W
anderley
B
ernardo
, J
osé
M
aria
J
r
., A
ntônio
S
alomão
, E
dmund
B
aracat
396
R
ev
A
ssoc
M
ed
B
ras
2014; 60(5):395-397
the right time to accommodate the limits of individual and
shared cognitive processing. Physicians should be alert to
the potential of hierarchical relationships that can promo-
te coercion or silence the voice of the patient, and regularly
check for understanding. They should also be aware of the
indirect signs of emotional distress and demonstrate relia-
bility and transparency, actively soliciting the patient’s ques-
tions and concerns. Self-knowledge, self-monitoring, ho-
nesty and the willingness to challenge one’s own assumptions
are key qualities, which, when cultivated by the physician,
will help him/her distinguish his/her participation in in-
creasing autonomy at the expense of well-meaning, but mis-
taken, imposition of values
4
.
P
roper
patient
care
requires
dialogue with
regard
to
options
and
decisions
,
which
is
not
accomplished
in
15
minutes
.
•
Talking about choices.
How to get patients to unders-
tand that there are reasonable options? The components of
this stage are: a) Step one – Summarize and say: “Now that
we have identified the problem, it’s time to think about what
to do next”; b) Offer choices - Please note that patients of-
ten misinterpret the presentation of choices and think the
doctor is either incompetent or uninformed, or both. Redu-
ce this risk by saying: “There is good information about how
these treatment options differ, and I would like to discuss
this with you”; c) Justify the choice - Emphasize: 1) The im-
portance of respecting individual preferences; 2) The role of
uncertainty.
Customize preferences:
explain that different is-
sues are more important to some people than to others,
which should be easily understood. Say: “Treatments have
different consequences. Some will be more important to
you than to others.”
Uncertainty
: Patients often are unaware
of the extent of uncertainty in medicine, how evidence can
be weak and the results, unpredictable at the individual le-
vel. Say: “Treatments are not always effective, and the chan-
ces of suffering side effects vary.” d) Check the patient’s reac-
tion – The choice among options can be confusing: some
patients may express concern. Suggested phrases: “Let’s con-
tinue” or “Should I tell you about the options”? e) Postpo-
ne the end of the conversation – Some patients react asking
doctors: “Tell me what to do.” Postpone the end in case this
occurs, assuring your patient that you are willing to support
his/her decision-making process. Say: “I’m happy to share
my opinions and help you reach a good decision. But befo-
re I do that, can I describe the options inmore detail so that
you understand what is at stake?
5
•
Talking about the options:
a) Check their knowledge
- Even well-informed patients may be only partially awa-
re of the options, and the harms and benefits associated
with the procedures, or they may be misinformed. Eva-
luate with the question: “What have you heard or read
about the treatment of obesity?”; b) Write the options -
Make a clear list of alternatives, as this offers good struc-
ture. Say: “Let me list the options before we go into more
detail”. If this is the case, add the option “wait watching”
or use positive terms such as “active monitoring”; c) Des-
cribe the options (in practical terms) - Generate dialogue
and explore preferences. If there are two medical treat-
ments, says: “Both options are similar and involve taking
medication regularly.” Point out when there are clear dif-
ferences (surgery or medication), situations in which it is
possible to postpone, or those in which decisions are re-
versible. Say: “These options have different implications
for you in relation to others, and so I want to describe ...”.
Harm and benefits - Being clear about the pros and cons
of the different options is crucial in shared decision-ma-
king. Learn effective communication about risk, effects
of the process, importance of providing data on absolu-
te risk, as well as in relative terms; d) Support the patient’s
decision – Synthetic tools make the options visible and
can save time. Some are sufficiently concise to use in cli-
nical visits. Examples: cards related to the subject, deci-
sion charts and option tables. Shared decision may need
more than a medical visit. More extensive tools for pa-
tient decision support can play a crucial role. Say: “The-
se tools are designed to help you understand the options
in more detail. Use them and come back so that I can ans-
wer your questions.” e) Summarize - List the options again
and assess understanding, asking reformulations
5
.
•
Talking about the decision:
a) Focus on preferences -
Guide the patient to express them. Suggested phrases:
“What, from your point of view, is more important to you?”
b) Inducing a preference - Be prepared to provide addi-
tional time or willing to guide the patient if he/she indi-
cates that this is his/her wish; c) Move to a decision - Try
to verify the need to postpone the decision or take it. Sug-
gested phrases: “Are you ready to decide?” / “Do you want
more time?” / “Do you have any other questions?” / “Is
there anything else that we need to discuss?” d) Review
the offer – Reminding the patient, whenever possible, that
decisions can be reviewed is a good way to end the con-
versation
5
.
Briefly, patients must decide not only through a theo-
retical exercise, but considering the context that preser-
ves the expression of their autonomy, in which there must
be: clarity on where the care is provided; about the treat-
ment process or outcome to achieve a particular health