might seem like a "no-brainer" to the physician. However, this isn't always true for the patient, according to Mary Catherine Beach, MD, MPH, core faculty at the Berman Institute of Bioethics at Johns Hopkins University in Baltimore.
"Obviously, we need to bring the patient's blood pressure down," she says. "But some patients may not want to take medication." If you give reluctant patients a prescription without asking what they think about it, they may not take the medication, says Beach.
Clarence H. Braddock III, MD, MPH, FACP, professor of medicine at Stanford (CA) University and director of clinical ethics at the Stanford Center for Biomedical Ethics, says that physicians may confuse a "shared decision-making" approach, which presents patients with various options along with the physician's recommendation, with simply asking patients what they want and giving it to them.
"The doctor may lay out options as you would with a restaurant menu, without offering any information about the relative merits of one or another," he says.
Instead of saying to a patient with high cholesterol, "You can take medication or you can work on your diet. Which would you rather do?" Braddock says that physicians should lay out the two options for the patient, and then decide together which one is best.
Using this approach, the physician might tell the patient, "Based on what I know about your situation and your risk factors, I think the best thing is to take the medication. Does that sound OK to you?"
The patient and physician can then have a conversation that leads to a decision, based on both medical considerations and the patient's values and preferences, says Braddock. "The physician is the expert on the medical stuff, and the patient is the expert on the way they want to live their life," he says.
Here are things to consider when engaging patients in medical decision making:
• The physician needs to decide how much to tell patients about risks of a particular treatment.
If the chance of an excellent outcome is 95%, but there is nevertheless a risk of death from surgery, how does the physician tell the patient there is a miniscule chance he or she might die?
"This is something that frequently troubles physicians," says John Banja, PhD, a medical ethicist at Emory University's Center for Ethics in Atlanta. "You don't want to scare the patient away by telling them everything that can possibly go wrong. That would take hours, which health professionals don't have."
• The physician needs to consider whether a particular treatment is likely to benefit the patient.
Some treatments might be available but are not worth the effort, says Banja. "If a treatment benefits only one patient out of 1000, is it reasonable to do?" he asks. "We sometimes meet up with these problems in what are called 'last chance therapies.' There are no good rules to guide us, because these cases are highly contextual."
What might be appropriate in one case isn't necessarily appropriate in another, but, nevertheless, health care providers may encounter angry, demanding family members who threaten to sue if everything isn't done for their dying loved one. "This can be very upsetting to the staff," Banja says.
• The provider may be putting too much pressure on the patient.
The trend of allowing patients more autonomy in making decisions is misinterpreted by some physicians, according to Beach.
"People do have the right to participate in decisions that are related to their health and well-being," she says. "Unfortunately, some doctors might feel like the patients have to make the decisions."
Patients may feel anxious about this because they feel they lack the information to make the right decision, she explains, and would rather be given a recommendation. "The notion of autonomy was never intended for patients to be given more responsibility than they want," she says.
At the same time, says Beach, even the most reluctant patient would probably like to have the doctor explain his or her reasoning, and say, "I think that under the circumstances, this is the best thing to do. How does that sound to you?"
• The provider probably won't be able to guess which patients want to be more involved.
Previous research done by Beach showed that doctors were not able to predict which patients wanted to be more involved in decision making.1
"We are very bad at guessing whether a patient wants to make the decision. That doesn't work very well," she says. Doctors wrongly assumed patients with lower literacy levels didn't want to be as involved in decision making, for instance, when the patient may simply have been uncomfortable using medical terminology.
If there is a decision to be made, Beach says that physicians should "lay that out for the patient. If you present options to people when those options exist, along with some guidance, I don't think that could harm anybody."
Inappropriate demands
Patients often come in demanding a particular medication before they've even been examined, says Banja, due in part to direct-to-consumer advertising. "Patients having a lot of room to make the decision implies they know a lot about what's going on," he says. "Often, they really don't know what they are asking for, because they don't know their condition all that well."
If a patient comes in asking for an antibiotic that isn't indicated, or a magnetic resonance imaging scan for knee pain, when this isn't the standard of care, says Beach, it doesn't make sense to allow the patient to make that decision.
"It's the physician's responsibility, not just to give over decision making to the patient, but, rather, to work with the patient to come up with a plan that doesn't put the patient at risk or hurt society," she says.
Always engage patients
"The patient and the physician usually have the same goal," says Beach. "They are both looking for the patient to get better, and some decisions are fairly straightforward." However, even if there is only one treatment that's appropriate, Beach says the physician should still engage the patient in decision making with "low-level participation."
"The physician could say, 'This is what I think, and this is why I think it. How does that sound?' It's just a double check that you are all on the same page," says Beach.
Patients aren't likely to have the medical expertise to make more serious medical decisions on their own, but they should still be engaged in a "substantive discussion," says Beach. "Once you know somebody understands the situation, you can engage them much more effectively."
To get relevant information from patients, physicians should ask questions such as, "What side effects are you willing to tolerate?" and "What is a good quality of life for you?" advises Beach.
"The doctor has to be willing to cross that bridge and really know who that person is and what they want out of the situation," she says. "The goal is for the doctor to get an idea of what the patient wants, and for the patient to understand what the doctor thinks."
Reference
- Beach MC. Is health literacy associated with patient and physician communication behaviors? Presented at the Society of General Internal Medicine's Annual National Meeting, 2007, Toronto, Canada.
Sourcs
- John Banja, PhD, Medical Ethicist, Center for Ethics, Emory University, Atlanta. Phone: (404) 712-4804. Email: [email protected].
- Mary Catherine Beach, MD, MPH, Associate Professor, Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD. Phone: (410) 614-1134. Email: [email protected].
- Clarence H. Braddock III, MD, MPH, FACP, Director, Clinical Ethics, Stanford Center for Biomedical Ethics. Phone: (650) 498-5923. Email: [email protected].
- Rosa Braga-Mele, MD, MEd, FRCSC, Associate Professor, University of Toronto. Phone: (416) 462-0393. Email: [email protected].
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