The Role of Future Orientation and Decision Regret in Health Care Decision Making

描述(由申请人提供)：改善对各种肺部疾病患者的护理的一个关键挑战是帮助他们在面对多种合理的诊断或治疗选择时做出最能促进其潜在价值的选择。不幸的是，患者和他们的代理决策者经常被正常的人类决策心理的弱点所转移，不能做出这样的“最佳选择”。例如，一名患有孤立性肺结节的前吸烟者，在重复的计算机断层扫描中表现稳定，但他仍可能选择接受活检，因为他担心，如果他选择监视，后来发现它是恶性的，他会感到后悔。这可能是真的，即使像他这样的患者实际上更有可能后悔接受活检的决定，因为当结果证明是正常的时候，这种方法存在可避免的风险、负担和成本。如此意料之中的遗憾--也就是， 患者或他们的代理决策者担心，他们后来会将实际结果与如果他们做出替代选择可能会发生的更好的结果进行比较--这可能会影响肺部疾病患者及其代理做出的一系列决定。这可能会阻碍最佳决策，因为决策者对后悔可能性的估计可能不准确，或者可能不适当地分散决策者对决策中更重要的因素的注意力。然而，这种后悔的影响也可能被利用，这样向患者或代理人提供关于决定后悔的数据可能会帮助他们将注意力集中在与他们最相关的结果上。在这一假设的指导下，我试图构建一个概念框架，以了解肺部疾病患者及其代理决策者在决策时如何考虑未来，并评估决策后悔信息对此类患者及其代理患者的治疗选择和决策过程质量的具体影响。为了实现这些目标，我将进行两项研究，以探索肺部疾病患者和从学术医疗中心的门诊环境中招募的潜在代孕者的悔恨。首先，我将通过对肺部疾病患者及其潜在代理人进行基于Vignette的半结构化访谈来产生概念框架。其次，我将进行一项随机析因实验，让参与者考虑与医学相关的假设情况，并在两个管理选项中进行选择，这两个选项被描述为同样合适，但预期后悔的几率和严重性有所不同。半结构化访谈将引出对决策过程的描述，关于寻求关于治疗决策结果的信息的偏好，在决策时考虑未来的反事实，所考虑的结果的相对接近，以及作为决策因素的后悔的概念。根据这些定性数据，随后的随机实验将确定为每个选项提供被操纵的后悔数据的具体影响，并不仅衡量所做的选择，而且衡量决策过程的质量。该项目将为计划中的NIH K23职业发展奖提供必要的初步数据，该奖项将(1)收集类似肺部疾病患者实际选择后的真实决策后悔数据，(2)开发包含患者及其代理人可以理解的决策后悔数据的决策辅助工具，以及(3)在实际肺部实践中测试这种增强的决策辅助工具的有效性。

DESCRIPTION (provided by applicant): A key challenge in improving the care of patients with a variety of pulmonary diseases is to help them make choices that best promote their underlying values when faced with multiple reasonable diagnostic or therapeutic options. Unfortunately, patients and their surrogate decision makers are often diverted from making such "optimal choices" by the foibles of normal human decision psychology. For example, a former smoker with a solitary pulmonary nodule that has been stable on repeated computed tomography may nonetheless choose to have it biopsied because he fears feeling regret if he chooses surveillance and later finds that it is malignant. This may be true even if patients like him are i fact more likely to regret decisions to pursue biopsy, due to the avoidable risks, burdens, and costs of this approach when the results turn out to be normal. Such anticipated regret - that is, the fear among patients or their surrogate decision makers that they will later compare the actual outcomes with better outcomes that might have happened if they had made an alternative choice - may influence a broad range of decisions made by patients with pulmonary diseases and their surrogates. This may deter optimal decision making, as the decision maker's estimation of the likelihood of regret may be inaccurate or may unduly distract decision makers from more important elements of the decision. However, the effects of such regret might also be harnessed, such that providing patients or surrogates with data on decision regret may help them focus their attention on the outcomes most relevant to them. Guided by this hypothesis, I seek to construct a conceptual framework for how patients with lung disease and their surrogate decision makers think about the future at the time of decision making, and to evaluate the specific effects of decision regret information on the treatment selections and decision process quality of such patients and their surrogates. To accomplish these goals, I will conduct two studies to explore regret among patients with pulmonary disease and potential surrogates recruited from outpatient settings at an academic medical center. First, I will produce the conceptual framework by conducting and analyzing vignette- based semi-structured interviews among patients with pulmonary diseases and their potential surrogates. Second, I will conduct a randomized factorial experiment in which participants consider medically relevant hypothetical situations, and choose between two management options described as being equally appropriate but in which the odds and severity of anticipated regret vary. Semi-structured interviews will elicit descriptions of the decision making process, preferences regarding information-seeking about outcomes of treatment decisions, consideration of future counterfactuals at the time of decision making, the relative proximity of the outcomes considered, and the concept of regret as a factor in decision making. Informed by these qualitative data, the subsequent randomized experiment will determine the specific influence of providing manipulated regret data for each option, and measure not only the choices made but the quality of the decision-making process. This project will provide essential preliminary data for a planned NIH K23 Career Development Award that would (1) collect real decision regret data following actual choices by similar patients with pulmonary diseases, (2) develop a decision aid that incorporates decision regret data that is understandable for patients and their surrogates, and (3) test the effectiveness of this enhanced decision aid in real pulmonary practice.