Clinical decision-making in the context of chronic illness

Viewpoint

Clinical decision-making in the contextof chronic illness

Susan Watt DSW CSW

School of Social Work, McMaster University, Hamilton, Ontario, Canada

Introduction

Mr and Mrs Arthur have come to see their

physician. Mr Arthur is recovering from a

surgery for prostate cancer. Mrs Arthur is being

treated for high blood pressure and arthritis. He

must decide whether or not he will begin a

course of radiation therapy; she will be told that

she should discontinue her arthritis medication

because her blood pressure is elevated. Mr

Arthur leaves the meeting with a clear course of

action, convinced that he soon will be healthy,

and planning for a winter vacation in Florida.

Mrs Arthur leaves the same meeting feeling

quite concerned about whether she could stay on

her medication until next weekend. Her niece is

getting married, and Mrs Arthur anticipates

increased di�culty getting around. She is

CorrespondenceDr Susan Watt

School of Social Work

McMaster University

1280 Main Street West

Hamilton, Ontario, L8S 4M4

Canada

E-mail: [email protected]

Accepted for publication28 September 1999

Keywords: clinical decision-making,

chronic illness

Abstract

This paper develops a framework to compare clinical decision

making in relation to chronic and acute medical conditions. Much

of the literature on patient-physician decision making has focused

on acute and often life-threatening medical situations in which the

patient is highly dependent upon the expertise of the physician in

providing the therapeutic options. Decision making is often

constrained and driven by the overwhelming impact of the acute

medical problem on all aspects of the individual's life. With chronic

conditions, patients are increasingly knowledgeable, not only about

their medical conditions, but also about traditional, comple-

mentary, and alternative therapeutic options. They must make

multiple and repetitive decisions, with variable outcomes, about

how they will live with their chronic condition. Consequently, they

often know more than attending treatment personnel about their

own situations, including symptoms, responses to previous treat-

ment, and lifestyle preferences. This paper compares the nature of

the illness, the characteristics of the decisions themselves, the role

of the patient, the decision-making relationship, and the decision-

making environment in acute and chronic illnesses. The author

argues for a di�erent understanding of the decision-making

relationships and processes characteristic in chronic conditions that

take into account the role of trade-o�s between medical regimens

and lifestyle choices in shaping both the process and outcomes of

clinical decision-making. The paper addresses the concerns of a

range of professional providers and consumers.

6 Ó Blackwell Science Ltd 2000 Health Expectations, 3, pp.6±16

worried about her doctor's comments that she is

at increased risk for a stroke if her blood pres-

sure remains high. She is convinced that she will

never make it to Florida. The physician is sure

that when he sees Mr Arthur in 3 months he will

be well on the road to recovery but that Mrs

Arthur will return to his o�ce next month in

ongoing distress. Each has participated in a

clinical decision-making encounter ± one related

to an acute illness, the other to chronic condi-

tions. Could we have anticipated these outcomes

and the reactions of the participants based on

our current understanding of clinical decision-

making?

As the population has aged and advances

have occurred in acute medical care, chronic

conditions have become more prevalent. It is

likely that as we age, we will acquire more than

one chronic condition. So great is this increase in

prevalence that recent estimates indicate that in

excess of 60% of the health care expenditures in

North America are committed to the manage-

ment of chronic illnesses. Therefore, on the basis

of clinical frequency and costs, how both

consumers and providers approach decision-

making in relation to chronic conditions

warrants consideration if we are to understand a

major part of our work environment and

improve the quality of clinical decision-making.

Increasingly, responding to people with

chronic illnesses challenges the health care

system, designed to address acute illnesses. The

literature on clinical decision-making largely has

focused on serious, acute medical situations.1±6

Little attention has been placed on under-

standing the similarities and di�erences in clin-

ical decision-making as we currently understand

it, when those decisions relate to chronic

conditions.

