Participatory decision-making

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Participatory decision-making ( PEF ; shared decision-making , SDM ) is the term used in medicine to refer to the interaction or communication between doctor and patient , which aims at reaching an agreement on appropriate medical treatment for which the patient and doctor are jointly responsible .

Patient-doctor relationship concepts

In the context of medical communication, a distinction is made between different models of the patient-doctor relationship , although PEF has recently been increasingly gaining acceptance as a general expectation of patients.

  • The traditional paternalistic model is characterized by the authority and sole decision-making sovereignty of the doctor. The doctor makes the diagnosis and decides on the best therapy for the patient from his point of view. He does not necessarily withhold information from the patient. A communication process can also take place, although this is structured by the functional information interests of the doctor for the purpose of optimized diagnosis and therapy. Not infrequently, however, information is withheld from the patient, supposedly for his own good, in order to avoid skepticism or decision-making conflicts.
  • The informative model , also known as the “consumer model”, is strongly characterized by “cognitivistic” interpretations of the patient-doctor relationship, which here assume a largely affect-neutral structure of the information exchange. The doctor provides the patient with a multitude of information, starting with hypotheses about possible causes of the illness and diagnostic findings up to therapeutic alternatives, including their advantages and disadvantages. The patient remains in control of the decision-making process in that he can or must organize the information offered and convert it into a decision. Personal experiences, needs or fears of patients are not denied here, but they are hidden from the patient-doctor relationship.
  • This approach also to emotional and sometimes less rational moments in the context of the disease experience and convalescence , however, is explicitly emphasized in the model of participatory decision-making. In addition, the direction of interaction in this concept is two-pronged, doctor and patient ask questions and answer questions.

Core elements

The core elements of participatory decision-making include: a. a “partnership relationship” between patient and doctor with the same level of information as possible about options regarding a medical decision. The doctor and patient should actively and equally contribute their decision-making criteria to the weighing and decision-making process and take responsibility for the decision as a partnership. From a legal point of view, however, the patient has the right to self-determination.

Process steps

Participative decision-making requires various steps to be taken. These include

  1. the agreement between doctor and patient that a decision is pending;
  2. the offer on the part of the physician that the decision regarding a treatment - option of Patient and doctor in equal is developed partnership;
  3. Identification of various equivalent (in the best case evidence-based) options
  4. comprehensive mutual information about treatment options, their evidence , alternatives , advantages and disadvantages - possibly with the use of decision-support materials, e.g. B. written patient information ;
  5. Feedback on understanding the options and inquiries about further options from the patient's point of view;
  6. Determination of the preferences of the patient or the doctor;
  7. Negotiating the choices;
  8. Joint (participatory) decision or unilateral decision by the patient (right of self-determination), even against the doctor's wishes;
  9. Possibly contract / voluntary commitment (plan to implement the decision).

Social and scientific backgrounds

PEF is not a modernist concept of the patient-doctor relationship that transfers different values ​​and norms (information, participation) that have emerged in the information society into the system of medical care or even "grafts" them onto it. PEF or SDM can be characterized as meaningful and presumably also future-oriented for the following reasons, among others:

  • For patients - especially through computers and the Internet - there are previously unknown possibilities of autonomous procurement of health and illness information in this dimension, which they also use. To hide this (partly correct, but partly “half-baked”) prior information from the patient would not mean taking him seriously, abstracting from his knowledge and related fears and desires, i.e. only seeing the disease and not the patient.
  • Extensive analyzes of medical interventions have made it clear that medical action and medical therapy decisions are presumably dependent to a very large extent on personal preferences or values ​​that cannot be clearly derived from the current state of research and knowledge.
  • The research results of evidence-based medicine (EbM) have not only made it clear that there is no scientific evidence of their efficiency for a large number of the therapeutic methods practiced every day in conventional medicine. It was also shown that there is no clear best treatment method for a large number of diseases, the “therapeutic royal road”, but that there are usually several options with different benefits and risks available without it being possible to make a clear medical decision as to what now is best for the patient.
  • "Compliance" as following medical therapy instructions or "Concordance" as a consensus between doctor and patient with regard to the therapy plans depends to a large extent on whether the patient's questions and wishes have actually been included in the medical consultation. This is not only of economic importance, as the estimates for prescribed, but also discontinued or not taken drugs show. In addition, there are indications that patient information and participation have a positive influence on the quality of treatment and the effects of the therapy.

