Decisions involving values and difficult personal choices

Shared decision making is particularly important when the decision to be made involves personal values or moral choices. The health professional may no longer be considered the expert because the decisions are based not just on what is medically best ( though it is important to remember that the health professional would still have to feel that the decision was medically reasonable ), but are entangled with values and difficult personal choices which are specific to individuals. This may mean that health professionals feel less able to give directive advice and the decision making is weighted more towards the patient, as the best choice is personal to them. (See ‘Different types of doctor patient relationships‘ and ‘Why do people want to be involved in shared decision making?‘.)

People’s values are always likely to have some effect, however small, on any decisions made. However, there are certain decisions, which people commonly find difficult to make. Such decisions span a wide range of health issues, but in the interviews we collected, they feature most strongly in decisions such as ending pregnancy; end of life care and decisions made on behalf of others. Health professionals may feel as a matter of principle that these are choices they should leave to the individual; patients may agree they are the best person to make such decisions, but sometimes they want someone to help them.

She describes the day she discussed whether to continue or end the pregnancy as traumatic and…

Age at interview 41

Gender Female

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Own value-based preferences

When making decisions which involve morals and values there are certain factors which shape the choices made. People often want to be more involved if they, or the person they are deciding for, have a preferred outcome based on values or beliefs, for example religious convictions. Sometimes people instantly know which choice is right for them, but in other cases people’s idea of what they would like to happen may change during the decision making process.

She did not have diagnostic antenatal screening because she knew she would not end the pregnancy,…

Age at interview 32

Gender Female

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When she realised that her baby would not have survived long after birth she changed her views on…

Age at interview 31

Gender Female

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One factor that affects decision making is how certain the likely outcome is. When people are able to be given a clear and definite idea about prognosis, it can be easier to make decisions about choices for the future. When it is not possible to be given that certainty, then people may find it more difficult to make decisions. The way in which this is explained to people is very important, the family below describe their experience of receiving differing opinions about their available options.

They were shocked when a nurse asked them, in a roundabout way, to consider turning off their son…

Age at interview 51

Gender Male

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When the doctor explained that her unborn child had a condition which was incompatible with life…

Age at interview 31

Gender Female

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It was difficult to decide on the best course of action because no one could be sure of the…

Age at interview 34

Gender Female

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External influences

Outside influences often shape how people make their decisions. People may choose to ask friends and family to help advise and support them in making difficult decisions.

While in intensive care, he had trouble making a decision about potentially risky medication for…

Age at interview 40

Gender Female

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When making the critical decision to allow her husbands leg to be amputated while he was in…

Age at interview 63

Gender Female

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Alternatively, people may choose not to involve family members in their decisions, either because they want to maintain the responsibility or to protect them from sensitive and sometimes political issues.

His wife would not let him sign the consent forms for her operation as there was a risk she could…

Age at interview 71

Gender Male

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If the choices made will also affect other family members, this may also guide and shape the decision.

Parents considered the effect that having a sibling with microcephaly would have on their two…

Age at interview 29

Gender Female

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When making the decision to end the pregnancy at 17 weeks, they wanted to do what was best for…

Age at interview 34

Gender Male

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Another external influence which affects such decisions is how people believe others will perceive them.

It was very important to this woman with terminal cancer to die with dignity before becoming…

Age at interview 41

Gender Female

Age at diagnosis 24

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A woman with chronic pain was concerned that she may become addicted to her medication, but…

Age at interview 49

Gender Female

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Making choices for others

There are times when people have to make decisions for another who is unable to decide for themselves, such as a young child, a relative who is unconscious in intensive care, or a family member with dementia. People talked about how it was important to establish what the person themselves would want or value.

She carefully considered the outcome of her son surviving intensive care and made choices guided…

Age at interview 59

Gender Female

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The husband and daughter of a woman in intensive care chose to not resuscitate her because they…

Age at interview 60

Gender Male

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He knew his wife Teresa, who had MND, would not have wanted invasive ventilation to keep her alive.

Age at interview 59

Gender Male

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In dementia it can be difficult to determine when patients are unable to still be in control of their decisions. The loss of this ability can cause distress and can be very difficult, and it impacts on whether and how decisions can be shared. While the situation was often deeply regretted, people rarely wanted decisions to be entirely taken out of their hands, and were grateful for advice.