Chronic conditions are those illnesses in which

no cure is possible and clinical decisions hold the

potential only for symptom reduction or

containment of deterioration. Even best e�orts

will not eliminate the ultimate life threatening

nature of some of these conditions (e.g. asthma,

chronic obstructive lung disease, and diabetes).

No one clinical decision will hold throughout

the course of the illness; decision-making in

relation to treatment, symptom management,

and lifestyle changes will recur with varying

frequencies. As a result of the increasing

prevalence of chronic conditions, the nature of

those conditions and the need to make multiple

decisions in relation to chronic illness, it is

important for clinicians and researchers to think

carefully about the ways in which decision-

making may vary when used in chronic and

acute illnesses.7

The purpose of this paper is to begin to

develop a framework for understanding the

similarities and di�erences in decision-making

when dealing with acute versus chronic illness.

Understanding clinical decision-making

Clinical decision-making has been studied in the

context of the doctor-patient* relationship.8±11

The models for this relationship, which range

from paternalism to collaborative problem

solving, place the doctor-patient encounter at

the centre of clinical decision-making with

peripheral and varying importance assigned to

the roles of signi®cant others, past experience,

personal preference, and lifestyle choices on the

decisions of the physician or the patient.12±14

Generally, research has focused either on how

to help patients make decisions or on how to

understand the degree of involvement in decis-

ion-making that is desired by the patient.

The ideal situation was cast as one in which the

patient and the physician would make the same

decision, or at least agree upon the most appro-

priate decision.15 It was supposed that decision-

making, which hitherto had been the sole

responsibility of the physician was a rational

process, based on scienti®c evidence and clinical

experience. Therefore, it was argued that patients

would make the same decision as would the

attending physician given an adequate exchange

of information between them.16 Rational, expert-

*The author is aware of the debate in the literature about the

use of the terms patient, consumer, and client. For the

purpose of this paper the term patient is used throughout

when referring to anyone receiving medical care unless a

clear distinction is made in the text.

Clinical decision-making in the context of chronic illness, S Watt

Ó Blackwell Science Ltd 2000 Health Expectations, 3, pp.6±16

7

driven decision-making was viewed as the most

common, if not always preferred, model for these

types of clinical encounters.17,18

It was also argued in this literature that decis-

ion-making was a stable, predicable activity such

that, given the same set of options, the same

patient would make the same decision at di�erent

points in time.19 Indeed, decision-making was

depicted as a single activity or at most a discrete

series of activities which could be systematically

dissected, understood, and analysed. This view of

decision-making as a rational and linear process,

located information seeking on the part of

participants as a central activity, and led to the

position that the sharing of medical information

was central to decision-making whilst the role of

context in the decision-making of either the

consumer or the provider was secondary.20±23

Failure to achieve mutuality, to agree upon a

course of action, was perceived negatively and

labelled in terms of deviance or pathology on the

part of the patient. The physician traditionally

has been seen as the repository of both medical

knowledge and social power. Therefore, any

variation on paternalism in the decision-making

relationship represented an abrogation of power

and authority on the part of the physician.24,25

This interpretation of the physician-patient

relationship has been ®rmly rooted in models of

acute care in which short-term trade-o�s are

made between the physician, the patient, and the

larger society in return for the restoration of

health. The only real choice for the patient is the

decision whether or not to comply with the

physician's recommendation.26

Given that many acute care decision situ-

ations are immediate and high risk, the expert

role of the physician has been valued and

legitimated in decision-making. Generally, in

North America, we look to the physician as the

singular expert on our illnesses and how to treat

them. We want to believe that they know how to

cure our pain and su�ering.

More recently that relationship has been

changing in response to increasingly know-

ledgeable consumers, more ambiguous clinical

challenges and an increasing role of funders in

de®ning the availability of clinical options.

Further, the legitimate claim of other health

clinicians to knowledge about health has chal-

lenged traditional doctor-patient relationships.

These changes have led to both clinicians and

consumers questioning the appropriateness of

the physician as the sole or even dominant

arbitrator of clinical decisions.

