Improving Medical Decisions

  • Jorge RiscoEmail author
  • Adam Kelly


In this chapter we conceptualize medical decisions in three steps: diagnosis, option assessment and shared decision making, with specific attention to how these steps apply to decisions in neuropalliative care. Diagnosis is a step that involves gathering information surrounding the problem. A physician must diagnose the medical problem, the problem from the patient’s perspective and the patient’s preferences and values. An assessment of patient capacity and skilled communication are intrinsic to the process. Option assessment is a step where the potential solutions are weighed against each other. This includes assessing benefits and risks of each option including a consideration of costs; understanding and managing uncertainty including the use of time limited trials and default options; and considering the biases associated with option assessment and ways to debias. Finally, shared decision making is a step that involves engaging with patients or surrogates to arrive at a medical decision. This involves incorporating patient values. The objective of a medical decision is to promote patient well-being.


Diagnosis Decision making Bias Paternalism Autonomy 


  1. 1.
    Mulley AG, Trimble C, Elwyn G. Stop the silent misdiagnosis: patients’ preferences matter. BMJ. 2012;345:e6572.CrossRefGoogle Scholar
  2. 2.
    Solomon AJ, et al. The contemporary spectrum of multiple sclerosis misdiagnosis: a multicenter study. Neurology. 2016;87(13):1393–9.CrossRefGoogle Scholar
  3. 3.
    Holloway RG, Gramling R, Kelly AG. Estimating and communicating prognosis in advanced neurologic disease. Neurology. 2013;80(8):764–72.CrossRefGoogle Scholar
  4. 4.
    Epstein RM. The science of patient-centered care. J Fam Pract. 2000;49(9):805–7.PubMedGoogle Scholar
  5. 5.
    Crane JA. Patient comprehension of doctor-patient communication on discharge from the emergency department. J Emerg Med. 1997;15(1):1–7.CrossRefGoogle Scholar
  6. 6.
    Roter DL. The outpatient medical encounter and elderly patients. Clin Geriatr Med. 2000;16(1):95–107.CrossRefGoogle Scholar
  7. 7.
    Makaryus AN, Friedman EA. Patients’ understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005;80(8):991–4.CrossRefGoogle Scholar
  8. 8.
    Gramling R, et al. Determinants of patient-oncologist prognostic discordance in advanced cancer. JAMA Oncol. 2016;2(11):1421–6.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Kutner M, Greenberg E, Jin Y, Paulsen C. In: U.D.o. Education, editor. The health literacy of America’s adults: results from the 2003 national assessment of adult literacy. Washington, DC: National Center for Education Statistics NCES; 2006. p. 2006–483.Google Scholar
  10. 10.
    Schillinger D, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83–90.CrossRefGoogle Scholar
  11. 11.
    Tarn DM, et al. Physician communication when prescribing new medications. Arch Intern Med. 2006;166(17):1855–62.CrossRefGoogle Scholar
  12. 12.
    Ha JF, Longnecker N. Doctor-patient communication: a review. Ochsner J. 2010;10(1):38–43.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Rogers ES, Wallace LS, Weiss BD. Misperceptions of medical understanding in low-literacy patients: implications for cancer prevention. Cancer Control. 2006;13(3):225–9.CrossRefGoogle Scholar
  14. 14.
    Graham S, Brookey J. Do patients understand? Perm J. 2008;12(3):67–9.CrossRefGoogle Scholar
  15. 15.
    Weiss BD. In: A.M.A.F.a.A.M. Association, editor. Health literacy and patient safety: help patients understand. 2nd ed. Chicago: American Medical Association Foundation and American Medical Association; 2007.Google Scholar
  16. 16.
    El-Jawahri A, et al. Qualitative study of patients’ and caregivers’ perceptions and information preferences about hospice. J Palliat Med. 2017;20(7):759–66.CrossRefGoogle Scholar
  17. 17.
    McIlfatrick S, et al. Exploring public awareness and perceptions of palliative care: a qualitative study. Palliat Med. 2014;28(3):273–80.CrossRefGoogle Scholar
  18. 18.
    Epstein RM, Peters E. Beyond information: exploring patients’ preferences. JAMA. 2009;302(2):195–7.CrossRefGoogle Scholar
  19. 19.
    Okonkwo O, et al. Medical decision-making capacity in patients with mild cognitive impairment. Neurology. 2007;69(15):1528–35.CrossRefGoogle Scholar
  20. 20.
    Triebel KL, et al. Treatment consent capacity in patients with traumatic brain injury across a range of injury severity. Neurology. 2012;78(19):1472–8.CrossRefGoogle Scholar
  21. 21.
    Karlawish J, et al. Cognitive impairment and PD patients’ capacity to consent to research. Neurology. 2013;81(9):801–7.CrossRefGoogle Scholar
