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Patient Involvement In Therapeutic Process On Clinical Pharmacology Patient Involvement In Therapeutic Process On Clinical Pharmacology

Patient Involvement In Therapeutic Process On Clinical Pharmacology - PowerPoint Presentation

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Patient Involvement In Therapeutic Process On Clinical Pharmacology - PPT Presentation

Setyo Purwono Department of Pharmacology amp Therapy Faculty of Medicine Universitas Gadjah Mada Ethical concerns over doctorpatient relationship Autonomy and patient choice ID: 731602

patients patient relationship decision patient patients decision relationship making doctor model empowerment physician patient

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Slide1

Patient Involvement In Therapeutic Process On Clinical Pharmacology

Setyo

Purwono

Department of Pharmacology & Therapy ,

Faculty of Medicine ,

Universitas

Gadjah

MadaSlide2

Ethical concerns over doctor-patient relationship

Autonomy and patient choice

Patient right

Vs

patient interest

Integrity of the medical profession

Shared decision-making in medical interventionSlide3

What constitutes a person’s autonomy?

Three aspects of autonomy

Freedom of thought

Freedom of will

Freedom of actionSlide4

Principles of medical ethics

Respect for patient autonomy

Beneficence

Non-

malficence

JusticeSlide5

Autonomy and patient rights

Which of the following are derived from the value of patient autonomy?

Right to treatment

Right to information

Right to choices

Right to privacy

Right to compliantSlide6

Conflicting Values

Paternalism:

The doctor should act in a way that protects or advances the patient’s best interests, even if it is against the

patient’s

will.

Patient autonomy:

The doctor should help the patient to make real choice, and provide intervention under the constraints of (a) informed consent and (b) confidentiality.Slide7

Difficult cases for doctors: some examples

Active and passive euthanasia

Right to refuse treatment

DNS (Do-not-resuscitate) order

Abortion

Experimental

/risky

interventionsSlide8

Ethical models at a glance

Paternalistic model

Informative model

Interpretive model

Deliberative modelSlide9

Evaluating the four modelsSlide10

Paternalistic model

Principle

Assumptions

Sources

Problems

Objection and modification

The doctor should make all the decisions for a patient.

People are not always rational/mature.

Experts know better about the needs of patients.

Qualified doctors have good will.

Hippocratic Oath; Plato.

Are the needs of patients objective? How can we be sure that doctors have good will?

John Stuart Mill’s liberal principleSlide11

Paternalism

Is widely regarded as the traditional form of doctor-patient relationship

A passive patient and a dominant doctorSlide12

Informative model

Principle

Assumptions

Problems

The doctor should provide all the relevant information for the patient to make a decision, and provide the

selected

intervention

on this basis

.

A fact/value division of labor yields the best medical result.

What is good for a patient depends on

what his/her personal values

.

Consumerism.

What if the patient is unconscious, incompetent, and making choices totally unacceptable by our ethical standards?Slide13

The interpretive model

Principle

Assumptions

Sources

Limitation

The doctor should help the patient to articulate his/her values

through interpretation

, and provide intervention which is truly wanted.

Patients

have unconscious and inconsistent desires.

Their conscious decisions may not reflect their deepest values.

Sigmund Freud; hermeneutics.

All that a doctor can do is to help the patient see his/her

own

desires

/values

more clearly, but not to criticize them.Slide14

The deliberative model

Principle

Assumptions

Source

Problems

The doctor should help the patient to deliberate well through dialogue and discussion, and so develop values which are objective and truly worthy.

The objectivity of values.

The patient’s good life consists not in the satisfaction of desires, but maturity and rationality.

Aristotelian ethics

Is the model different from the paternalistic model? What is the difference between dialogue and persuasion?Slide15

Prototypes of doctor-patient relationship

Physician control (Low)

Physician control (High)

Patient control (Low)

Default

Paternalism

Patient control (High)

Consumerism

MutualitySlide16

Consumerism

The patients’ challenge to unilateral decision making by physicians in reaching closure on diagnoses and working out treatment plans

Reversing the very basic nature of the power relationshipSlide17

Patient’s role

Health shoppers

Indications of consumer behavior

Cost-consciousness

Information seeking

Exercising independent judgment

Consumer knowledgeSlide18

Doctor’s role

Health care providers

Technical consultant

To convince the necessity of medical services

A tendency for the “consumer to be right”Slide19

Advantages

Patients can have their own choices

Medicine is not an accomplished science.

