Evidence-based Patient Choice Research Articles

An ethics analysis of antipsychotic dose reduction and discontinuation: Principles for supporting recovery from psychosis.

To examine the evidence and practice of antipsychotic dose reduction from the lens of biomedical ethics (specifically principlism) to support evidence-based practice and patient choice and self-determination. An overview of the evidence from randomized controlled trials of antipsychotic dose reduction versus maintenance is presented. This is followed by a theoretical examination of the four key biomedical ethical principles of autonomy, nonmaleficence, beneficence, and justice and how they apply in the case of antipsychotic dose reduction. Existing clinical trial research is dominated by relapse as the primary outcome, with dose reduction associated with a higher risk of relapse than maintenance. Few studies have measured other patient-centered outcomes but have shown preliminary evidence for superior cognitive functioning, lower negative symptoms, and better functioning following dose reduction. Respect for autonomy is a cornerstone of psychiatric rehabilitation, and this includes the right of people to choose to reduce or discontinue antipsychotic medication. Reduced capacity for treatment decision making can be supported. Autonomy and appraisal of nonmaleficence and beneficence associated with dose reduction can be facilitated through shared or supported decision making. Clinicians should continue to strive for justice through the fair allocation of resources to support all people who request antipsychotic dose reduction. Clinicians have a responsibility to balance the four core ethical principles to the best of their ability when supporting a person in their recovery journey. Exploring, trialing, and supporting antipsychotic dose reduction may be part of this process if that is the patient's choice. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Risk communication in cataract surgery

PurposeRisk communication is an integral aspect of shared decision-making and evidence-based patient choice. There is currently no recommended way of communicating risks and benefits of cataract surgery to patients. This...

Medical information therapy and medical malpractice litigation in South Africa

In South Africa, increases in both the size and amount of medical malpractice claims have resulted in a move towards so-called defensive medicine, and have had devastating emotional effects on healthcare professionals. Among several recommendations for addressing these consequences, the first author’s recent doctoral study critically analysed evidence-based patient choice as a partnership model in clinical decision making. This study indicated that none of the key skills of this approach are completely adequate in honouring the principle of respect for autonomy in clinical decision making. Instead, the study proposed the concept of medical information therapy – an expanded conception of the generic concept of information therapy – as an adequate approach to reconciling the opposing perspectives of patients and healthcare professionals in a therapeutic alliance. Recent case law, as well as relevant provisions of the National Health Act, emphasise patient autonomy, as well as the notion of shared decision making in the context of informed consent. The South African healthcare context is characterised by specific challenges affecting the process of obtaining informed consent. The article submits that the concept of medical information therapy will help address the significant increase in litigation against healthcare practitioners based on a lack of informed consent, in both the public and private healthcare sectors.

Option grids: an idea whose time has come?

![][1] It is more than 30 years since I first heard the expression ‘patient empowerment’, 25 years since I heard ‘shared decision making’, and 12 years since Edwards and Elwyn first published their multi-author edited volume Evidence-Based Patient Choice .1 Even the stirring maxim ‘No decision about me without me’ is beginning to sound old hat. Few of us are opposed to patient autonomy or shared decision-making. But there is a substantial gap between what we support in principle and what we can or do deliver within the confines of a 10-minute consultation. Be honest. What happens when a patient attends your surgery … [1]: /embed/graphic-1.gif

Collaborative Empiricism in Cognitive Therapy for Psychosis: A Practice Guide

We outline our understanding of collaborative empiricism (CE) as used in cognitive therapy (CT) for psychosis. We discuss how CE can be thought of as a technique for facilitating cognitive change in the service of a client's goals, but also as an expression of respect for client autonomy, recognizing the ethical imperative to empower clients by involving them in decisions about their care. Taking a CE approach is therefore consistent with user-led conceptualizations of recovery, and the related movements of “shared decision-making” and “evidence-based patient choice.” We discuss how CE can aid with engagement, assessment, formulation, and intervention in CT, illustrating this with case material. We focus on how CE can help with distressing intrusive experiences and beliefs, and also consider its role in helping clients achieve wider life goals. Adaptations to CE for working with people with problems with learning, attention, and memory are discussed, as are considerations for working with high conviction and conceptual disorganization.

