International Conference on

Communication in Healthcare Oslo 2008 From equipoise to deliberation

exploring shared decision making Glyn Elwyn

Nothing is more difficult, and therefore more precious, than to be able to decide.

Napoleon

Making decisions…

• Are we doing the right thing when we deliberate?

• Why do we pay attention to some decisions more than others?

• From equipoise to deliberation…

• Decision quality is about process not about outcome

Making decisions…

• Are we doing the right thing when we deliberate?

• Why do we pay attention to some decisions more than others?

• From equipoise to deliberation…

• Decision quality is about process not about outcome

Making decisions…

Are we doing the right thing when we deliberate?

• Need high quality data

• Need more time

• Need new skills

• Need new attitudes

• Perhaps more fundamental problems…

It is a profoundly erroneous truism… that we should cultivate the habit of thinking of what we are doing.

The precise opposite is the case. Civilization advances by extending the number of operations which we can perform without thinking about them.

Operations of thought are like cavalry charges in a battle—they are strictly limited in number, they require fresh horses, and must only be made at decisive moments. Whitehead, 1911

Deliberation versus intuition?

Ap Dijksterhuis 2006 On Making the Right Choice: The Deliberation-Without-Attention Effect

Tordesillas and Chaiken 1999 Thinking too Much or too

Little? The Effects of Introspection on the Decision-Making Process

Wilson and Schooler 1991 Thinking too much: Introspection can reduce the quality of preferences and decisions.

On Making the Right Choice: The Deliberation-Without-Attention Effect

On Making the Right Choice: The Deliberation-Without-Attention Effect

Ap Dijksterhuis, Maarten W. Bos, Loran F. Nordgren, Rick B. van Baaren

Contrary to conventional wisdom, it is not always advantageous to engage in thorough conscious deliberation before choosing. On the basis of recent insights into the characteristics of conscious and unconscious thought, we tested the hypothesis that simple choices (such as between different towels or different sets of oven mitts) indeed produce better results after conscious thought, but that choices in complex matters (such as between different houses or different cars) should be left to unconscious thought. Named the "deliberation-without-attention" hypothesis, it was confirmed in four studies on consumer choice, both in the laboratory as well as among actual shoppers, that purchases of complex products were viewed more favorably when decisions had been made in the absence of attentive deliberation.

SCIENCE 17 FEBRUARY 2006, 311: 1005 - 1007

Deliberation as placebo-clasm

• Placebo effect rests on belief (Evans, 2004).

• Does talk about uncertainty foster belief?

• Does deliberation over competing options foster belief in the chosen treatment?

Deliberation for healthcare decisions?

• Evidence from trials of decision support technologies (aids) are consistent (benefits outweigh harms)

• However, implementation of decision aids into routine settings remains arduous: numerous barriers

• Clinical infrastructures are resistant to changes that require increased time, information, skill enhancements

and emotional work.

Why do some decisions need deliberation?

• Respect for the concept of agency: that individuals have the right to self-determine (autonomy).

• Uphold the ethical stance determined by veracity (truth-telling) and beneficence / non-maleficence (non nocere).

• The impact of undeclared uncertainty (unexpected outcomes, regret and dissatisfaction)

• Withholding information about choice sets and their attributes is a form of coercion (undeclared options are discounted)

• Personal preferences are unknowable if choice sets are invisible• Cognitive benefits (knowledge, decision conflict, satisfaction)• No long-term health benefits demonstrated; increase in conservative approaches to

elective surgery. • Sapere aude – dare to know – Horace, Kant, Foucault…

Before Deliberation

• Practical deliberation (known to Aristotle as bouleusis) is about ‘what to do’ not about a judgement (a ‘yes or no’ decision).

• The precondition is the awareness of choice – that options exist, and more than that, they legitimately exist, and that the choice is not obvious, false or contradictory.

• See Buridan’s Ass • See Hobson’s Choice• See Catch-22• See Morton’s Fork

Buridan's ass

Will the ass starve, unable to make a rational decision which haystack to move to? The paradox is attributed to Jean Buridan, a French philosopher (14 C).

Hobson (1544–1630), a stable owner at in Cambridge, who, in order to rotate the use of his horses, offered customers the choice of either taking the horse in the stall nearest the door or taking none at all.

Hobson’s Choice

The insane cannot claim insanity

Morton’s Fork

Tax those who look wealthy, its obvious, they have too much money.

John Morton, Lord Chancellor, England 1487.

Morton’s Fork

Tax those who look wealthy, its obvious, they have too much money.

Tax those who look poor, they must be hiding their wealth.

John Morton, Lord Chancellor, England 1487.

Making decisions…

• Are we doing the right thing when we deliberate?

• Yes – we need to deliberate – at a minimum, we do need to know what our options are, and we need to know at least something about these options

• But we do not know … how best to deliberate

Making decisions…

• Are we doing the right thing when we deliberate?

• Why do we pay attention to some decisions more than others?

• From equipoise to deliberation…

• Decision quality is about process not about outcome

Before Deliberation

• Practical deliberation (known to Aristotle as bouleusis) is about ‘what to do’ not about a judgement (a ‘yes or no’ decision).

