The Practitioner Proposes a Treatment Change and the Patient Declines: What to do next?

Abstract

Objective: This study describes how pain practitioners can elicit the beliefs that are responsible for patients’ judgments against considering a treatment change and activate collaborative decision making. Methods: Beliefs of 139 chronic pain patients who are in treatment but continue to experience significant pain were reduced to 7 items about the significance of pain on the patient’s life. The items were aggregated into 4 decision models that predict which patients are actually considering a change in their current treatment. Results: While only 34% of study participants were considering a treatment change overall, the percentage ranged from 20 to 70, depending on their ratings about current consequences of pain, emotional influence, and long‐term impact. Generalized linear model analysis confirmed that a simple additive model of these 3 beliefs is the best predictor. Conclusion: Initial opposition to a treatment change is a conditional judgment and subject to change as specific beliefs become incompatible with patients’ current conditions. These beliefs can be elicited through dialog by asking 3 questions.

What Is Shared in Shared Decision Making? Complex Decisions When the Evidence Is Unclear

“…In these situations, common in clinical medicine, preferences are more prone to change; preferences are influenced to a greater degree by context, framing, ordering, affect, unrelated recent events, perceived credibility of the source of information, perceived social norms, and numerous other factors (Table 2; Epstein & Peters, 2009;Fischhoff, 2005;Lichtenstein & Slovic, 2006;Little et al, 2008;Slovic, 1995;Ubel, Loewenstein, Schwarz, & Smith, 2005). In complex situations it is common for decisions to be conditional-depending on disease activity, symptoms, and the personal meaning of the illness (Falzer et al, 2012).…”

“…Considering one complex situation (e.g., deciding whether to change a patient's chronic low back pain treatment plan). Falzer et al (2012) suggest that often clearly stated preferences ("I understand that I still have pain but I don't want to change my pain medications") often prove to be conditional over time. The situation is often reevaluated as the context changes (e.g., worsening symptoms, worry, or existential distress), prompting a change in preference.…”

Implementing Treat‐to‐Target Practices for Chronic Pain Through Shared Decision Making: Requisites, Prospects, and Challenges

“…Discrepancies that emerge out of this awareness determine whether there is a move from current situation to the first stage of decision making . If the discrepancy is insignificant, the move does not occur and there is no decision to be made . Obviously, there are instances in which a practitioner determines that a patient who ought to be experiencing a discrepancy does not.…”

“…63 If the discrepancy is insignificant, the move does not occur and there is no decision to be made. 58 Obviously, there are instances in which a practitioner determines that a patient who ought to be experiencing a discrepancy does not. Heightening a discrepancy to stimulate decision making has been identified as a valuable tactic of clinical practice.…”

“…Image theory studies have found that decision making at the first stage involves a simple count of discrepant attributes. The counting test has been applied to a variety of decisional situations, including the decision‐making process of chronic pain patients and clinicians . The counting test requires a threshold score to be obtained for each relevant attribute.…”