Development of a shared decision making coding system for analysis of patient–healthcare provider encounters

ObjectivesTo describe the development and refinement of a scheme, detail of essential elements and participants in shared decision making (DEEP-SDM), for coding shared decision making (SDM) while reporting on the characteristics of decisions in a sample of patients with metastatic breast cancer. MethodsThe evidence-based patient choice instrument was modified to reflect Makoul and Clayman's integrative model of SDM. Coding was conducted on video recordings of 20 women at the first visit with their medical oncologists after suspicion of disease progression. Noldus Observer XT v.8, a video coding software platform, was used for coding. ResultsThe sample contained 80 decisions (range: 1–11), divided into 150 decision making segments. Most decisions were physician-led, although patients and physicians initiated similar numbers of decision-making conversations. ConclusionDEEP-SDM facilitates content analysis of encounters between women with metastatic breast cancer and their medical oncologists. Despite the fractured nature of decision making, it is possible to identify decision points and to code each of the essential elements of shared decision making. Further work should include application of DEEP-SDM to non-cancer encounters. Practice implicationsA better understanding of how decisions unfold in the medical encounter can help inform the relationship of SDM to patient-reported outcomes.

Communicating risk to patients and the public

Risk communication is an essential part of shared decision making and evidence-based patient choice.1 Discussing a patient's cardiovascular risk, their risk reduction from taking a statin, the risks and benefits of colorectal screening, or the truth behind the tabloids latest claim that vegetable X reduces the risk of cancer Y by 50%, are all examples of everyday general practice consultations that involve communication about risk information. Effective risk communication is important for the doctor and the patient. Mrs Jones is more likely to choose to take her statin if she understands what is meant by her 10-year cardiovascular risk being 24%, and if she decides based on the information her doctor provides that reducing this risk is worth the trouble of taking a tablet, she may be more likely to adhere to the chosen treatment.2 Otherwise, it may end up contributing to the large stockpile of pills in her bathroom cabinet. Conversely, both Mrs Jones and her doctor may be satisfied about a decision not to take medication, if it is based on clearly understood information about the harms and benefits of medication. Risk communication is defined as: > ‘The open, two-way exchange of information and opinion about risk, leading to a better understanding of the risk in question, and promoting better (clinical) decisions about management.’3 The communication of risk has to meet some complex needs for patients, and is difficult to achieve well. Be it a public screening programme or a matter of starting a new treatment, providing evidence-based risk and benefit information to patients and ensuring adequate understanding and accurate perception of such information by patients, forms the cornerstone of informed decision making. Evidence suggests that greater levels of informed choice are associated with greater satisfaction with the process of care and, crucially, improved adherence to …

The use of formal and informal knowledge sources in patients’ treatment decisions in secondary stroke prevention: qualitative study

There is robust empirical evidence to support clinical decision making in secondary stroke prevention after transient ischaemic attack (TIA) or recovered stroke. However, little attention has been paid to patients' utilization of this evidence in coming to decisions about their treatment choices. To examine the use of formal and informal knowledge by patients in making decisions about carotid endarterectomy (CEA) and medical treatment after TIA/recovered stroke. Twenty participants were recruited from an outpatient vascular surgical assessment clinic in England. Ten were receiving medical treatment alone, and 10 were undergoing CEA after TIA or recovered stroke. Twenty-eight in-depth qualitative interviews were conducted. An iterative approach was used whereby emergent themes were further explored in later interviews. Interviews were audiotaped, transcribed and coded. Participants gathered and utilized several types of knowledge in the process of making treatment decisions: Empirical knowledge (e.g. clinical trial findings); Pathophysiologic findings (e.g., results of clinical investigations); Experiential knowledge (e.g., personal experience of stroke); Goals and values (e.g., potential impact on family); System features (e.g., apparent urgency of treatment). In addition to formal evidence, patients use other sources of informal or 'non-evidentiary' knowledge to support their decisions about treatment after TIA or recovered stroke. To enable evidence-based patient choice, health professionals need to appreciate the diverse types of evidence which patients use, to help them to access relevant and high-quality evidence, to balance evidence from different sources and to make choices which are congruent with their values and expectations.

