Chapter 4 Collaborative decision making
One of the great debates in health care in the 21st century centres on the tension between patient-centred health care and evidence-based practice. Within this debate lies an important clinical reasoning issue, namely the patient’s role in clinical decision making. This chapter explores Franziska Trede’s doctoral research (supervised by Joy Higgs and Rodd Rothwell), which investigated explorations and experiences of emancipatory practice and collaborative decision making involving patients (or clients), relevant others (families, carers, advocates) and practitioners (Trede 2006, Trede & Higgs 2003, Trede et al 2003). (Please note that although we acknowledge the importance of the term client in many fields of health practice and health promotion, and to clients themselves, in order to probe into the need for a critical perspective – or at least its consideration and challenge – we use the term patient in most of this chapter, it being the common term used in traditional healthcare settings.)
Of particular significance in this research was the consideration of the interests of participants in the decision-making process. Healthcare practitioners participating in this study were asked to reflect on how they made decisions, what criteria they used to justify their approach to decision making and what role they assigned to, or encouraged in, their patients in the decision-making process. A critical hermeneutic approach was used to interpret interview transcripts and identify interests, assumptions, motivations and biases that the practitioners brought to their decision-making practice. In this chapter we report on a critical practice perspective on collaborative decision making.
Practitioners make numerous daily decisions about their patients: which questions to ask, which label or diagnosis to assign, which treatment options to discuss, which information to share or not share with patients, which treatment interventions and care plans to pursue. The way decisions are made impacts on patients’ persistence with treatment, sense of ownership, control and perceptions of healthcare outcomes. For many patients, the more they participate in decision-making processes the more likely they are to be well informed, involved, satisfied and feeling valued (Trede & Higgs 2003).
Many factors support the case for collaboration in decision making (Hall & Visser 2000), including ethical issues related to quality of life (Mueller et al 2004), legal issues regarding informed consent (Braddock et al 1997), the patient’s right to self-determination (Snapshot 2004), patient safety and the duty to prevent and do no harm (Winokur & Beauregard 2005), and cultural safety in terms of respecting and valuing diversity (Richardson & Carryer 2005). Patient dissatisfaction with communication aspects of health care has been shown to contribute to 40% of health complaints, implying that decisions were not collaborative but were imposed (NSW Health Care Complaints Commission 2005). Collaboration and communication are now considered as important as delivering care (Department of Health and Ageing 2000). These expectations are influenced by such factors as changing societal attitudes to health and patients’ rights, cultural variations in attitudes towards health care, the advocacy of community support and patient groups, increasing litigiousness, improved patient education and greater availability of health information.
Patients may indicate their agreement with health professionals’ decisions explicitly or implicitly through actual or apparent compliance with treatment or healthcare programmes. However, practitioners need to consider whether this agreement is genuine. Patients enter healthcare situations with a wide range of preparedness for the events that will unfold during their journey of ill-health or disability and for the processes of decision making they encounter. They may or may not have had time to investigate the nature of their condition or its medical management, to prepare mentally, physically or emotionally for the health situation they are facing, and to develop a position on what they would like their health outcome to be. In addition, they commonly do not have the relevant medical knowledge or expertise adequately to understand the nature of the condition, the treatment options and potential health outcomes. So, when it comes to the point of agreeing with a health professional or healthcare team in decision making, the patient’s agreement could be influenced by many ‘entry’ factors. Any agreement or otherwise could also be influenced by factors within the communication or interaction, such as the relationship built up with the practitioner(s), language or cultural familiarity or barriers, aspects of behaviour such as intentions, motivations and practitioners’ practice models (e.g. biomedical, biopsychosocial and emancipatory models). In addition, decision-making processes are influenced by professional authority, professional roles, and expectations held by professional groups and the community.
When clinicians and patients share the same values, intentions and interests, agreement is more likely. However, agreement or compliance that is unarticulated or unquestioned may not be true agreement at all. It is tempting to assume that patients adopt the role that practitioners assign to them, without checking with patients either at the point of decision making or during subsequent treatment programmes. Are patients reporting honestly on their perceptions of progress or their pain levels, etc? A critical perspective to decision making reminds us that commonality of values and interests between patients and practitioners should not be taken for granted.