When a consumer is facing a chronic illness,

the roles of the physician and the patient are

di�erent. By de®nition, the physician although

an expert, is not the healer and the patient,

despite good intentions and decisions, will not

be cured. How then are decisions and decision-

making under these conditions the same as and

di�erent from decision-making in acute

illnesses?

A framework for understanding

decision-making in chronic conditions

A variety of factors a�ect decision-making in the

context of chronic conditions. Whilst all the

factors exist in both the acute and chronic situa-

tions, their expression may be quite di�erent in

chronic illnesses. The factors that will be

considered in this framework are the nature of

the illness; the characteristics of the decisions to

be made; the role of the individual patient; the

nature of the decision-making relationship; and

the decision-making environment. Each factor is

discussed in the following sections with attention

to the similarities and di�erences in decision-

making in acute and chronic illnesses, and is

summarized in Table 1.

Nature of the illness

Illness in any form disrupts the life of a patient

but acute and chronic illnesses do so in di�erent

ways. When acutely ill, we expect that the

disruption will be time-limited and that we will

return to our previous good health. Having been

diagnosed with a chronic illness, we must

abandon the expectation of recovery in the

foreseeable future.

The division between acute and chronic illness

is an increasingly hazy one. What may begin as

an acute illness may end up being a chronic one

(e.g. a heart attack may herald the presence of


Clinical decision-making in the context of chronic illness, S Watt8

chronic arterial disease). Chronic illnesses may

have acute episodes (e.g. episodes of acute

hypoglycaemia in diabetics). Both types of

illness may be life threatening, time and energy

consuming, and ®nancially draining. They both

may have insidious or acute onset and symptoms

with varying degrees of incapacity. Acute

illnesses may also leave the patient with chronic

residual e�ects (e.g. paralysis after a stroke)

which may be devastating in and of themselves

regardless of the underlying pathological

processes.

However, unlike an acute illness, chronic

illness is, by de®nition, long lasting. It also may

produce di�ering, variable, and unpredictable

levels of incapacity and in many cases that

incapacity will increase over time. Even with

good choices, the results of following treatment

recommendations will not be a cure. At best, the

individual with a chronic illness can expect

remission or control of symptoms, a delay in

disease progression, or the prevention of

sequelae.

The illness remains and is likely to have an

increasing impact on the life of the individual.

One may be able to `buy time' or delay

symptoms, but the illness persists and one is

never again completely well. Normal life

routines will now include simple or complex

observation, intervention, and evaluation of

not only one's own health but also one's

illness.

One's de®nition of self as healthy and able,

which may be shaken by an acute illness, is

forever changed by a chronic illness.27±31 In its

simplest course, with an acute illness, the indi-

vidual gets sick, gets treatment, and gets well.

This is not the case with a chronic illness.

Even when making decisions in relation to

acute medical conditions, the pervasiveness of

the chronic condition is evident. For example,

decisions concerning the management of relat-

ively minor infections are modi®ed by the

presence of diabetes; chronic obstructive lung

disease changes treatment options for a

myocardial infarction. Patients may see them-

selves, or be seen by others including their

physicians, family, and coworkers, as their

disease (e.g. the diabetic, the arthritic) again

demonstrating the invasive and pervasive

quality of chronic illness.

Decisions ± nature, number and evidence used

For an acute illness, there is a direct relationship

between the illness and its treatment. There is an

assumption that the treatment will result in a

Table 1 Comparison of factors in clinical decision-making

Factors Acute illness Chronic illness

Nature of illness Discrete; time-limited; treatable Pervasive; long-term; manageable