Incorporating a Client-Centered Approach to Audiologic Rehabilitation

Incorporating a Client-Centered Approach to Audiologic Rehabilitation

A qualitative examination of patient experiences of dietetic consultations

Background: There is considerable interest in healthcare research regarding communication skills (Ong, de Hoes, Hoos & Lammes, 1995) and some debate surrounding the effectiveness of a patient-centred approach to care (Mead & Bower, 2000). Understanding patient experiences of consultations can help indicate how consultations can be modified to improve effectiveness (Stewart & Browne, 1996). There is currently little research exploring patient experience of dietetic consultations. The aim of this project was to achieve a better understanding of patients’ experiences of dietetic consultations. Methods: Nine patients who had undergone one or more consultations with a dietitian were invited to take part in individual interviews and a focus group to discuss their experience of the consultation. A topic guide was used to ensure that relevant information was collected by the researcher, who was a dietitian not involved in patient care, and the interviews and focus group were audio taped and transcribed. Transcripts of these interviews were analysed using the framework approach (Spencer, Ritchie, Lewis & Dillon, 2003; Ritchie & Lewis, 2003), a systematic approach to qualitative data analysis which comprised five distinct stages: familiarisation, development of thematic framework, indexing, charting and synthesising and mapping and interpretation. Ethical approval for the data collection was granted by the NHS Research Ethics Committee and the Ethics Committee of London Metropolitan University. Results: Patient experiences of dietetic consultations were varied. Factors influencing the experiences were categorised into three categories, each with a series of sub categories: information and resources (accuracy/consistency, clarity, sufficiency, adaptation for patient, effectiveness); healthcare system (time, multi-disciplinary team involvement, access to dietitian, access to group/peer support) and support (communication, dietitian's manner, approach, motivation, empathy). Discussion: Patients agreed that certain factors, such as good communication and rapport, receiving effective and reliable information and resources, and non-judgemental, regular support were important factors in creating a positive experience of their dietetic consultation. However, patients differed as to what constituted achievement of these factors. Patients would like dietitians to adopt a patient-centred approach insofar as it takes account of what they want from consultations and adapts to meet their individual requirements, even if these requirements are for a more prescriptive, biomedical approach. Conclusion: This study examined the experiences of a small group of patients and found that even within this group, experiences of dietetic consultations varied widely. Whilst the specific findings of this study may not be not be generalisable to the experience of all patients, they show that the most important issue for patients is that their individual needs and circumstances are recognised by a dietitian during a consultation. Awareness of this is essential if dietitians are to function effectively as facilitators of behaviour change.

