An Unusual Lesson on Informing a Shared Decision

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A home repair issue problem may serve as an analogy for informed consent and shared decision-making (SDM).
A home repair issue problem may serve as an analogy for informed consent and shared decision-making (SDM).

The winter our heating pipes burst because of structural problems with our home's foundation, my spouse and I were forced to embark on a renovation. We needed a contractor, whom I will call Sam, to manage the complicated details of the project and coordinate all of the sub-contractors. Sam came with strong references and a demeanor that suggested we could work easily with him. Over the course of the project, however, I was struck by how Sam withheld information that I thought was important for my wife and me to inform our decision-making about the project.

This problem reminded me of my work promoting high quality informed consent and shared decision-making (SDM) with other health care professionals. As a physician and ethics consultant, I am continually challenged with finding creative and compelling ways of sensitizing other health care professionals to the principles of medical ethics and their practical and fundamental relationship to everyday patient care. Busted pipes and building contractors seemed to offer a compelling analogy that might resonate where dry explanations of policy and informed consent would not. 

Advocates for preventing sexual assault have already successfully engaged the public with this type of approach by disarmingly comparing affirmative consent for sexual contact with offering someone a cup of tea.1 Physicians have turned to fairy tales and the power of storytelling to teach medical students about the power of empathy for interviewing and engaging with difficult-to-help patients.2 

In this analogy, my house was the patient and my wife and I were the parents.  Sam was the “house doctor” with vast expertise and experience in the care and repair of houses. I offer that the experiential process of submitting one's home to “major surgery” might help physicians better understand the patient's experience of the informed consent process and how it is central to providing high quality care.

Sam did not always provide me all the information I needed to make building decisions that were right for my wife and me. When the bathroom pocket door was finished, I asked why the door's roller hardware was not exposed like I had seen before. “We could have done that, but it wouldn't look as good. This is better,” he said. Well, in fact, I thought his choice did not look better, and I was not prepared to prioritize his aesthetic opinion. I thought it highlighted an aspect of SDM that physicians are likely to overlook. 

SDM promotes patients and physicians working together to identify an optimal treatment recommendation by combining the evidence for a range of available treatment options with a patient's articulated values and preferences. Making treatment recommendations and engaging in SDM requires that physicians differentiate their personal values from their patient's because patients appreciate and experience risks and benefits of treatments differently than physicians.  Providing clinical recommendations without adequate SDM could leave physicians subject to cognitive bias based on their personal values.3,4  For example, when discussing the role of anticoagulation in non-valvular atrial fibrillation, physicians should help patients understand and appreciate the evidence-based bleeding risks and stroke-reduction benefits associated with treatment, and then decide together if anticoagulation is right for the patient.  There is not necessarily a “right” answer about anticoagulation, but rather what is “right for an individual patient” based on the patient's values and preferences elicited as part of a SDM process. 

Sam unilaterally deciding that exposed door hardware looks worse is conceptually no different than a physician unilaterally deciding that a patient should tolerate the increased risks of bleeding on anticoagulation to prevent a future stroke. Both decisions are preference-sensitive—a term used in medical ethics to denote health care decisions that are related to patient's values, preferences, and needs—and thus should be considered by physicians as part of the decision-making process. Most medical decisions are preference-sensitive.

My colleagues readily recognize the analog of this process when making decisions together with patients about PSA screening or even when deciding to initiate dialysis. For sure, the physician needs the medical expertise and experience to identify safe and appropriate care options. But identifying a patient's preferences and goals leads to a care plan that can reflect those goals which can improve patient satisfaction.  

Even though I like to imagine that my house has discrete organ systems, I know I am stretching the analogy too far. The high-pressure water pipes are not arteries and snaking a clogged pipe is not just like a TURP. Although contractors obviously have more dissimilarity with physicians than the few things they might share in common, I have found that comparative exercises like these help to lower my intellectual defenses to consider new ideas. I am eager to see where these conversations can take us.

David J. Alfandre, MDDavid J. Alfandre MD, MSPH, is a health care ethicist for the National Center for Ethics in Health Care (NCEHC) at the Department of Veterans Affairs (VA) and an Associate Professor in the Department of Medicine and the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the NCEHC or the VA.



References

1. Consent: Not actually that complicated. 2015; http://rockstardinosaurpirateprincess.com/2015/03/02/consent-not-actually-that-complicated/. Accessed December 16, 2016.

2. Joachim N. Teaching the art of empathic interviewing to third-year medical students using a fairy tale--"The prince who turned into a rooster." Am J Psychother. 2008;62:395-418.

3. Alonso-Coello P, Montori VM, Diaz MG, et al. Values and preferences for oral antithrombotic therapy in patients with atrial fibrillation: physician and patient perspectives. Health Expect. 2015;18:2318-2327.

4. Ubel PA, Angott AM, Zikmund-Fisher BJ. Physicians recommend different treatments for patients than they would choose for themselves. Arch Intern Med. 2011;171:630-634.

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