Objectives: To assess whether consultants do what they say they do in reaching decisions with their patients. Design: Cross-sectional analysis of hospital outpatient encounters, comparing... Show moreObjectives: To assess whether consultants do what they say they do in reaching decisions with their patients. Design: Cross-sectional analysis of hospital outpatient encounters, comparing consultants' self-reported usual decision-making style to their actual observed decision-making behaviour in video-recorded encounters. Setting: Large secondary care teaching hospital in the Netherlands. Participants: 41 consultants from 18 disciplines and 781 patients. Primary and secondary outcome measure With the Control Preference Scale, the self-reported usual decision-making style was assessed (paternalistic, informative or shared decision making). Two independent raters assessed decision-making behaviour for each decision using the Observing Patient Involvement (OPTION)(5) instrument ranging from 0 (no shared decision making (SDM)) to 100 (optimal SDM). Results: Consultants reported their usual decision-making style as informative (n=11), shared (n=16) and paternalistic (n=14). Overall, patient involvement was low, with mean (SD) OPTION5 scores of 16.8 (17.1). In an unadjusted multilevel analysis, the reported usual decision-making style was not related to the OPTION5 score (p>0.156). After adjusting for patient, consultant and consultation characteristics, higher OPTION5 scores were only significantly related to the category of decisions (treatment vs the other categories) and to longer consultation duration (p<0.001). Conclusions: The limited patient involvement that we observed was not associated with the consultants' self-reported usual decision-making style. Consultants appear to be unconsciously incompetent in shared decision making. This can hinder the transfer of this crucial communication skill to students and junior doctors. Show less
The current Dutch guideline on care at the edge of perinatal viability advises to consider initiation of active care to infants born from 24 weeks of gestational age on. This, only after extensive... Show moreThe current Dutch guideline on care at the edge of perinatal viability advises to consider initiation of active care to infants born from 24 weeks of gestational age on. This, only after extensive counseling of and shared decision-making with the parents of the yet unborn infant. Compared to most other European guidelines on this matter, the Dutch guideline may be thought to stand out for its relatively high age threshold of initiating active care, its gray zone spanning weeks 24 and 25 in which active management is determined by parental discretion, and a slight reluctance to provide active care in case of extreme prematurity. In this article, we explore the Dutch position more thoroughly. First, we briefly look at the previous and current Dutch guidelines. Second, we position them within the Dutch socio-cultural context. We focus on the Dutch prioritization of individual freedom, the abortion law and the perinatal threshold of viability, and a culturally embedded aversion of suffering. Lastly, we explore two possible adaptations of the Dutch guideline; i.e., to only lower the age threshold to consider the initiation of active care, or to change the type of guideline. Show less
Rationale The health care landscape is changing: it has become the largest part of the economy and changes in public management systems will greatly affect how we practice medicine in the future.... Show moreRationale The health care landscape is changing: it has become the largest part of the economy and changes in public management systems will greatly affect how we practice medicine in the future. Medical education will be more important than ever to ensure patients get the best care with empathy. However, new public management systems implemented without thorough analysis might challenge medical education. An increasing number of public health care institutions provide services based on competitive market rules and express their goals in financial terms and have set financial gains as their main goal, which contradicts the fundamental nature of medical ethics and practice. Aims and objectives To explore new public management to identify potential problems and offer possible solutions for medical education and health care institutions. Methods A scoping review of the literature on public administration, hospital management, professionalism, ethics, and medical education was undertaken to map evidence on the topic and identify main concepts and knowledge gaps in the influence of management systems on the quality of medical educational practices. Results If the accelerating changes in public management are cursorily analysed, medical education may lose the esteem in which it has long been held globally. Without precautions, the so-called new public management medical faculties will-at best-generate economic benefit, following a business model with strict quality rules, regulations, standardized products, and complex analysis and measurement systems. However, these faculties will function at a level far below the ideal of teaching institutions distinguished for their outstanding components, creativity, and ambience. Conclusions Patients and teaching values are not reducible to financial terms only and the acknowledgement of non-financial values is fundamental to achieve quality in health care and education. The most essential step could be selecting managers who will implement public management principles while taking into account both business requirements and medical ethics. Show less
