Academic journal article Human Factors

When the Patient Chooses: Describing Unaided Decision in Health Care

Academic journal article Human Factors

When the Patient Chooses: Describing Unaided Decision in Health Care

Article excerpt


In contemporary health care a dramatic shift has occurred in the way treatment decisions are made. In situations in which medically equivalent therapies are available, it is now customary for the patient to be involved in the selection of the treatment. The responsibility of choosing the optimal medical therapy is shared jointly by physician and patient: The physician provides an accurate diagnosis, outlines recommended therapies, and projects the most likely outcomes; the patient makes a choice that best reflects his or her personal values, preferences, and expectations.

Unfortunately, the freedom to choose among medical treatments can be an additional burden on individuals who are already distressed physically and perhaps emotionally. Patients are often overwhelmed by the responsibility of making medical decisions; they do not know how to go about it or fear making a mistake that may lead to an outcome they will later regret.

It is critically important to develop a better understanding of the cognition and behavior of the patient as decision maker under stressful, time-constrained, and sometimes life-threatening conditions. The complexity of the decision problem is increased by the technical language of the clinical setting and the use of probabilistic information about outcomes and complications, if such information is available. However, the decision must be made, and it is rare that one can indulge in the luxury of lengthy reflection.

Simply importing existing normative theories into the clinical domain has neither broadened the existing understanding of complex decision processes nor led to fruitful prescriptives of how to help patients make better decisions. Therefore, the question is not how well or how poorly a decision maker fares according to some preexisting set of objective requirements or rules, but how a patient arrives at a particular health care decision and knows that decision is internally consistent with his or her personal needs and desires. What principles or strategies are people using if they are not using normative rules? What are the general rules of choice of the unaided decision maker? Can the decisions people make be better explained by reflecting on the rules and strategies used to derive their choices? This paper is motivated by these questions. Its purpose is to outline a theoretical model of unaided decision making in a health care setting.


Patients' unaided decision-making behavior has been explored in two major contexts: first in a study of women with early-stage breast cancer and second in a study of cardiovascular patients with potentially lethal cardiac dysrhythmias (disturbances in heart rhythm). In a recent report Pierce (1993) described the decision-making behavior of 48 women confronting the choice between mastectomy and lumpectomy followed by radiation therapy for the treatment of early-stage breast cancer. Mastectomy and lumpectomy with adjuvant radiation therapy are the two major treatments for early-stage breast cancer and have been shown to have equivalent survival outcomes. Mastectomy involves the surgical removal of the breast, whereas the conservative therapy - lumpectomy - removes only the tumor and surrounding tissue and is followed by a course of radiation therapy.

The decision-making process begins with the physician's presentation of the treatment options. This is followed by the patient's decision, which can be either immediate or deliberative, depending, it appears, on the salience of the alternatives and their respective attributes. (A salient alternative is one that is clear to the decision maker and appears to be the most preferable at that moment. Alternatives that are not immediately salient tend to stimulate a need in the decision maker for more information or consultation so that he or she will be able to better evaluate its characteristics.) Interviews were tape recorded, transcribed, and systematically analyzed (e. …

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