Medication adherence and patient choice in mental health

British Journal of Hospital MedicineVol. 72, No. 1 EditorialMedication adherence and patient choice in mental healthKirsty Mackay, Mark Taylor, Maxine X PatelKirsty MackaySearch for more papers by this author, Mark TaylorSearch for more papers by this author, Maxine X PatelSearch for more papers by this authorKirsty Mackay; Mark Taylor; Maxine X PatelPublished Online:16 Aug 2013https://doi.org/10.12968/hmed.2011.72.1.6AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Hope T (2002) Evidence based patient choice and psychiatry. Evid Based Mental Health 5(4): 100–1 Crossref, Medline, Google ScholarKnapp M, King D, Pugner K, Lapuerta P (2004) Non adherence to antipsychotic medication regimens: associations with resource use and costs. Br J Psychiatry 184: 509–16 Crossref, Medline, Google ScholarKreyenbuhl J, Dixon LB, McCarthy JF et al. (2010) Does adherence to medications for type 2 diabetes differ between individuals with vs without schizophrenia? Schiz Bull 36(2): 428–35 Crossref, Medline, Google ScholarMendonca PJ, Brehm SS (1983) Effects of choice on behavioural treatment of overweight children. J Soc Clin Psychol 1(4): 343–58 Crossref, Google ScholarPatel MX, David AS (2007) Medication adherence: predictive factors and enhancement strategies. Psychiatry 6(9): 357–61 Crossref, Google ScholarRankin J (2005) A Good Choice for Mental Health. Working paper three. Institute for Public Policy Research, London Google ScholarRittmannsberger H, Pachinger T, Keppelmuir P, Wancata J (2004) Medication adherence among psychotic patients before admission to inpatient treatment. Psychiatric Services 55: 174–9 Crossref, Medline, Google ScholarRoter D, Hall JA, Merisca R, Nordstrom B, Cretin D, Svarstad B (1998) Effectiveness of interventions to improve patient compliance – a meta analysis. Medical Care 36: 1138–61 Crossref, Medline, Google ScholarSamele C, Lawton-Smith, Warner L, Mariathasan J (2007) Patient choice in psychiatry. Br J Psychiatry 191: 1–2 Crossref, Medline, Google ScholarTacchi MJ, Nendick J, Scott J (2010) Patient choice and improving the uptake of long-acting injectable medication. In: Haddad P, Lambert T, Lauriello J, eds. Antipsychotic Longacting Injections. Oxford University Press, Oxford: 188 Crossref, Google ScholarWorld Health Organization (2003) Adherence to Long Term Therapies. Evidence for action. World Health Organization, Geneva Google Scholar FiguresReferencesRelatedDetailsCited byShared decision-making interventions for people with mental health conditions11 November 2022 | Cochrane Database of Systematic Reviews, Vol. 2022, No. 11Should long-acting (depot) antipsychotics be used in early schizophrenia? A systematic review3 December 2012 | Australian & New Zealand Journal of Psychiatry, Vol. 47, No. 7Long-acting antipsychotic drugs for the treatment of schizophrenia: use in daily practice from naturalistic observations21 August 2012 | BMC Psychiatry, Vol. 12, No. 1 1 January 2011Volume 72Issue 1ISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 16 August 2013 Published in print 1 January 2011 Information© MA Healthcare LimitedPDF download

Patient choice in administering anti-TNF for severe, active Crohn's disease in adults

The use of tumour necrosis factor antagonists have revolutionized the modern approach to the management of Crohn's disease, and with two proven therapies available in the UK (adalimumab and infliximab), the concept of patient choice is now being considered to assist in determining which therapy to use with each individual patient. While offering patients a choice of treatment therapy is not a new principle, offering choice within this therapy area certainly is. This article will summarize the evidence for the two therapies and outline the issues related to offering evidence-based patient choice in treatment. The evidence related to patient choice using adalimumab and infliximab will be reviewed alongside the implications for practice.

Shared Decision-making in Health Care – Achieving Evidence-based Patient Choice (2nd ed.)

Shared Decision-making in Health Care – Achieving Evidence-based Patient Choice (2nd ed.)

Physicians’ responsibility: Doctor-patient relationship

The physician-patient relationship is of fundamental importance not only for individual patients but for the health care system in general and thus also for bioethical reflections. We give an overview on current research and analyses regarding the physician-patient relationship. A comprehensive ethical analysis takes conditions (historical and societal influences, norms and principles), the action itself and its consequences on the individual level (patient, physician) and societal level (health care system) into consideration. At present, two models of the physician-patient relationship are predominantly discussed, especially in terms of care ethics: evidence-based patient choice and shared decision making. These forms of relationships seem to be promising for several reasons, but might not fit all situations, and suitable for all preferences of patients and physicians in the same way. We conclude with a summary of the current debate and point out some of its shortcomings.

