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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