Empirical research results

Patient expectations

“Until the 1980s, the majority of patients still preferred a passive role in the medical treatment process. The active and dominant role of the doctor apparently met the needs of most patients […]. Today, many patients want to be involved in medical decisions [...] and politicians also demand greater patient involvement and participation. "

Klemperer / Rosenwirth draw this conclusion about a change in patient demands based on two larger patient surveys. In telephone interviews with 8,119 respondents in eight European countries, 23% said they would like to determine the treatment themselves, 26% would rather let the doctor decide and 51% would like to decide on the treatment method together with the doctor. Survey results from the Bertelsmann Foundation's “ Health Monitor ” among 9,146 Germans lead to a comparable result: 58% want joint decision-making, only 14% an autonomous decision and 28% would rather let the doctor decide alone. In the "PIA study" (patient information in general medicine), more than 1,100 patients in general practitioners' practices in the Ruhr area were asked about the role of the patient, and here, too, the overwhelming majority of 77% would like to participate in therapy decisions.

The position of the doctors

A survey by the “Health Monitor” shows predominantly positive judgments: 67% are in favor of this concept, 21% prefer the doctor's decision alone, 8% the patient decision, 4% make this dependent on the individual case. Younger doctors seem to be a little more open to shared decision making. However, more detailed inquiries also show that this overall positive vote is interspersed with skepticism and discomfort to a not inconsiderable extent and is assessed at least ambiguously. When asked what effect it has when patients have informed themselves about complaints, treatments, etc. before the doctor's appointment, it becomes clear that around two thirds of the 500 doctors surveyed in the “health monitor” attest these patients a “high self-interest” and just under This makes their work easier for half. Almost half also perceive this prior information from the patient as an additional burden and around 40% discredit the patient's knowledge as “a mixture of more or less applicable or useful information that only hinders me.” Almost a third of the doctors also give derogatory judgments in such a way that their own information would only confuse patients or they, as doctors, usually lack the time to deal with it.

Effects

Participatory decision-making generally has positive effects on compliance , treatment success and patient satisfaction. It should be noted, however, that the patient ultimately and legally alone decides whether or not an intervention or other treatment is carried out ( patient's right of self-determination ).

See also

Web links

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  1. ↑ See Ernest WB Hess-Lüttich, Jan CL König: Medical communication. In: Gert Ueding (Hrsg.): Historical dictionary of rhetoric . Volume 10, WBG, Darmstadt 2011, Sp. 660-669.
  2. ↑ N. Giersdorf, A. Loh, C. Bieber, C. Caspari, A. Deinzer, T. Doering and others: Development of a questionnaire for participatory decision-making. In: Federal Health Gazette, Health Research and Health Protection. 47, 2004, pp. 969-976.
  3. ↑ D. Klemperer, M. Rosenwirth: Shared Decision Making: Concept, Requirements and Political Implications. Chartbook. 2005, p. 12.
  4. ^ A. Coulter, M. Magee: The European Patient of the Future. Open University Press, 2003.
  5. ↑ J. Böcken et al.: The Health Monitor 2004. The outpatient care from the point of view of the population and the medical profession. Bertelsmann Foundation, 2004.
  6. ↑ J. Isfort et al .: Shared Decision Making - are patients ready to do so in the general practitioner's practice ?: (partial results of the PIA study).
  7. ↑ M. Butzlaff, B. Floer, J. Isfort: “Shared Decision Making”: The patient at the center of health care and everyday practice. In: J. Böcken, B. Braun, M. Schnee (Ed.): Health monitor. Gütersloh 2003, pp. 41–55.
  8. ↑ D. Klemperer, M. Rosenwirth: Third background paper on the Shared Decision Making Chartbook: The Doctors' View. P. 4.