There are tremendous gaps in knowledge.

Indeed, it has been estimated that the

e

ffectiveness

of treatment is unknown for about 90% of the medical condition seen in routine practiceSlide20

Disadvantages

Patients are being more selective in the acceptance of provider advice, based on its cost

When things seem to go wrong, when satisfaction is low, or when a patient suspect less than optimal care or outcome, patients are more likely to question physician authoritySlide21

Discussion

The doctor-patient relationship of consumerism seems easily to be adopted, we can simplify the complicated relationship with “buyer and seller” relationship, is it good or bad? What is your opinion?Slide22

Mutuality

The optimal doctor-patient relationship model

This model views neither the patient nor the physician as standing aside

Each of participants brings strengths and resources to the relationship

Based on the communication between doctors and patientsSlide23

Patient’s role

Patients need to define their problems in an open and full manner

The patient’s right to seek care elsewhere when demands are not satisfactorily metSlide24

Doctor’s role

Physicians need to work with the patient to articulate the problem and refine the request

The physician’s right to withdraw services formally from a patient if he or she feels it is impossible to satisfy the patient’s demandSlide25

Advantages

Patients can fully understand what problem they are coping with through physicians’ help

Physicians can entirely know patient’s value

Decisions can easily be made from a mutual and collaborative relationshipSlide26

Disadvantages

Physicians do not know what certain degree should they reach in communication

If the communication is fake, both physicians and patients do not have mutual understanding, making decision is overwhelming to a patientSlide27

Discussion

Is the patient capable of making the important therapeutic decision even though they have good communication of the physician?Slide28

Default

When patient and physician

expectation are at odds

, or when the need for change in the relationship cannot be negotiated, the relationship may come to a dysfunction standstill

.

Discussion

How to resolve this kind of embarrassed situation?Slide29

Doctor-patient relationship in the past

Paternalism

Because physicians in the past are people who have higher social status

“doctor” is seen as a sacred occupation which saves people’s lives

The advices given by doctors are seen as paramount mandate Slide30

Doctor-patient

relationship at present

Consumerism and mutuality

Patients nowadays have higher education and better economic status

The concept of patient’s autonomy

The ability to question doctorsSlide31

Reasons for the change

Doctors’ condition

Patients’ condition

Environmental factors

Relationship

between patients and doctors are often unstated, and they are dynamic

As conditions change, the kind of relationship that works best for a patient may change

Doctors and patients should choose a “relationship fit”

HOW?Slide32

What is Patient Empowerment?

32Slide33

Patient Empowerment

Empowerment is a

concept

that has recently emerged in the health scene. It embraces the idea that

everyone

has

the right to make their own choices about their health care

because patients are the ones who experience the consequences of both having and treating their illnesses, they have the

right to be the primary decision makers regarding their medical conditions

33Slide34

Patient Empowerment

A key part of empowerment is that the patient, personally, must

actively search out sufficient information to fully understand their health conditions and their treatment plans

Although their

physician should be involved

in the decision-making process, the

final determination of what is best for the patient is both the right and responsibility of the individual patient.

34Slide35

Why Patient Empowerment?

Remember the “patient centered clinical method”

Evaluating both the disease and the illness experience

Understanding the whole person

Finding

common ground with the patient

about the problem and its management

Incorporating prevention and health promotion

Enhancing the doctor-patient relationship

Being realistic

35Slide36

Why Patient Empowerment?

Only

9% of consultations with surgeons and primary care physicians meet full criteria for informed decision making.

Braddock JAMA 1999

Distinguishing elements of shared decision making occurred in 0-11% of audio taped patient interviews with general practitioners.

Elwyn 2001

“..

Checking of understanding, and the involving of patients in decision making .. are rarely demonstrated” [in video taped consultations submitted for MRCGP examination].

Campion BMJ 2002

36Slide37

37

What is shared decision making?Slide38

Two definitions of shared decision making:

The process of interaction of patients with their health care providers in making health care decisions

Involvement of patients with their providers in making health care decisions that are informed by the best available evidence about treatment / screening / illness management options, potential benefits, and harms, and that consider patient preferences.