Decisions Cure focused Control focused

Nature Deal with cause; minimal side effects Symptom reduction; sequellae prevention;

side effects trade-off

Number Single Multiple; repetitive

Evidence used Focused on illness Focused on illness plus lifestyle; little on

multiple chronic conditions and their

interaction

Role of individual Clear de®nition; socially endorsed and exemption

provided; de®ned in relation to providers

Unclear; little social de®nition or support;

self-care emphasis

Patient Consumer

Decision-making Patient and treatment focused Consumer and symptom focused

relationship Permission for provider to act Permission for consumer to act

Decision-making Secondary consideration Primary consideration

environment Temporary disruption until patient is well Permanently altered to accommodate

symptoms and management


9Clinical decision-making in the context of chronic illness, S Watt

cure. The range of options that will cure the

illness with the fewest and/or least serious side-

e�ects frames a care decision faced by both the

provider and the patient. Providers know, and

patients are cautioned, that in some instances a

cure will not result from treatment or that there

will be side-e�ects from the treatment. However,

any decision to act is predicated on a funda-

mental assumption that the disease can be cured

and that providers know what treatment will

work for a speci®c condition. Therefore, in

addition to a positive outcome in an acute

illness, there is a presumption that only one

major decision is necessary in relation to any

given episode.

For example, for the patient with an acute

appendix, decision-making is highly restricted ±

operate or risk dying from a ruptured appendix.

Once this decision has been made, it is assumed

that a reasonably predicable course of treatment

and recovery will follow. The trade-o� is clear

and, in this example at least, normally would

require little deliberation. With more high-risk

procedures the decision to treat, whilst more

complicated, is focused by an assumption of

cure.

In chronic illnesses, the nature of the decision

is often what Gafni has de®ned as `what if'

options.11 What if we were able to prevent future

damage? What if we could reduce, but not

eliminate, symptoms? What if we could reduce

your pain, but shorten your life?

The outcomes of each option are often

unpredictable, involve trade-o�s amongst neg-

ative options, and are not perceived by either the

provider or the patient as optimal. They are

essentially `phantom options' which inevitably

fall short of the desired outcome of cure. The

essential trade-o�s, which de®ne the decision

options, are far less clear or certain than in most

acute situations. The focus becomes manage-

ment not cure.

The number of decisions that must be made in

relation to a chronic illness also di�ers from the

number of decisions made about an acute illness.

There is no one decision. Instead, there is a series

of multiple decisions, often made each day, and

most often requiring trade-o�s with non-medical

variables.32±34 For example, diabetics must

decide many times each day whether or not to

inject insulin, how much insulin to take, and

consequently, how much of what type of food

they will eat, how much they will exercise, and

when all of these activities will occur. These

decisions become solely those of the patient who

then must develop a sophisticated understanding

of their illness and treatments, therapeutic

options, and the short and long-term conse-

quences of their decisions, some of which, as in

the case of the diabetic, may be immediately life

threatening.

Normally an individual has only one acute

illness at a time. However, individuals often

have more than one chronic illness. Each illness

has its own management regimen and, with this

accumulation, the regimens may become

competitive. For example, one medication is

taken twice a day whilst another, if compatible

with the ®rst, is taken every 4 hours. One illness

may require bed rest whilst another, regular

aerobic exercise. Choices must be made between

these competing regimens. Each choice requires

an evaluation of the relative merits of potential

outcomes created by sacri®cing one regimen to

another. These judgements are often made

without expert guidance but with con¯icting and

compelling advice from the respective specialists

consulted for each condition.

The accumulation of chronic illnesses will

impair the overall health status of the individual

and may drive certain clinical decisions.

The impact may not be just additive but also

exponential. For example, the person with

hypertension may take medications that predis-

pose them to Type II diabetes.

Time also takes on a di�erent meaning.

Treatments, like the illnesses themselves, never

end. Whilst they may change from time to time

to re¯ect changes in knowledge, treatment

options, or treatment preferences,35±38 they must

become part of the life of the individual and

their family for an inde®nite period and tend to

increase rather than decrease over time.

Normal life events further complicate many

chronic conditions (e.g. pregnancy and dia-

betes).26 Commitment to long-term treatment


10 Clinical decision-making in the context of chronic illness, S Watt

regimens is increasingly di�cult, as both the

temporal and causal link between treatment and

outcome is attenuated.39

Although the relationship between treatment

and outcome is clearer in acute illnesses,

compliance with treatment regimens has been

estimated at only 30±40%. When this rela-

tionship is even less evident, as it is in chronic

conditions, it is hard to imagine that someone

will be able to adhere to often complex,

demanding, and expensive treatment regimens.

