3.5 Skills for decision-taking

As Henry Kissinger emphasised, decision-making lines up the options and sorts out the values, and then comes the crunch - decision-taking.

3.5.1 Each patient has a preferred style

There are different ways of describing the decision-taking style. An American study of women with breast cancer, (7) classified the style into three main types:

• doctor-led
• patient-shared
• patient-led

This study found that:

• 22% wanted to select their own treatment - patient-led
• 44% wanted a collaborative approach - shared decision-taking
• 34% wanted to delegate responsibility to their clinician - doctor-led

Of particular concern was the finding that there was poor correlation between the preferred style of decision-taking and the way in which the decision was actually taken. Only 42% of women achieved their preferred level of control. Although the patient's preference for style can be matched to that of the doctor, a study in the British Medical Journal (8) classified decisions as either 'directed' or 'shared' and with this classification found that 39.8%, or four out of ten patients, wished to have shared decision-making. Importantly, the study concluded that:

'although this variation seemed to depend on the presenting problem, age, social class and smoking status, these associations are not absolute, with large minorities in each group. It is therefore not possible to assume what style of decision-making a patient wishes.'

Encouragingly, it was found that:

• the majority of patients who preferred a sharing scenario had a doctor whose style was to share the consultation, and
• the majority of those who preferred a directed scenario had a doctor whose style was directive

3.5.2 All patients must be given information

Patients who say they do not want an open style of decision-making should nevertheless be offered all the information about treatment options, if for no other reason than that patients sometimes complain or sue when things go wrong, solely on the grounds that they do not recollect being informed about the risks of treatment. In The Patient by Michael Palmer, the process of bringing these unpleasant outcomes to the attention of Sara, the patient, before her operation is clearly described:

'You may lose the vision in one or both of your eyes.'

'As long as it's only one or both.'

'Okay, then. Initial here… You may lose the use of one or both of your arms.'

'Arms? I mean, really. What do I need arms for, anyhow? Show me one unhappy amoeba.
I can scratch my back on a tree like the bears and eat pie like those guys in the
county fair.'

'Initial… You may lose the use of one or both of your legs.'

'Jessie, please.'

'Sara, hospital policy says I have to read this neurosurgery op permit to you out loud, and
you know what a policy nerd I am. So stop giving me a hard time and let me finish.'

'Giving you a hard time? It's my damn brain tumour.'

'Touché.'

3.5.3 Reaching agreement on style

When patients become more resourceful, it will become necessary for clinician and patient to agree on how the decision should be taken, because the decision may not even be constant for the one patient, and it is clear that doctors will need both time and skill to determine the style of decision- making preferred by each patient. It is very important to do this because the systematic review of the literature on this subject (9) emphasised that 'some interventions cannot be uniformly introduced into practice without an assessment of informational needs. Evidence indicates that a disparity between information needs and information given can result in patients being more likely to develop affective disorders.'

3.5.4 Resources for action

Once the decision to intervene has been made, the patient needs different types of resources - guidebooks and pathways - to help him find his way to cure and health

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