The GP told her it was no longer safe for her mother to drive. She found it difficult to take…

Age at interview 45

Gender Female

Age at diagnosis 77

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Her husband’s dementia had undermined the equality of their partnership. She reflects on how much…

Age at interview 62

Gender Male

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They were frustrated when their GP did not listen to their concerns about a family member with…

Age at interview 59

Gender Female

Age at diagnosis 82

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Carefully considered motives

Sometimes people making difficult decisions involving values immediately knew what their ‘right’ choice was.

This couple had no doubts about ending their pregnancy because they felt their baby would have no…

Age at interview 38

Gender Male

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Other people felt less certain and some felt that all the options available were undesirable. People described considering their own motives carefully, and it was often clear that people took great care when making tough choices. Sometimes people also felt they were under scrutiny and had to justify their choices. The amount of time that people felt they had often influenced how they felt about the decision’ those who felt rushed were often dissatisfied.

A woman with terminal cancer has carefully considered the implications and how she feels about…

Age at interview 41

Gender Female

Age at diagnosis 24

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After making the decision to end the pregnancy she did not welcome the extra questioning she…

Age at interview 38

Gender Female

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She felt rushed into the decision to end her pregnancy (due to a foetal abnormality), but took back some control by deciding to allow the baby to be born alive.

Age at interview 31

Gender Female

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Heightened emotions

Dealing with difficult value-based issues meant that people were in a heightened emotional state and could sometimes feel offended or upset during or after consultations. Feeling confused and unsure of the best course of action is common when coming to terms with a difficult diagnosis. People described how they looked for hope in what the doctor said to them and sought ways to share the decision or seek emotional support from health workers or friends and family.

She consented to giving her mother a tracheotomy when the doctor explained that without one her mother would die. But she still felt devastated about this choosing this risky procedure.

She felt uncomfortable that she had to have sole responsibility for signing the consent form to…

Age at interview 38

Gender Female

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Experiences with health professionals

Health professionals may feel that value-based decisions should involve the individual and may therefore offer less directive advice than they might in other circumstances. However, if they offer an opinion, it can be welcomed and appreciated.

They would have liked more direction from health professionals when making difficult decisions…

Age at interview 36

Gender Male

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The consultant told her that in her position she, too, would have opted for a caesarean. This helped to reassure her that she had made the right choice. Played by an actor.

Age at interview 40

Gender Female

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Others were offended by the direction, especially when their values seemed to conflict with the health professionals’. Conflict in values sometimes caused people to be proactive to get the action they required.

Richard got his GP to refer him to a psychiatrist because he suspected he may have Asperger’s…

Age at interview 58

Gender Male

Age at diagnosis 51

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People sometimes found their values did not fit easily into a standardised health care system.

She took control of how she wanted the birth to go, and thinks this made things easier for the…

Age at interview 37

Gender Female

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Her husband was annoyed that the option to save eggs was not presented to them before his wife…

Age at interview 33

Gender Female

Age at diagnosis 30

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Sometimes people liked it when health professionals put themselves in the patient’s position and advised them what they would do in similar situations and people may ask their doctor to do this. This can help people feel as though doctors were alongside them when making their decisions. (See ‘Why people want to be involved in shared decision making’). However, although some patients find this useful it is can be a difficult position for the health professionals, especially if it is a decision based on personal values as well as objective knowledge or facts.

Conclusion

While making decisions involving values medical opinion is not always the most important consideration. The individual has to make a choice that is personal to them and their family, and family members were often used as a source of advice and reassurance. Accommodating values in clinical settings is not always simple as people’s preferences are so diverse. Although health professionals aim to give less direction in such issues, in reality this is dependent on the issues, and sometimes assumptions based on values are made.

Responsibility for making decisions is often both accepted and appreciated but sometimes the weight of responsibility, especially at an emotional time, can be hard to bear. Making decisions for others is difficult because (in cases of dementia) it often means dramatic change in roles within a parent-child relationship, or a previously equal partnership. Those who know the person best are most able to consider which outcome the patient would value themselves (for example in intensive care). Such decisions are tough and people struggle with them but would rarely want to leave them entirely in the hands of clinical staff.

What information needs to be shared?

In order to successfully share the decision making process, doctors and patients must work together to share information with each other. Using their knowledge, experience...