132 Canadian Family Physician • Le Médecin de famille canadien VOL 49: FEBRUARY • FÉVRIER 2003 VOL 49: FEBRUARY • FÉVRIER 2003 Canadian Family Physician • Le Médecin de famille canadien 133
editorial
Decisions about hormone replacement therapy
Whose responsibility are they?
France Légaré, MD, MSC, CCFP, FCMF Annette O’Connor, RN, PHD
I
t is rare that the most prominent daily newspaper in the country carries an editorial about clinical decision making, more specifically, about whether to prescribe hormone replacement therapy (HRT). This is what the Globe and Mail did on Thursday, July 11, 2002, in response to the widely disseminated results of the Women’s Health Initiative (WHI). Entitled“Trouble with what the doctor ordered,” the edito- rial attracted our attention because it focused on the responsibility of doctors to transmit to their patients all the information available on the risks and benefits of HRT.1
The editorial concluded that physicians need to make wiser decisions from now on: “… [D]octors … are now being asked to make their decisions more wisely.” That editorial disturbed us because it sug- gested that doctors are entirely responsible not only for prescribing, but also for making decisions about, HRT. Is this really the way this decision should be made in the context of family medical practice in Canada? Should it be a decision made solely by doc- tors and imposed on patients, as the editorial in the Globe and Mail suggested, or should it be a decision made solely by patients after they have been fully informed by their doctors?2
Probably, and thank goodness, neither the one nor the other. Between these two extremes, we firmly believe that the discipline of family medicine can offer a third way: shared decision making.3 In fact, in the last few years, this concept has strongly attracted the attention of researchers and family medicine teachers.4,5 A shared decision is one made jointly by physician and patient based on the best evidence, informed by the patient’s specific characteristics and values, and for which the responsibilities and “rights”
of each of the parties are clear.6 For family physicians in Canada, this concept is similar to “finding common ground” in which physician and patient, at the end of a clinical encounter, agree on the extent and nature of the problem, the options available, and, finally, on the role of each in decision making.7 This satisfies
Canadian patients’ need to participate in decision making and also their desire to share fairly in the responsibility for decisions.8
Why focus on decision making?
Why are we focusing on the process of shared deci- sion making in an editorial for Canadian Family Physician before we mention the recent evidence on HRT? It is because, in fact, the choice facing women and their physicians is fraught with uncertainty.
Arguments for and against are in perfect balance (ie, equipoise); it is one of those clinical situations for which the available scientific evidence on the various options shows no clear indication of whether risks outweigh benefits or vice versa.4
When the options are not in perfect balance, the scientific evidence indicates clearly, for example, that an option should be avoided because the risks out- weigh the benefits. When there is perfect balance, neither of the options is clearly supported by the available scientific evidence. With this type of deci- sion, it is always possible that a “good” decision could have an undesirable clinical outcome. Consequently, the decision-making process takes on a huge impor- tance because a favourable clinical outcome cannot be guaranteed. We can only reassure ourselves that we have made the decision in the best possible way.
What is the process for making the best decision possible in such a context? First, it must be an informed decision, hence a process in which a patient under- stands the various options available and their possible outcomes, clarifies her expectations so that they are reasonable and possible, and is aware of the conflict inherent in the decision.9 Also, the decision must be in agreement with a patient’s personal values. She must weigh the pros and cons and choose the option best suited to her in a kind of “personal negotiation” that will leave her feeling satisfied with the decision.
High-quality evidence indicates that interventions that support shared decision making increase knowl- edge, foster realistic expectations, and encourage
Editorial Editorial
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patients to participate actively in clinical encounters with their physicians.10 Such interventions also lessen patients’ discomfort in the face of decisions. This discomfort, also known as “decisional conflict,” is defined as uncertainty about which option to choose, implying a choice among contradictory options with which risks, losses, and regrets could be associated, or conflict with personal values.9 A low level of deci- sional conflict indicates that a person’s decision-making process is proceeding well in a clinical context. It is also associated with greater patient satisfaction fol- lowing decisions and with greater compliance.11 Measuring decisional conflict
The level of decisional conflict can be measured with the aid of a scale.12 Such a scale is widely used in studies of patients’ individual decision making. It has excellent reliability and validity, has been translated and validated in several languages, and exists in ver- sions adapted for research and for clinical use.13
Decisional conflict should not be confused with anxiety, a pathologic state in which patients feel uneasy or apprehensive and in which the autono- mous nervous system is activated in response to a perceived menace.14 We should add that interven- tions to enable shared decision making do not appear to be responsible for raising this type of anxiety in patients.15
Determinants of decisions about HRT
Our work, using the theory of planned behaviour, focused on the intention of 644 middle-aged, pre- menopausal Quebec women from the general popula- tion to adopt HRT. This study showed that women’s personal values were a significant determinant of their decisions about therapy.16 When the women were contacted a year later and almost half of them confirmed they were perimenopausal, their personal values had gained importance in predicting their intention to adopt HRT.17
In another study involving 516 Quebec physi- cians, we looked at their intention to prescribe HRT to middle-aged women who had no contraindica- tions, and found that the physicians’ personal val- ues also seemed to be a significant determinant of their intention to prescribe.18 When we analyzed the tapes of the clinical encounters between a group of physicians and their patients on the subject of HRT, we found that women’s personal values, expecta- tions, beliefs, and personal experiences were rarely taken into consideration.19 This is not surprising given the literature on patient-physician communi- cation in general.20 For decisions that seem perhaps a little more strongly determined by women’s and
physicians’ values than other factors and for which the scientific evidence gives no clear preference for either option, it is always astonishing to find that these values are so rarely discussed and clarified.
We must return to the principles of the practice of family medicine.
In light of the intense debate that surrounds pub- lication of the results of the WHI study, the nature, role, and very essence of the relationship between family physicians and their patients must be rein- forced. The patient-centred approach reminds family physicians how important it is for them to listen to women, to ask them about their values and expec- tations, to tell them of the risks and benefits of the available options, to ensure that they have a shared understanding of the problem and the options, to find out what role they want to play in the decision-making pro- cess, and to encourage them to participate actively in shared decisions.
Sharing the latest information
This requires that we integrate the latest evidence- based data into our practices and share the informa- tion with the women who consult us. In the case of integrating data from the WHI, our interventions should support shared decision making in family medicine because it has been demonstrated to be efficacious.10 Remember that these interventions have been developed to help patients understand the probable risks and benefits associated with the avail- able options, take into consideration and clarify the values that accompany these risks and benefits, per- sonalize decisions, and participate actively with their physicians in the decision-making process.9,21 Finally, family physicians could integrate the concept and measurement of decisional conflict (ie, comfort with decisions) into their professional services.
The next time the Globe and Mail comments on the clinical decisions of Canadian doctors, we hope that it will underline the fact that, in uncertain situa- tions, patients and physicians share responsibility for decision making.
Dr Légaré is a Clinical Professor in the Department of Family Medicine at Laval University in Quebec city, Que, and a doctoral student in population health at the University of Ottawa in Ontario. Ms O’Connor holds the Canadian Chair in Support of Decision Making and is a Professor in the Faculty of Nursing Sciences at the University of Ottawa.
Correspondence to: Dr France Légaré, Family Medicine Unit, Hôpital St-François d’Assise, 10, rue Espinay, Quebec, QC G1L 3L5
134 Canadian Family Physician • Le Médecin de famille canadien VOL 49: FEBRUARY • FÉVRIER 2003
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The opinions expressed in editorials are the opinions of the authors and do not imply endorsement by the College of Family Physicians of Canada.
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