• The precondition is the awareness of choice: that options exist, and more than that, they legitimately exist, and that the choice is not obvious, false or contradictory.

• This precondition may be named – equipoise – that there is a situation of balance – that all the options available have positive and negative attributes (pros and cons), and, at some level, a ranking or weighing is needed – a deliberation process.

• What therefore are the determinants of equipoise… a necessary precursor to deliberation.

Deliberative Zone of Complexity: after Stacey

Shared decision making• Problem definition• Equipoise• Options• Checking understanding • Ideas, concerns, expectations• Role preference• Decision making• Deferment• Review arrangements

Tough decisions

• Amniocentesis: offered to women at higher risk of having a baby with chromosomal abnormality

• Breast cancer: wide local excision versus mastectomy. Similar morbidity and mortality, but different psychosocial attributes.

• PSA test: possible early diagnosis of prostate cancer but with what benefit, given the long lead time to aggressive expression and also uncertainty about treatment.

Amniocentesis

• Amniocentesis: offered to women at higher risk of having a baby with chromosomal abnormality

• Offer of amniocentesis, consequent on screening test. Not always obvious that the screening test would lead to this dilemma.

• 1 in a hundred chance of losing a normal pregnancy, 3 in 100 chance of detecting e.g. trisomy 21.

Equipoise

Decision CharacteristicsHigh or low stakes (urgency, consequences, non-reversibility)Choice set (simple or complex)Financial parametersLegal parametersCultural norms

Uncertainty ProfileEvidentiary uncertainty Precision uncertainty Stochastic uncertaintyPreference uncertainty

Amniocentesis

Health Professional:Ethical Stance

Agency / Autonomy

Veracity

Beneficence, Non-maleficence

Patient: Self-relevant Importance

Anticipated regret

Fear or anxiety

Risk aversion

Other emotions

Making decisions…

• Why do we pay attention to some decisions more than others? Towards an understanding of equipoise.

Important (relevant to self), obvious uncertainty (different types), preference-sensitive, therefore legitimate deliberation

Making decisions…

• Are we doing the right thing when we deliberate?

• Why do we pay attention to some decisions more than others?

• From equipoise to deliberation…

• Decision quality is about process not about outcome

Laplace’s demon

An intellect which at a certain moment would know all forces that set nature in motion, and all positions of all items, if this intellect were also vast enough to submit these data to analysis, it would embrace in a single formula the movements the universe...

Laplace’s demon

… for such an intellect nothing would be uncertain and the future just like the past would be present before its eyes.

Pierre-Simon LaplaceEssai philosophique sur les probabilitiesal, 1814

Visions of rationality

Laplace’s demons

Bounded rationality

Unbounded rationality Optimization under constraints

SatisficingFast and Frugal

Heuristics

OutcomeProbability 0.6

OutcomeProbability 0.4

Option A

Option B

Utility 0.33

Utility 0 .66

Expected Utility0.20

Expected Utility0.26

Unbounded rationality

Visions of rationality

Laplace’s demons

Bounded rationality

Unbounded rationality Optimization under constraints

SatisficingFast and Frugal

Heuristics

Fast and Frugal Heuristics

Examples of heuristics

• One reason decision making

• Tallying integration

Making decisions…

• Are we doing the right thing when we deliberate?

• Why do we pay attention to some decisions more than others?

• From equipoise to deliberation…

• ‘Decision Quality’ is about process not about outcome

What is a good decision?

• Avoid dependence on outcomes

‘because a good or bad outcome may powerfully influence perceptions (of decision quality)… such a judgement is best made before the outcome is known’

Fisher and Fisher 1999

Concept of “decision quality”

“... decision quality can be measured by… knowledge about the options and outcomes, realistic perceptions of outcome probabilities, and agreement between patients' values and choices ”

O’Connor 2003

Concept of “decision quality”

“... the quality of a preference-sensitive clinical decision can be defined as the extent to which the implemented decision reflects the considered preferences of a well-informed patient…”

Sepucha et al 2007

What is a good decision?

• Avoid dependence on outcomes

‘… a major concern being that decisions cannot be evaluated after they have been made. For the most part, researchers are vague on this issue’

Elwyn, Elwyn and Miron-Shatz, 2008

What is a good decision?Focus on a good deliberation process

• Nature of decision• Valid option set• Attribute data (over a range of issues)• Probability data• Preference elicitation, construction, evaluation

(Elwyn, Elwyn and Miron-Shatz, 2008)

Development of a Deliberation Process Measure

• How to ‘deliberate’? … a research issue… stay tuned.

What is a good decision?

Focus on a good deliberation process

• Post-deliberation > pre-decision• Post-deliberation > post-decision > pre-enactment • Post-deliberation > post-decision > post-enactment

(Elwyn, Elwyn and Miron-Shatz, 2008)

Development of a Deliberation Process Measure

• How to ‘deliberate’? … a research issue… stay tuned.

“When we want your opinion, we’ll give it to you”

I’m sorry doctor, but again I have to disagree

From equipoise to deliberation…

• Are we doing the right thing when we deliberate?

• Why do we pay attention to some decisions more than others?

• From equipoise to deliberation…

• Decision quality is about process not about outcome

This is a tough decision …