When the patient cannot ®nd an immediate

link between treatment and its bene®ts, the

likelihood of compliance is decreased. Non-

compliance often leads to both the patient and

the provider believing that they have failed.

Even when available, research evidence

concerning treatment e�cacy is usually

restricted to speci®c illnesses.25 Little evidence

is available to either the physician or the

patient upon which to base decisions about

competing therapeutic choices for multiple

conditions ± a situation already identi®ed as

an increasingly common one.

In summary, the characteristics of the decis-

ions facing people with acute and chronic

conditions share some common features such

as weighing trade-o�s and anticipating

outcomes. However, in terms of the nature of

the decisions, the number of decisions, and the

evidence availability of useful evidence for both

providers and consumers, there is a major

di�erence in the characteristics of the decisions

themselves.

The role of the individual

The `sick role' de®nes the behaviours and

responsibilities expected of acutely ill individuals

as patients, exempting them from a variety of

social responsibilities, whilst getting well. On the

other hand, the person with a chronic condition

is often not perceived to be sick, despite the

presence of symptoms, a diagnosis, and medical

regimens. In fact, their patient role, present at

the time of initial diagnosis, is transformed often

into the role of a health care consumer.

In the process of decision-making, the indi-

vidual who is chronically ill lacks a clearly

established and socially validated role. Anger

and demands for accountability may replace

concern and exemption, the initial response of

others to an episode of acute illness.

There is signi®cant impact on family rela-

tions. Marriage can serve as either a bu�er or

`stressor' for the chronically ill person.40

Partners, relatives, friends, and colleagues are

often at a loss to know how to respond

beyond the acute phase or initial diagnosis.

They often interpret symptom remission, a

primary goal of intervention, as a sign of cure.

They, too, are faced with integrating decision-

making concerning their roles in relation to

the chronic illness into their lives and their

relationship with the patient.

The family may have to reorient their decis-

ion-making activities. Families, which are

traditionally oriented to the rearing of children,

are faced with both participating in decision-

making and being a�ected by the decisions made

by the chronically ill person (e.g. how much of a

care giving role will they take on; mother will no

longer drive the kids to hockey practice). They

will become active or passive participants in

decision-making.

There may be not only a decrease in the

resources available for the family but also a

redistribution of resources to meet the require-

ments of the chronically ill member. New

decisions will have to be made about how to deal

with these changing resources. Time, money,

emotional and social resources are changed by

the results of these decisions. Unlike child

rearing, the outcomes of these allocations are

not decreasing demands on resources, but the

probability of changing and likely increasing

demands over time. Much variation has been

found in the ways in which families adapt to

these changes; but they will change and be

changed.27,41,42

Chronic illnesses are the subjects of beliefs,

superstitions, cultural interpretation, and indi-

vidual meaning in much the same way as acute

illnesses.29,43 The meaning of chronic illness is

di�erent from acute illness for patients, provi-

ders and signi®cant others.14,28,30,31 Notions of

impairment, disability, and incapacity modify



the sick role. Individuals must adapt their de®-

nitions of themselves to the limitations, demands

and anticipated future imposed by the chronic

condition. In keeping with the ways in which

they change their self-image, the person with a

chronic illness will approach decision-making

with a di�erent perspective.

The patient largely operationalizes complex

and ongoing care decisions. The patient-as-pro-

vider becomes yet another role that distinguishes

the individual with an acute illness from one

with a chronic illness. Self-care is a hallmark of

chronic illness.28,29 Instead of the usual exemp-

tion from responsibility, self-care increases

responsibility on the patient often requiring that

the patient assimilate new knowledge and add

skills, which were neither sought nor desired by

the patient. Imposed by providers and the

community, the new role of `person with a

chronic illness' ± a health care consumer ± now

must be learned, practiced and adapted to the

con®guration of that particular individual in

their unique biopsychosocial environment.