Beyond Shared Decision Making: An Expanded Typology of Medical Decisions

The most popular current models of medical decision making, identified by names such as shared decision making, informed decision making, and evidence-based patient choice, portray an empowered patient actively involved in his or her medical choices and generally assume that patient and physician reach agreement. These models are limited to a specific type of decision (in which there is more than one choice) and a specific process (in which agreement is reached). The authors extend the model of medical decision making beyond shared decisions in 2 dimensions. First, the authors incorporate a class of medical decisions in which there is only one medically reasonable treatment option, such as the removal of a primary melanoma. Patient preferences are irrelevant to whether or not the melanoma should be removed, so there is no treatment choice in which the patient can share. When there is only one realistic treatment option, the clinician's job is not to offer alternatives but to explain why there is only one viable choice and move the decision-making process forward. The physician does not thereby abridge the patient's autonomy; rather, the disease process itself constrains both patient and physician. Second, the authors include decisions in which patient and physician do not reach agreement. Sometimes the patient insists on a particular treatment and the physician reluctantly yields, sometimes it is the other way around, but disagreement is commonplace in clinical medicine and its presence deserves inclusion in the way we think about medical decisions. Conflict resolution requires acknowledging the potential for conflict.

Professional centred shared decision making: patient decision aids in practice in primary care.

BackgroundPatient decision aids are increasingly regarded as important components of clinical practice that enable shared decision making (SDM) and evidence based patient choice. Despite broad acceptance of their value, there remains little evidence of their successful implementation in primary care settings.MethodsHealth care practitioners from five general practice surgeries in northern England participated in focus group sessions around the themes of patient decision aids, patient and practitioner preferences and SDM. Participants included general practitioners (n = 19), practice nurses (n = 5) and auxiliary staff (n = 3). Transcripts were analysed using a framework approach.ResultsWe report a) practitioners' discussion of the current impetus towards sharing decisions and their perspectives on barriers to SDM, and b) the implementation of patient decision aids in practice and impediments such as lack of an evidence base and time available in consultations.ConclusionWe demonstrate two orientations to sharing decisions: practitioner-centred and patient-centred with the former predominating. We argue that it is necessary to rethink the changes required in practice for the implementation of SDM.

Void for Vagueness

When law regulates a profession, where does it get its standards? Largely from the profession. Members of professions acquire esoteric and abstract knowledge through formal education and the experience of practice. They use professional judgment in applying this knowledge to each case. Because legislatures and courts lack this expertise, they adopt the standards of the experts. Thus in a malpractice suit, juries are instructed to determine whether the doctor met medicine's standard of care. Furthermore, physicians must be called as expert witnesses to guide juries in that work. Even when lawmakers contemplated intensifying their regulation of medicine by creating the duty of consent, they could consult a literature to which doctors and medical ethicists contributed crucially. In some jurisdictions, even the scope of the duty is determined by using the medical standard of disclosure (although in other jurisdictions the standard is the degree of disclosure sufficient to permit the ordinary patient to make a sound decision). Nor have lawmakers striven to extend the reach of consent beyond the norms of medicine. They might have done so in two ways. First, they might have broadened the legal standard of disclosure. This seems to have happened only sporadically and tentatively. Second, fact-finders (juries and trial-court judges) might have interpreted the legal standard as demanding elaborate or unusual disclosures. This too has apparently not much happened. Indeed, plaintiffs rarely bring consent actions (except as appendages to malpractice suits), rarely win them, and rarely obtain large verdicts. In short, lawmakers have essentially established rules intended to hold medicine to its own standards and then mostly left the system to work unmolested. What lawmakers have not noticed, however, is that the status of consent in the medical literature has become parlous. Two developments particularly matter. First, a torrent of empirical evidence now suggests that consent does not work as intended: Doctors generally tell patients too little and patients generally understand too little for patients to make the choices that lawmakers had imagined. Second (and relatedly?), the literature seems to be deserting the term informed consent. And what instead? A comet shower of novel terms. [T]here is now a profusion of competing models that attempt to convey subtle differences in the sharing of information and power between clinician and patient. (1) A smattering of the latest models: evidence-based patient choice, informed decision-making, informed medical decision-making, informed treatment decision-making, physician as perfect agent, decision-making, clinical decision-making, medical decision-making, and treatment decision-making. From this welter of multiplying, mystifying distinctions, one term has emerged most stoutly--shared decision-making. So, what is shared decision-making? Would that I knew. Or that anyone did. Makoul and Clayman heroically slogged through the literature and concluded that there is no shared definition of shared decision making. They identified 31 separate concepts used to explicate SDM, only two of which appeared in more than half of the conceptual definitions. In fact, 60% of articles that purport to focus on shared decision-making failed to include any conceptual definition at all. (2) As this suggests, many proponents of shared decision-making seem to regard its meaning as self-evident. And no doubt most people suppose that they understand the term. Sharing does the real rhetorical work here. Who doesn't understand sharing? Who could oppose it? Yet the skimpiest reflection reveals that the slogan is ambiguous unto incoherence. For example, what makes a decision shared? It is logical, plausible, reasonable to say, as many advocates of shared decision-making seem to say, that anyone who helps shape a decision, helps give the decision meaning, helps give it effect, shares in it. …

