What makes a decision ‘shared’?
RCPsych Article of the Month for April is from The British Journal of Psychiatry (BJPsych) and is entitled ‘Involving patients with dementia in decisions to initiate treatment: effect on patient acceptance, satisfaction and medication prescription’ by Authors Jemima Dooley, Nick Bass, Gill Livingston and Rose McCabe.
Shared decision making can be a contentious concept. The mantra ‘no decision about me without me’ is increasingly prominent in health policy. However, some argue that the right to autonomy can be at a detriment to other patient rights, such as the right to best treatment or to living well in society. This is a particularly hot topic in psychiatry, as discussed by Lepping and Raveesh in this journal last year.
As researchers of communication, we approach shared decision making from a different angle. We are concerned with how decisions are shared, as visible in doctor-patient interactions. In our paper, we used a conversation analysis based coding scheme developed by Stivers and colleagues from analysis of primary care, psychiatry and neurology consultations. This coding scheme used conversation analytic principles of identifying what we are doing with our talk, rather than describing its content.
This enabled us to detect subtle differences in doctors’ recommendations for treatment which allows less or more patient autonomy in the decision making process. We found patients also detected these differences: satisfaction scores were lower when doctors offered patients little input into decisions by using highly directive ‘pronouncements’ to recommend treatment, e.g. “I will prescribe medication for you”. We could also detect subtle differences on how patients responded, i.e., in accepting or resisting the recommendation.
Doctors mostly used formats that encourage a shared decision, most commonly suggestions: “would you like to think about medication?”. This allowed patients to express their agreement or disagreement. However, we found that patient preference was not associated with prescription rates, raising questions about whether the decision was truly ‘shared’. Only a minority of patients explicitly accepted the treatment recommendation, but medication was prescribed in 75% of the consultations.
As discussed in the paper, there are likely to be more factors at play than doctors simply ignoring patient preferences. In talking to doctors who participated in the study, many expressed a desire to help patients after receiving the life-changing news of a dementia diagnosis, and medication symbolises hope for the future. The role of the carer is also key: even if they have not verbalised their opinion about treatment, doctors may believe that it is in the best interest of the carer for patient symptoms to be controlled with medication.
There is also the question of capacity. Only 10-15 years ago there was still debate on whether it was necessary to tell people they had a diagnosis of dementia, with capacity to process and understand being a prevailing argument against. While this has changed dramatically in the last decade, we know less about whether this has extended to attitudes to including patients in treatment decisions.
Our paper speaks to the shared decision making debate, shedding light on how this manifests in memory clinics. Understanding how patient preferences are elicited, explored and embedded in treatment decisions, as well as the contextual factors affecting this, is integral to truly empowering patients, and doctors, to make decisions together.
RCPsych Article of the Month
Each month a paper is selected by one of the Editors of the five RCPsych Journals (The British Journal of Psychiatry (BJPsych), BJPsych Open, BJPsych Advances, BJPsych Bulletin and BJPsych International) View the full collection here.
Why I chose this article:
“Dementia care is put under the microscope by Dooley et al, who report that doctors, when offering diagnostic information to patients with cognitive impairment, most often make suggestions and assertions, and less often pronouncements and offers of intervention. Despite this range, 80% of patients did not clearly accept the advice, and were likely to resist suggestions. The level of cognitive impairment in patients did not influence the type of communication method chosen, and patient preferences did not influence recommendations for use of medication.”
Professor Kamaldeep Bhui CBE, Editor-in-Chief, The British Journal of Psychiatry (BJPsych)
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