Qualitative analysis of how patients decide that they want risk-reducing mastectomy, and the implications for surgeons in responding to emotionally-motivated patient requests.
Qualitative analysis of how patients decide that they want risk-reducing mastectomy, and the implications for surgeons in responding to emotionally-motivated patient requests.
复制标题
DOI：
10.1371/journal.pone.0178392
复制
发表时间：
2017
期刊：
影响因子：
3.7
通讯作者：
Salmon P
中科院分区：
文献类型：
--
作者：
Brown SL;Whiting D;Fielden HG;Saini P;Beesley H;Holcombe C;Holcombe S;Greenhalgh L;Fairburn L;Salmon P
现代医疗决策方法建议临床医生应该尊重患者的决定。然而，患者的决定往往是由心理学塑造的，例如受情感的指导，而不是客观的风险和利益。降低风险的乳房切除术（RRM）决策集中在这个困境尖锐。RRM降低了乳腺癌（BC）的风险，但具有侵入性，并可能产生医源性后果。以前的证据表明，情绪引导患者对RRM的决策。我们采访了患者，以更好地了解他们如何做出关于RRM的决定，利用调查结果来考虑临床医生如何在道德上回应他们的决定。定性面对面访谈34例患者列出的RRM手术和两个谁决定不RRM。患者通常不使用客观的风险评估，或者实际上不考虑RRM的风险和获益。相反，情绪引导着他们的决定：他们选择RRM是因为他们害怕BC，并希望尽“一切努力”来防止它。因此，大多数人认为RRM是“显而易见的”选择，并很容易做出决定。然而，许多人叙述了广泛的决定后审议，一般是为了证明最初的决定是正确的。一些病人在做出决定之前进行了深思熟虑，因为对手术的恐惧抵消了对BC的恐惧。患者寻求RRM的动机是害怕BC，并需要避免潜在的遗憾，没有尽一切努力，以防止it.We建议的选择，如RRM，这是情绪化的，可以尊重自主决定，提供患者考虑的风险和利益。根据人们如何做决定的心理学理论，以及他们应该如何做决定的规范观点，我们建议医生可以指导考虑风险和收益，即使在必要的情况下，在患者选择手术后。这种实践模式可以扩展到其他受患者情绪影响的医疗决策。
Contemporary approaches to medical decision-making advise that clinicians should respect patients’ decisions. However, patients’ decisions are often shaped by heuristics, such as being guided by emotion, rather than by objective risk and benefit. Risk-reducing mastectomy (RRM) decisions focus this dilemma sharply. RRM reduces breast cancer (BC) risk, but is invasive and can have iatrogenic consequences. Previous evidence suggests that emotion guides patients’ decision-making about RRM. We interviewed patients to better understand how they made decisions about RRM, using findings to consider how clinicians could ethically respond to their decisions. Qualitative face-to-face interviews with 34 patients listed for RRM surgery and two who had decided against RRM. Patients generally did not use objective risk estimates or, indeed, consider risks and benefits of RRM. Instead emotions guided their decisions: they chose RRM because they feared BC and wanted to do ‘all they could’ to prevent it. Most therefore perceived RRM to be the ‘obvious’ option and made the decision easily. However, many recounted extensive post-decisional deliberation, generally directed towards justifying the original decision. A few patients deliberated before the decision because fears of surgery counterbalanced those of BC. Patients seeking RRM were motivated by fear of BC, and the need to avoid potential regret for not doing all they could to prevent it. We suggest that choices such as that for RRM, which are made emotionally, can be respected as autonomous decisions, provided patients have considered risks and benefits. Drawing on psychological theory about how people do make decisions, as well as normative views of how they should, we propose that practitioners can guide consideration of risks and benefits even, where necessary, after patients have opted for surgery. This model of practice could be extended to other medical decisions that are influenced by patients’ emotions.