Observing decision‐making in the general practice consultation: who makes which decisions?

To investigate opportunities for, and types of decision making in the general practice (primary care) consultation, and examine differences in skills of those doctors who are successful at meeting their patients' preferences and those who are less successful. Observation study of doctor-patient consultations in general practice. Patients attending for routine appointments in 12 general practice surgeries across Oxfordshire. A total of 212 doctor-patient consultations were video-recorded. The patients involved completed a questionnaire to elicit their perceptions of how decisions were made. The video-taped recordings were coded with a new instrument, the Evidence Based Patient Choice Instrument (EBPCI), to classify the number and type of decision-making opportunities arising during each consultation. A total of 149 recordings were coded using the Oxbridge Rating Scale to assess the doctors' consultation styles. There was a range of decision-making opportunities in addition to those involving medical treatment. With the exception of 'fitness for work', decisions were generally 'doctor led'. There was only moderate agreement between patient perceptions of their level of involvement in decision making and the objective ratings using the EBPCI. There was wide variation in the ability of doctors to meet their patients' preferences for involvement. There are many decisions made in primary care consultations, in addition to those about medical treatments, in which patients could be involved to a greater extent than they currently are. Some doctors are significantly better than others at meeting different patients' preferences for their decision-making role. Patients' perceptions of shared decision making appears to be influenced by the doctors' general consultation skills.

Contraception

An evidence-based patient choice approach to contraception, assisting the patient to choose the contraceptive method she feels most comfortable with at this moment of her life, will provide high patient satisfaction with the consultation, and hopefully better adherence to the method of choice.

The contextual influence of professional culture: Certified nurse-midwives’ knowledge of and reliance on evidence-based practice

This paper reports research undertaken to assess US certified nurse-midwives’ (CNMs) knowledge of, access to, and use of evidence-based medicine (EBM). Findings are presented in the context of interprofessional, institutional, and popular culture. The descriptive study follows concepts of diffusion of innovation, evidence-based patient choice, and authoritative knowledge to analyse incentives and barriers to the implementation of evidence-based midwifery care. Structured interviews were conducted with practicing CNMs in an urban practice site and a regional teaching centre. The analysis of responses explored congruence between practitioner knowledge, professed practice, and published professional as well as hospital-based internal practice guidelines, for two specific interventions for which there is ample systematic review, epidural and episiotomy. The CNMs demonstrated enthusiasm for their own individual understanding of EBM, but responses to specific questions about EBM-supported practice indicate that many had an incomplete understanding of the concept. Furthermore, in those cases where CNMs demonstrated accurate knowledge of EBM, practice protocols followed subspecialty dictates, thereby preventing their knowledge from translating into adherence to EBM-guided clinical practice guidelines. Finally, patient expectations for technological intervention appeared to influence CNMs’ care decisions, even when those expectations lacked sound supporting evidence. If, as conceived by its originators and champions, EBM is to be widely adopted, then practitioners such as CNMs need to accurately understand its concepts and also to be afforded the opportunity to exercise professional control over its implementation. Central to an epistemically balanced EBM is the need to ensure that midwifery knowledge contributes in a robust and ongoing fashion to EBM's scientific research base. Lastly, EBM advocates must identify balanced strategies to both rationally and fairly address consumerist pressures for aggressive health care consumption.