Titrating Guidance: A Model to Guide Physicians Assisting Patients and Families Facing Complex Decisions

摘要

Over the last century, developments in new medical treatments have led to an exponential increase in longevity, but as a consequence, patients may be left with chronic illness associated with long-term severe functional and cognitive disability. Patients and their families are often forced to make a difficult and complex choices between death and long-term debility, neither of which are acceptable outcomes. Traditional models of medical decision making, however, do not fully address how clinicians should best assist with these decisions. In this manuscript, we present a new paradigm which demonstrates how the role of the physician changes over time in response to the curved relationship between the predictability of a patient's outcome and the chance of returning to an acceptable quality of life. To translate this model into clinical practice, we present a five step model for physicians where they: 1) determine where the patient is on the curve; 2) identify the cognitive factors and preferences for outcomes which affect the patient/family's decision-making process; 3) reflect on their own reaction to the decision at hand; 4) acknowledge how these factors can be addressed in conversation; and 5) guide the patient/family in creation of plan of care. This model can help improve patient-physician communication and decision making so that complex and difficult decisions can be turned into ones that yield to medical expertise, good communication, and personal caring.