Keijzer-van Laarhoven, A.J.J.M.; Touwen, D.P.; Tilburgs, B.; Tilborg-den Boeft, M. van; Pees, C.; Achterberg, W.P.; Steen, J.T. van der 2020
Importance and objective Conducting advance care planning (ACP) conversations with people with dementia and their relatives contributes to providing care according to their preferences. In this... Show moreImportance and objective Conducting advance care planning (ACP) conversations with people with dementia and their relatives contributes to providing care according to their preferences. In this review, we identify moral considerations which may hinder or facilitate physicians in conducting ACP in dementia. Design For this meta-review of systematic reviews and primary studies, we searched the PubMed, Web of Science and PsycINFO databases between 2005 and 30 August 2019. We included empirical studies concerning physicians' moral barriers and facilitators of conversations about end-of-life preferences in dementia care. The protocol was registered at Prospero (CRD42019123308). Setting and participants Physicians and nurse practitioners providing medical care to people with dementia in long-term and primary care settings. We also include observations from patients or family caregivers witnessing physicians' moral considerations. Main outcomes Physicians' moral considerations involving ethical dilemmas for ACP. We define moral considerations as the weighing by the professional caregiver of values and norms aimed at providing good care that promotes the fundamental interests of the people involved and which possibly ensues dilemmas. Results Of 1347 studies, we assessed 22 systematic reviews and 51 primary studies as full texts. We included 11 systematic reviews and 13 primary studies. Themes included: (1) beneficence and non-maleficence; (2) respecting dignity; (3) responsibility and ownership; (4) relationship and (5) courage. Moral dilemmas related to the physician as a professional and as a person. For most themes, there were considerations that either facilitated or hindered ACP, depending on physician's interpretation or the context. Conclusions Physicians feel a responsibility to provide high-quality end-of-life care to patients with dementia. However, the moral dilemmas this may involve, can lead to avoidant behaviour concerning ACP. If these dilemmas are not recognised, discussed and taken into account, implementation of ACP as a process between physicians, persons with dementia and their family caregivers may fail. Show less
Zethof, S.; Bakker, W.; Nansongole, F.; Kilowe, K.; Roosmalen, J. van; Akker, T. van den 2020
ObjectiveSurgical informed consent is essential prior to caesarean section, but potentially compromised by insufficient communication. We assessed the association between a multicomponent... Show moreObjectiveSurgical informed consent is essential prior to caesarean section, but potentially compromised by insufficient communication. We assessed the association between a multicomponent intervention and women's recollection of information pertaining to informed consent for caesarean section in a low-resource setting, thereby contributing to respectful maternity care.DesignPre-post implementation survey, conducted from January to June 2018, surveying women prior to discharge.SettingRural 150-bed mission hospital in Southern Malawi.ParticipantsA total of 160 postoperative women were included: 80 preimplementation and 80 postimplementation.InterventionBased on observed deficiencies and input from local stakeholders, a multicomponent intervention was developed, consisting of a standardised checklist, wall poster with a six-step guide and on-the-job communication training for health workers.Primary and secondary outcome measuresIndividual components of informed consent were: indication, explanation of procedure, common complications, implications for future pregnancies and verbal enquiry of consent, which were compared preintervention and postintervention using chi(2) test. Generalised linear models were used to analyse incompleteness scores and recollection of the informed consent process.ResultsThe proportion of women who recollected being informed about procedure-related risks increased from 25/80 to 47/80 (OR 3.13 (95% CI 1.64 to 6.00)). Recollection of an explanation of the procedure changed from 44/80 to 55/80 (OR 1.80 (0.94 to 3.44)), implications for future pregnancy from 25/80 to 47/80 (1.69 (0.89 to 3.20)) and of consent enquiry from 67/80 to 73/80 (OR 2.02 (0.73 to 5.37)). After controlling for other variables, incompleteness scores postintervention were 26% lower (Exp(beta)=0.74; 95% CI 0.57 to 0.96). Recollection of common complications increased with 0.25 complications (beta=0.25; 95% CI 0.01 to 0.49). Recollection of the correct indication did not differ significantly.ConclusionRecollection of informed consent for caesarean section changed significantly in the postintervention group. Obtaining informed consent for caesarean section is one of the essential components of respectful maternity care. Show less