  22. 22.
    Raymont V, et al. Prevalence of mental incapacity in medical inpatients and associated risk factors: cross-sectional study. Lancet. 2004;364(9443):1421–7.CrossRefGoogle Scholar
  23. 23.
    Kim SY, Karlawish JH, Caine ED. Current state of research on decision-making competence of cognitively impaired elderly persons. Am J Geriatr Psychiatry. 2002;10(2):151–65.CrossRefGoogle Scholar
  24. 24.
    Abu Snineh M, Camicioli R, Miyasaki JM. Decisional capacity for advanced care directives in Parkinson’s disease with cognitive concerns. Parkinsonism Relat Disord. 2017;39:77–9.CrossRefGoogle Scholar
  25. 25.
    Kapoor A, et al. “Good outcome” isn’t good enough: cognitive impairment, depressive symptoms, and social restrictions in physically recovered stroke patients. Stroke. 2017;48(6):1688–90.CrossRefGoogle Scholar
  26. 26.
    Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010;362(13):1211–8.CrossRefGoogle Scholar
  27. 27.
    Appelbaum PS. Clinical practice. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;357(18):1834–40.CrossRefGoogle Scholar
  28. 28.
    Karlawish JH, et al. The ability of persons with Alzheimer disease (AD) to make a decision about taking an AD treatment. Neurology. 2005;64(9):1514–9.CrossRefGoogle Scholar
  29. 29.
    Martin RC, et al. Medical decision-making capacity in cognitively impaired Parkinson’s disease patients without dementia. Mov Disord. 2008;23(13):1867–74.CrossRefGoogle Scholar
  30. 30.
    Tymchuk AJ, Ouslander JG, Rader N. Informing the elderly. A comparison of four methods. J Am Geriatr Soc. 1986;34(11):818–22.CrossRefGoogle Scholar
  31. 31.
    Krynski MD, Tymchuk AJ, Ouslander JG. How informed can consent be? New light on comprehension among elderly people making decisions about enteral tube feeding. Gerontologist. 1994;34(1):36–43.CrossRefGoogle Scholar
  32. 32.
    Brady MC, Fredrick A, Williams B. People with aphasia: capacity to consent, research participation and intervention inequalities. Int J Stroke. 2013;8(3):193–6.CrossRefGoogle Scholar
  33. 33.
    Stein J, Brady Wagner LC. Is informed consent a “yes or no” response? Enhancing the shared decision-making process for persons with aphasia. Top Stroke Rehabil. 2006;13(4):42–6.CrossRefGoogle Scholar
  34. 34.
    Aura Kagan MDK. Informed consent in aphasia: myth or reality? Clin Aphasiology. 1995;23:65–75.Google Scholar
  35. 35.
    Lautrette A, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med. 2007;356(5):469–78.CrossRefGoogle Scholar
  36. 36.
    Cegala DJ, Marinelli T, Post D. The effects of patient communication skills training on compliance. Arch Fam Med. 2000;9(1):57–64.CrossRefGoogle Scholar
  37. 37.
    Major EO. Progressive multifocal leukoencephalopathy in patients on immunomodulatory therapies. Annu Rev Med. 2010;61:35–47.CrossRefGoogle Scholar
  38. 38.
    Guyatt GH, Sackett DL, Cook DJ. Users’ guides to the medical literature. II. How to use an article about therapy or prevention. B. What were the results and will they help me in caring for my patients? Evidence-Based Medicine Working Group. JAMA. 1994;271(1):59–63.CrossRefGoogle Scholar
  39. 39.
    Berkowitz SA, Seligman HK, Choudhry NK. Treat or eat: food insecurity, cost-related medication underuse, and unmet needs. Am J Med. 2014;127(4):303–10. e3CrossRefGoogle Scholar
  40. 40.
    Simpkin AL, Schwartzstein RM. Tolerating uncertainty – the next medical revolution? N Engl J Med. 2016;375(18):1713–5.CrossRefGoogle Scholar
  41. 41.
    Quill TE, Holloway R. Time-limited trials near the end of life. JAMA. 2011;306(13):1483–4.CrossRefGoogle Scholar
  42. 42.
    Thaler, RH, Sunstein CR, Balz JP. Choice Architecture. 2010.
  43. 43.
    Hart J, Halpern SD. Default options in the ICU: widely used but insufficiently understood. Curr Opin Crit Care. 2014;20(6):662–7.CrossRefGoogle Scholar
  44. 44.
    Halpern SD, et al. Default options in advance directives influence how patients set goals for end-of-life care. Health Aff (Millwood). 2013;32(2):408–17.CrossRefGoogle Scholar
  45. 45.
    Blinderman CD, Krakauer EL, Solomon MZ. Time to revise the approach to determining cardiopulmonary resuscitation status. JAMA. 2012;307(9):917–8.CrossRefGoogle Scholar
  46. 46.
    Saposnik G, et al. Cognitive biases associated with medical decisions: a systematic review. BMC Med Inform Decis Mak. 2016;16(1):138.CrossRefGoogle Scholar
  47. 47.
    Bornstein BH, Emler AC. Rationality in medical decision making: a review of the literature on doctors’ decision-making biases. J Eval Clin Pract. 2001;7(2):97–107.CrossRefGoogle Scholar
  48. 48.
    Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775–80.CrossRefGoogle Scholar
  49. 49.