Taking on this new role will in¯uence how the

patient approaches and deals with decision-

making.

Thus, whilst individuals with any illness take

one of their roles from that circumstance, an

acute illness casts the individual in the socially

de®ned and recognized role of patient with all

the rights and responsibilities characteristic of

that role. For the individual with a chronic

illness, the role is less well de®ned and tested. It

appears to be emerging as one more closely

aligned with our concept of a consumer rather

than a patient. Consumers are distinct from

patients in as much as they are expected to make

decisions based on the best available evidence,

product availability, and personal preference.

Consumer loyalty and trust is thought to be

earned through demonstration rather than

assumed as a function of provider status. Decis-

ion-making by the consumer is viewed as

rational and within their exclusive control.

Consumers are not provided with the exemp-

tions and protections associated with being a

patient.

The nature of the decision-making relationship

In chronic illnesses, the patient's relationships

with health care providers are complex. In the

Canadian health care system, family physicians

carry the major medical role with specialists

having episodic involvement. Therefore, clinical

decision-making involves at least two providers

as well as the patient. In contrast to the patient-

physician dyad, typically described in acute

illnesses, dyadic coalitions of provider-provider

or provider-patient can complicate decision-

making. Where medical information is not

de®nitive, physicians may disagree with one

another. For every additional provider the

probability of disagreement and of coalitions

increases.

The relationship with a family physician, and

probably a specialist, is necessarily long-term.

Systems of delivery may restrict the degree of

consumer choice of physician either by the

method of payment or the availability of provi-

ders. Episodic acute illness may add other

providers and further complicate decision-

making relationships.

With both acute and chronic illnesses, these

relationships exist for the sole purpose of caring

for the patient. The relationships are the vehicles

for the conveying of particular types of infor-

mation between the patient and the provider. As

they are professional relationships, they are

simultaneously patient and task focused, invol-

ving a series of negotiations about the care of the

patient. In relation to an acute illness, those

actions usually are performed or directed by the

provider. On the other hand, in relation to

chronic illness, the patient usually performs

those actions. Thus, the focus in one relationship

is on decisions that permit the provider to act

whilst, in the other, it is on permission for the

patient to act.

Patients are faced with the pre-eminence of

physical health criteria in evaluating their ability

to cope. The signs and symptoms of illness have

di�erent meanings for patients and providers

and hence di�erent impacts on the decision-

making relationship. For example, for the

rheumatologist, newly reported pain in ®nger



joints is an indication of increased joint

involvement in arthritis. For the patient, the

same change in pain may prompt the giving up

of an activity such as sewing.

This di�erence in interpretation may not seem

to be a major problem. However, if sewing is the

individual's way to clothe a family or to give

gifts, or to be creative, the decision to give up

this one activity may have major ®nancial,

social, or psychological rami®cations of long

duration. Those who make the decision to

continue the activity in the face of painful

symptoms are likely to be criticized. Their ability

to make future decisions may be called into

question by providers and other signi®cant

people in their lives. These people may fail to

understand the di�erent meaning given to

symptoms by patients and providers, and the

trade-o� between physical symptoms and func-

tioning that are made by patients.

Whilst patients generally have become more

knowledgeable about health matters, those with

chronic conditions and access to the latest

information through the World Wide Web and

self-help sources, and a focus on their particular

problem, may have even more recent informa-

tion than many of their service providers. Their

decisions are in¯uenced by this information not

only in terms of treatment choices, but also in the

ways in which they evaluate treatment outcomes.

As providers of much of their own treatment,

whether willing or unwilling, patients with

chronic illnesses become both their own care

providers and evaluators. In the truest sense they

become consumers rather than patients. Thus,

whilst decision-making in acute situations

provides direction to providers, generally, decis-

ion-making in relation to chronic illnesses

directs the activities of patients.

The decision-making environment

Decisions concerning both acute and chronic

illnesses happen in a personal and social context.

