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