Preference for Treatment Decision Making among Greek Medical Patients

Nikolaos Bilanakis¹ MD, PhD, MSc, Aikaterini Vratsista² MD, MSc Vaios Peritogiannis^3*, MD, MSc, PhD

¹Psychiatric Department of General Hospital of Arta, Arta, Greece

²Psychiatric Department of General Hospital of Arta, Arta, Greece

³Psychiatrist, Private Sector, Ioannina, Greece

*Corresponding Author:

Vaios Peritogiannis
E-mail: vaios.peritogiannis@medai.gr

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Dear Editor,

In contemporary clinical practice of medicine and psychiatry patients’ involvement in decision-making procedure prior to treatment initiation is important. We investigated Greek medical inpatients’ (n =78, mean age 61.8 years) preference (Deegan & Drake 2006) on decision making procedure. Those patients had been admitted to the internal medicine ward of the General Hospital of Arta, northwest Greece, during a two-month period and provided consent for being interviewed. Patients were asked directly about their wish to participate in treatment decision procedure. The question was if they prefer physicians to decide on treatment, if they favor shared decisionmaking, or if they prefer themselves solely to take such decisions. The vast majority of patients (77%) stated their preference for physician’s treatment decision-making, and only 21.8% favored shared decisionmaking. This suggests that medical patients in Greece may not be familiar with the concept of shared treatment decision-making, and raises questions about patients’ autonomy in medical wards in our country.

Additionally, we inquired for the level of treatment decisionmaking capacity of those patients with the use of the Greek version of the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) (Bilanakis, Vratsista, Kalampokis et al., 2013), which is a valid and widely used tool for capacity assessment (Grisso, Appelbaum, & Hill-Fotouni, 1997). Treating physicians’ estimation on patients’ capacity was also inquired for. Interestingly, treating physicians identified as incompetent of receiving valid treatment decisions less (8.9% vs. 15.4%), and importantly, different patients than those rated as such by the investigators (Bilanakis, Vratsista, Athanasiou et al., 2014) with the use of the Greek version of the MacCAT-T. This means that treating physicians perceived as capable for participation in the treatment decision-making process patients who were not, and vice versa. These findings underline the need to inform patients about their rights and to educate physicians on accurate recognition of incapable patients.

From the dimensions of the MacCAT-T only reasoning appeared to be associated with physicians’ impression of patients’ capacity. Reasoning refers to the way patients are thinking through treatment decision, and use the information provided by clinicians in a decision-making process. It seems that physicians have difficulties in recognizing patients’ poor reasoning abilities through their interaction with them, and they perceive the way patients think about treatment as reliable in cases where this is not. Interestingly, recent research has shown that poor reasoning has been associated with treatment decision incapacity in medical patients (Owen, Szmukler, Richardson et al., 2013). Conceivably, efforts should be made to educate physicians on better evaluation of patients’ reasoning process.

The generalizability of these findings may be limited. Our study involved a mixed urban/rural, mostly elderly population hospitalized in a general hospital of a city of 40000 inhabitants. It is unknown whether younger patients in large cities are more familiar with the concept of shared decision-making. Physicians’ abilities to identify incapable patients are referred to a single ward and may not be the case of other medical wards in Greece, although we believe that the sample of physicians (n =5) is representative, in terms of experience and expertise. More studies in different medical settings in Greece are needed to clarify these issues.

Despite these limitations we believe that our study has some implications. There are several types of interventions which are used to foster patients’ informed decision, including interpersonal counseling, tailored and untailored print materials, videotapes, audiotapes, scripted telephone counseling, computer programs, Web sites, and decision boards (Rimer, Briss, Zeller et al., 2004). Regular use of such interventions in medical settings would facilitate patients’ informed decision making and would promote patients’ autonomy.

References

1. Bilanakis,N., Vratsista,A., Kalampokis,G., Papamichael, G.,&Peritogiannis, V. (2013).The Greek version of the MacArthur competence assessment tool for treatment: reliability and validity: evaluation of capacity for treatment decisions in Greek psychiatric patients. Annals of General Psychiatry, 12, 10
2. Bilanakis, N., Vratsista,A., Athanasiou, E., Niakas, D., &Peritogiannis, V. (2014).Medical patients’ treatment decision making capacity: A report from a General Hospital in Greece. Clinical Practice and Epidemiology in Mental Health,10, 133-139
3. Deegan, P.E., &Drake, R.E. (2006).Shared Decision Making and Medication Management in the Recovery Process.Psychiatric Services, 57, 1636-1639
4. Grisso, T., Appelbaum, P.S., &Hill-Fotouni, C. (1997). The MacCAT- T: A clinical tool assess patients’ capacities to make treatment decisions. Psychiatric Services,48, 1415-1419
5. Owen, G.S., Szmukler, G., Richardson, G., David, A.S., Raymont, V., et al. (2013). Decision making capacity for treatment in psychiatric and medical in-patients: cross-sectional, comparative study. British Journal of Psychiatry, 203, 461-467
6. Rimer, B., Briss, P., Zeller, P., Chan, E., &Woolf, S. (2004). Informed Decision Making: What Is Its Role in Cancer Screening? Cancer 101(Suppl 5): 1214-1228.