Both acute and chronic illnesses are a�ected by

and disrupt this environment but in di�erent

ways.

Acute illness necessitates an abrupt but

temporary disruption. Decisions need to be

made in a timely manner and there is often a

sense that the illness is the dominant factor in

the life of the patient and their support system.

Tasks of daily living are displaced by the

immediate care seeking activities. Environment

is an obstacle to be overcome and is secondary

to the clinical decisions that are being made.

Tasks related to help seeking become the focus

of everyone's attention.

Chronic illness lacks the urgency accorded

acute illness. There is a sense, beyond the

initial diagnosis, that there is little urgency in

the situation. Securing and attending at

appointments is somehow less important than

with an acute illness. At least on the surface,

daily routines retain their pre-illness import-

ance and care seeking is `worked into' existing

schedules and commitments. There seems to be

time to think about clinical decisions, to delay

commitment, and to change your mind. The

home and work environment retains its pre-

eminence despite being permanently altered by

the symptoms and management of a chronic

illness.

As a result of the duration of the illness and

the complexity of treatment regimens, chronic

illnesses necessarily involve others who parti-

cipate in decision-making in multiple and

meaningful ways. As discussed early in this

paper, family members, friends and colleagues

are called upon to participate in decision-

making and to enact the decisions that are

made. The degree of involvement of others is

variable, determined not only by the care and

support needs of the patient but also by their

pre-illness relationships. They are called upon

to make a long-term commitment to support

the patient in making and acting upon their

decisions. Relationships must be renegotiated

to accommodate these new responsibilities and

obligations.

Conclusions

Decision-making is a complex process in which

both individual and environmental factors play

important roles. In both acute and chronic

conditions, the patient and provider are faced



with making decisions based on limited infor-

mation as to which option will produce the best

results in a speci®c situation.

In this paper it has been argued that clinical

decision-making in relation to acute and chronic

illnesses share some similarities but also striking

di�erences. These di�erences re¯ect the charac-

teristics of the illnesses, the diversity in the

nature and number of decisions to be made, the

di�erential availability of clinical evidence,

the distinctiveness of the patient role in each

situation, the subtleties of decision-making

relationships, and the di�erential impact of these

components in the decision-making environ-

ment.

Any individual who is chronically ill may be

involved in many types of clinical decision-

making. The presence of a chronic illness does

not determine how all clinical decisions will be

made. There may be di�erent decision-making

processes used at di�erent stages of the illness,

or for acute episodes of an illness that is

normally quiescent. Still another decision-

making process may be invoked for acute

illnesses.

Patients' decision-making ability is deter-

mined in large measure by their ability to exert

command over symptoms, treatments, personal

and social resources, and even over providers.

This ability is compromised during an acute

illness when providers control the information,

skills, and resources needed to restore health.

The patient's ability to exercise control in this

situation is seriously limited and their involve-

ment in decision-making re¯ects the willingness

of providers to relinquish clinical decision-

making control.

In chronic conditions, providers normally

hold little in the way of unique expertise and no

curative ability. Therefore clinical decision-

making is focused on disease management and

the patient is not only empowered, but also often

required, to take an active and central role in

this process.

Thus, the management strategies and expected

outcomes signi®cantly alter the role of both

patient and provider. Little is known about how

either patients or providers de®ne and adapt to

these changes. The added complexity of moving

from acute to chronic situations in the same

relationship, as is the case with the family

physician-patient relationship, is even less well

understood.

The framework presented in this paper begins

to address some of the distinguishing factors

that characterize these processes. In addition to

understanding the roles of the participants, we

need to understand the environments in which

the decision is being made and the processes

used in these decision-making circumstances.

Therefore, we need to research di�erent decis-

ion-making styles of both patients and of

providers and how these styles are enacted in a

variety of clinical decision-making encounters.

We need a better understanding of how decision-

making results in congruent or con¯icting

outcomes and how all participants evaluate such

outcomes if we are to understand this aspect of

clinical decision-making.

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Clinical decision-making in the context of chronic illness

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