    Blumenthal-Barby JS, Krieger H. Cognitive biases and heuristics in medical decision making: a critical review using a systematic search strategy. Med Decis Mak. 2015;35(4):539–57.CrossRefGoogle Scholar
  50. 50.
    Redelmeier DA, Shafir E. Medical decision making in situations that offer multiple alternatives. JAMA. 1995;273(4):302–5.CrossRefGoogle Scholar
  51. 51.
    Sorum PC, et al. Why do primary care physicians in the United States and France order prostate-specific antigen tests for asymptomatic patients? Med Decis Mak. 2003;23(4):301–13.CrossRefGoogle Scholar
  52. 52.
    Sloman SA. The empirical case for two systems of reasoning. Psychol Bull. 1996;119(1):3–22.CrossRefGoogle Scholar
  53. 53.
    Mamede S, et al. Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. JAMA. 2010;304(11):1198–203.CrossRefGoogle Scholar
  54. 54.
    van den Berge K, Mamede S. Cognitive diagnostic error in internal medicine. Eur J Intern Med. 2013;24(6):525–9.CrossRefGoogle Scholar
  55. 55.
    Makoul G, Clayman ML. An integrative model of shared decision making in medical encounters. Patient Educ Couns. 2006;60(3):301–12.CrossRefGoogle Scholar
  56. 56.
    Curtis JR, White DB. Practical guidance for evidence-based ICU family conferences. Chest. 2008;134(4):835–43.CrossRefGoogle Scholar
  57. 57.
    Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA. 1992;267(16):2221–6.CrossRefGoogle Scholar
  58. 58.
    Hart JT. The autonomous patient: ending paternalism in medical care. J R Soc Med. 2002;95(12):623–4.PubMedCentralGoogle Scholar
  59. 59.
    Barry MJ, Edgman-Levitan S. Shared decision making – pinnacle of patient-centered care. N Engl J Med. 2012;366(9):780–1.CrossRefGoogle Scholar
  60. 60.
    Deber RB, et al. Do people want to be autonomous patients? Preferred roles in treatment decision-making in several patient populations. Health Expect. 2007;10(3):248–58.CrossRefGoogle Scholar
  61. 61.
    Heyland DK, et al. The seriously ill hospitalized patient: preferred role in end-of-life decision making? J Crit Care. 2003;18(1):3–10.CrossRefGoogle Scholar
  62. 62.
    Braddock CH 3rd, et al. Informed decision making in outpatient practice: time to get back to basics. JAMA. 1999;282(24):2313–20.CrossRefGoogle Scholar
  63. 63.
    Shippee ND, et al. Patient and service user engagement in research: a systematic review and synthesized framework. Health Expect. 2015;18(5):1151–66.CrossRefGoogle Scholar
  64. 64.
    Heesen C, et al. Risk perception in natalizumab-treated multiple sclerosis patients and their neurologists. Mult Scler. 2010;16(12):1507–12.CrossRefGoogle Scholar
  65. 65.
    Polman CH, et al. A randomized, placebo-controlled trial of natalizumab for relapsing multiple sclerosis. N Engl J Med. 2006;354(9):899–910.CrossRefGoogle Scholar
  66. 66.
    Stacey D, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014;1:CD001431.Google Scholar
  67. 67.
    O’Connor A. Ottawa personal decision guides. The Ottawa Hospital Research Institute. 2017.
  68. 68.
    Spatz ES, Krumholz HM, Moulton BW. Prime time for shared decision making. JAMA. 2017;317(13):1309–10.CrossRefGoogle Scholar
  69. 69.
    Hanson LC, et al. Improving decision-making for feeding options in advanced dementia: a randomized, controlled trial. J Am Geriatr Soc. 2011;59(11):2009–16.CrossRefGoogle Scholar
  70. 70.
    Shay LA, Lafata JE. Where is the evidence? A systematic review of shared decision making and patient outcomes. Med Decis Mak. 2015;35(1):114–31.CrossRefGoogle Scholar
  71. 71.
    Deinzer A, et al. Is a shared decision-making approach effective in improving hypertension management? J Clin Hypertens (Greenwich). 2009;11(5):266–70.CrossRefGoogle Scholar
  72. 72.
    Heisler M, et al. Physicians’ participatory decision-making and quality of diabetes care processes and outcomes: results from the triad study. Chronic Illn. 2009;5(3):165–76.CrossRefGoogle Scholar
  73. 73.
    Kravitz RL, et al. Internal medicine patients’ expectations for care during office visits. J Gen Intern Med. 1994;9(2):75–81.CrossRefGoogle Scholar
  74. 74.
    Macfarlane J, et al. Influence of patients’ expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. BMJ. 1997;315(7117):1211–4.CrossRefGoogle Scholar
  75. 75.
    Marple RL, et al. Concerns and expectations in patients presenting with physical complaints. Frequency, physician perceptions and actions, and 2-week outcome. Arch Intern Med. 1997;157(13):1482–8.CrossRefGoogle Scholar
  76. 76.
    Fenton JJ, et al. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012;172(5):405–11.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of NeurologyUniversity of RochesterRochesterUSA

Personalised recommendations