It is interesting to note that most of the literature on decision making has a tendency to use the term shared decision making rather than collaborative decision making. Makoul & Clayman (2006), in a systematic review of the literature on shared decision making, found great fluidity in what was understood by the term, ranging from clinician-led to patient-led decision making. The authors listed essential elements of shared decision making as: defining the problem, presenting the options, identifying patient values and preferences as well as doctor knowledge, and clarifying understanding. This checklist reflects the transactional procedures in decision making but it falls short of considering how various interests and motivations influence the reasoning behind decision making. Instead it is useful to consider a series of questions that helps to clarify assumptions about knowledge and how knowledge is generated (Edwards et al 2004). When is it appropriate to be practitioner-centred and when patient-centred? Who has permission to define the problem? Who is authorized to identify and legitimize what all the options are? How are patients invited and encouraged to share their values? Whose understanding needs clarification? What counts as knowledge and evidence?
To adopt a critical perspective towards answering the above questions and to pursue collaborative decision making in a critical frame of reference requires also pursuing awareness of ‘self’, ‘the other’, and the wider clinical and patient context. To understand this perspective we turn to the work of Habermas, a prominent critical social scientist and philosopher who developed a theory of knowledge and human interest (1972). Interests are the motivations, intentions and goals that guide behaviours.
Habermas divided interests into three categories, technical, practical and emancipatory. He argued that technical interest has a scientific bias and aims for technical success, practical interest has a pragmatic bias and aims for consensual understanding, whereas emancipatory interest is directed towards critique and emancipation, and aims for critical understanding. We discussed and illustrated the relationship between interest and practice in Chapter 3 (see especially Table 3.1).
Many scholars have delineated the dualism between practitioner-centred and patient-centred care (e.g. Arnetz et al 2004), leaving the reader and practitioner appreciating differences between these terms but not helping them to communicate and transcend this dualism. A critical perspective in this context starts with critical self-awareness of what motivates professional bias, professional authority and professional roles, and illuminates the various interests and interpretations underpinning practice approaches, especially those interests that pursue and drive power rather than reason. For example, adopting a critical perspective means seeking first to understand the historical and social factors and influences that have led practice to be accepted and valued the way it is (in a given context) and then to challenge and change this practice with the goal of emancipating those who are restricted or disempowered by it. Within this framework, practitioner-centred practice is typically practice that favours technical rationalism and those in power (commonly the practitioners), whereas in truly (critical) patient-centred practice the practitioner seeks to share knowledge and power with the patient and to respect the input the patient can make to clinical decision making and healthcare management.
People who reason with scientific rationality and objectivity risk silencing emotional, cultural and self-determining rationality. Such communication occurs when practitioners are firmly entrenched in the biomedical model, see evidence-based practice as driven by and contained within scientific method research, and seek an objective and authoritarian pattern of interaction and communication with patients. This practice approach can be highly altruistic, or it can be focused on other interests such as practitioner authority, economic and technical rationalism, and income generation. In each case it is practitioner-centred rather than patient-centred in a critical sense.
Those who reason with cultural and historical rationality tend to silence science and objectivity. Their practice is more patient-centred and can react in an anti-science manner to biomedical model practices. Wellness model advocates and practitioners fit into this category. They have questioned the values and cultural norms of the hegemonic practice model and favour greater levels of person- and patient-centredness. These practitioners embrace subjectivity and holistic approaches to health care but retain their position of authority. This is patient-centredness within a ‘caring for’ (rather than an egalitarian) frame of reference.
Both these perspectives neglect the goal of emancipating patients from the dualism between practitioner-centred and patient-centred care and its potential manipulation and coercion. By comparison, the ideology of a critical perspective to collaboration is a commitment to critical rationality (Habermas 1972).
This leads to consideration of what a collaborative decision-making approach that is informed by a critical perspective would be like. Habermas developed his theory of communicative actions based on a critical perspective of intersubjective communications and interpretations (1984, 1987). This theory describes ideal speech situations (in our case collaborative decision making) as undistorted, open, egalitarian debates that silence unwarranted authority and tradition. Making the intentions and arguments for decisions transparent is seen as the key to making truly collaborative decisions. In addition, collaborative decision making requires critique (including self-critique) and moderation of interests, values and expectations of all parties involved in the decision-making process, and safe, democratizing and caring environments to foster open transparent collaboration where patients feel they are listened to and taken seriously.
In ideal decision-making processes, all involved are aware of their own interests and motivations; this clarifies the reasoning process and enables collaborators to reach critical decisions that include objective, emotional, political, cultural and other factors. The interests of critical rationality and collaborative decision-making processes are emancipatory in that the goal is to find consensus free from traditions, domination and hidden motives. Decisions that are based on critical self-reflection, mutual respect and interest in emancipation are collaborative decisions and are differentiated from false consensus (Roderick 1986).