38Slide39

What is it?

an individual being an active member of his/her disease management team

39

Laura E. Santurri. Patient Empowerment: Improving the Outcomes of Chronic Diseases Through

Self-Management Education. http://www.case.edu/med/epidbio/mphp439/Patient_Empowerment.htmSlide40

40

Shared decision making

combines the measurement of patient preferences with

evidence-based practice

.Slide41

41

Why is shared decision making important

? Slide42

Interventions have different benefits/ risks that patients value differently There is no single right answer for everyone

Ethical principle of patient autonomy and legal requirement of informed consent

Evidence-based practice movement

Increasing realization that an important piece of evidence is missing without the patient’s perspective

42Slide43

Patients cannot be forced to follow a lifestyle dictated by others. Preventive medicine requires patient empowerment for it to be effective.

Patients as consumers have the right to make their own choices and the ability to act on them

43Slide44

Why is the concentration of power in this relationship with physician?

P

a

t

ient

is sick, weak, vulnerable, not feeling fully oneself…

P

a

t

ient

may be afraid

P

a

t

ient

in a state of dependency

Lack of medical knowledge

Lack of knowledge

on the “system” and how it worksUnfamiliar environment44Slide45

Why is the concentration of power in this relationship with physician?

Education

Professional status/authority

Knowledge

Skills

Expertise

Experience

On familiar territory

GATEKEEPER TO HEALTHCARE SYSTEM

45Slide46

Why Patient Empowerment?

“People whose lives are affected by a decision must be a part of the process of arriving at that decision.”

John Naisbitt,

Megatrends

46Slide47

Education

supporting self care and self-management

Offering a choice of providers

Sharing treatment decisions

47

H

ow to empower patientsSlide48

Benefits of Patient Empowerment

Learning from our

patients

Taking a proactive

r

ole

Providing a support & information service to our patients and staff

Complaint Resolution

Negotiation & Mediation

Building trust

48Slide49

49

The old model vs. the newSlide50

Patient says:

Doctor responds

(Old model)

(New model)

"I hate this exercise plan."

"Then try walking after dinner every night with your husband for 10 minutes

"What do you hate about it? What would help you do better at it?"

"I don't think I can quit smoking."

"

Smoking is the leading cause of preventable death ..."

Why do you think that? What has happened in the past when you tried to quit? What concerns you most when you think about trying to quit

?

I haven't been able to test my blood sugar four times a day."

"It's hard at first, but just keep trying. You really need to keep track of it."

"What is preventing you from doing that? Do you know what the numbers mean?"

50Slide51

Some useful hints

The skilled family physician can spend 10 minute with a patient and the patient feels it was 20 minutes

Even the busiest physician can accomplish wonders in a few minutes by indicating that their full attention is on the patient

Please conclude every interview with the statement “is their anything else bothering you that we have not discussed?”

Rather than assuming that the patient have understood the instructions, ask them to repeat as they understood

Use the patients name or ask him what he prefer to be called as

Use “how can I help you? Rather than “what brings you here today?”

51Slide52

52

Follow-up

Management / treatment

Presenting concern

“patient’s story”

History and physical exam

Hypothesis

Identified problem or diagnosis

Identify choices

Review pt’s preference for information

Present evidence

Respond to pt’s ideas, concerns and expectations re: management

Assess partnership (review previous steps)

DOCTOR

-

PATIENT COMMUNICATION

Establish pt’s role in decision making

Agree on an action plan

Negotiate a decision

Model for

Clinical Problem Solving & ISDM

Step 1

Step 2

Step 3

Step 4

Step 5

Step 6

Step 7

Step 8

*

ISDM

: Informed Shared Decision MakingSlide53

Common problems that can lead to poor decisions:

Relationships and roles are unclear

Objective data are inadequate

Values, interests and assumptions are unexplored

Too few options have been considered

Alternatives are unclear

Communication is poor

53Slide54

What is a "good" health care decision?

Well informed, supported by the best available evidence, weighs pros and cons, compatible with patient's values and practical (Dow, 1999).

54Slide55

55

Empowerment allows our relationships to grow in strengthSlide56

56

“Coming together is a beginning; keeping together is progress; working together is success.”

Henry FordSlide57

First, they have to be informed.

Specifically

, they have to be given an objective

,

unbiased

presentation

of reasonable options

to

consider

and the

pros and cons of those options.Second, once informed, patients have to spend some time to consider their goals and concerns and how each option is likely to play out with

respect

to those goals and concerns.

Third

,

they

have

to have an interaction with their

providers

in

which their goals and concerns are shared

and

incorporated

into the decision-making process.

11

For patients to have a meaningful say in their medical decisions, three essential

conditions