Accepting patient’s decision

Troubleshooting: Common Challenges In Aligning Decisions With Patients’ Health Priorities

Challenge: Tips to help accept a patient’s decisions

It can be a challenge when patients make decisions that you don’t agree with.

It is helpful to consider that older adults have less future so they may appropriately be more focused on current than future health status.

Scripts

Invite dialogue on future health events:
“I understand that your healthcare preference is to stop/not trial (fill in intervention) especially since you experienced (fill in prior health event). Will it be ok if I share my thoughts on how today’s decision could impact your health priority to (fill in health outcome goal)?”

Offer anticipatory guidance:
“Would it be ok with you if I share what (adverse health event) would be like if it happened”

Base risk of future adverse events on priorities:
“I understand how meaningful it is to you to be able (fill in health outcome goal). I worry that (fill in adverse possible health outcome) may interfere with your ability to achieve that.”

Scenario

Invite dialogue
“I understand that want to stop using the CPAP. Would it be ok if I share my thoughts on how stopping the CPAP may make you too tired to volunteer which you said is what matters to you?”

Response: “Sure”

“You will become fatigued as you had been before starting the CPAP. I am concerned you may feel less motivated or have too little energy to sign up for volunteering.”

Scenario

Anticipatory guidance
A patient who doesn’t want anticoagulation because they knew someone who had a bleed while taking it.

“Would it be ok with you if I share what a stroke could be like if it happened and how that could impact your goal to continue to volunteer at the library?”

Response: “I am listening”

“A stroke can cause changes in thinking and physical abilities like walking. Even small strokes can have a big impact on a person’s function. I think that your work at the library requires your current thinking and physical abilities and we can work to preserve those by preventing a stroke with the blood thinner.”

Tips

Acknowledge that the benefits of any individual treatment may be small in the face of other cases contributing to function and survival. It may be worth focusing on treatments the patient is willing and able to do. When faced with the potential for small benefits, patients may value preventing current symptoms more than the potential benefit. This trade off should be discussed explicitly to help guide decisions.

Scenario

Patient wants to discuss changes to metoprolol:

“Metoprolol or similar medications are given to people when they have heart failure. The studies show that when people with heart failure take them, they can help you live longer. Those studies, though don’t include people with many other heath conditions such as the ones you have, so I cannot say for certain if you will get that same benefit.

We have to consider this trade off. If we reduce the dose of the medication or stop it, you may feel less tried now, but you may not live as long.

What are your thoughts?”

Scenario

The benefits from each different treatment are smaller when there are a number of different health conditions to consider.

“Because you don’t want to do anticoagulation right now, let’s focus on treatments like PT and preventing stroke which are most likely to help you achieve your goal to volunteer at the library.”

Script

“We discussed the implications of not doing “XX” the patient understands it may lead to problems such as “XX” and still does not desire intervention given its effect on their current symptoms and function.”

Scripts

Offer opportunity to readdress in the future:
“I am glad you were able to share your experiences and concerns and were able to arrive at a decision. We can never know how priorities and preferences might change moving forward. We can always discuss this matter again in the future.”

State commitment to ongoing collaboration:
“I am committed to moving forward in caring for you”

Tips

The future is unpredictable. Even when we do our best, patients can have bad outcomes. This can sometimes be a result of them choosing treatment options that you don’t necessarily agree on. While this can be a difficult position to be in, if the patient chooses a treatment option based on their unique priorities and was willing to accept a potential bad outcome, they made an informed decision.