Lecture2+2021_Clinical decision making.pdf

BDTS 216: Clinical Reasoning & Decision Making Lecture 2: Clinical decision making  https://forms.gle/TjvLbrVYNe16XacR7  Lecture 2 Clinical decision making Factors affecting clinical decision making Role of patient in clinical decision making 6/15/2021...

BDTS 216: Clinical Reasoning & Decision Making Lecture 2: Clinical decision making  https://forms.gle/TjvLbrVYNe16XacR7  Lecture 2 Clinical decision making Factors affecting clinical decision making Role of patient in clinical decision making 6/15/2021 3  Lesson Objectives At the end of the lesson, students should: 1. Define clinical decision making Rules of thumb, heuristics and bias Intuition Assessment Judgements Social judgement theory Cognitive continuum theory. 6/15/2021 4  Course Objectives At the end of the lesson, students should: 2. Explain the nature of decision analysis Stages in decision analysis Defining the problem Rational models Certainty, uncertainty and probability The decision tree Clinical decision support systems 3. Reflect on the underpinning theories of clinical decision making 6/15/2021 5  Introduction Decision making is at the heart of clinical encounters or operational decisions (decisions that generate action). The better our decisions, the more successful and effective our clinical practice will be. Sound decision making and operational decisions depend upon fully informed assessments and astute, analytic judgements.  Defining CDM Clinical decision making is a cognitive process concerned with problem recognition through the identification of cues or of relevant clinical features, data gathering, assimilation, analysis, evaluation and choice, to produce an operational decision  Remember… Data gathering, assimilation and analysis are part of the assessment process. Evaluation and choice are part of the judgement process. Clinical judgement is the outcome of the assessment.  Clinical judgement… Uses the skills of critical analysis, through which the clinician makes an evaluation of the status and quality of the presenting phenomenon or condition and forms an opinion or conclusion (inference) about what is (or will be) needed for an operational decision; it is an evaluation and choice between alternative courses of action.  Clinical judgement can be… Descriptive – attributes observed directly or from other sources (‘the jaundiced baby was as orange as orange juice’) Evaluative – expresses a qualitative difference (‘the baby’s temperature is normal today after the pyrexia recorded yesterday’) Causal – attributes that explain a problem (‘the baby’s weight gain can be attributed to increased feeding’)  Clinical judgement can be… Inference – not based on facts gathered from the patient (‘if there is an increase in preterm deliveries then admissions to the neonatal unit may be higher’) Predictive – what might happen to the patient (‘if the term ventilated baby remains poorly sedated, he may develop a pneumothorax’).  Operational Decision An operational decision is what you do or do not do as a consequence of your judgement. – They are made in the course of managing and delivering care. – They are the reasons for assessment and could be described as the assessment goal. An operational decision is about acting on a judgement choice. Operational decisions are concerned with action. Rules of thumb, heuristics and bias These are short cuts used by health professionals when making judgements and, consequently, decisions to access the vast amount of knowledge and information in our memories.  Rules of thumb, heuristics and bias The availability heuristic tends to use information closest to hand. Evidence demonstrates that the way individuals judge events is based on the evidence available to them. The representative heuristic involves reasoning influenced by prior experiences of similar events – This may lead to over-reliance on certain evidence while other facts are ignored  Intuition In clinical decision making some health professionals have repeatedly stated reliance on intuitive judgement A deeply grounded knowledge base, developed through critical thought, helps experienced practitioners to practice intuitively (Hams, 2000). Therefore each clinical experience becomes a lesson, which informs the next one.  Intuition Intuition is much more than a ‘gut feeling’. Stored emotional interpretation of clinical phenomena and its interface with reasoning, via neural pathways, creates intuitive responses by the expert practitioner (McKinnon, 2005) McKinnon (2005) stresses the importance of the link between cognition and emotion to explain intuitive thought and response.  Assessment Assessment is the first stage of the decision- making process and it is used to ‘build a picture’ of the patient’s situation [cognitive process of A] Is fundamental and crucial to accurate clinical judgements and reliable operational decisions Key data-gathering strategies of the assessment process are: listening, asking, observing, doing, filtering and synthesising and interpreting.  Knowledge Knowledge is fundamental to the ability to accurately interpret and synthesize data. Types of knowledge used in CDM – Empirical: Scientific, technical or factual knowledge – Ethical: moral experiences gained through life [r & w] – Aesthetic: usually intuitive and has no rational/logical explanation – Personal: self-knowledge, prejudices & biases – Socio-political: social, economic and political considerations relevant to the society  Knowledge Two other important domains that impact on the assessment and decision- making process: – domain-specific knowledge and – prior knowledge of the patient and their circumstances.  Judgements However, it is possible for clinicians to come to different decisions even though they are presented with the same set of cues. One can explain this through: – Social judgement theory. – Cognitive continuum theory  Social judgement theory (SJT) Using social judgement theory we can answer the question: Did the clinician get it right? SJT claims that an individual's position on an issue depends on three things: – anchor, or their preferred position on the issue. – alternatives, classified as acceptable, rejected, or noncommittal – Personal ego-involvement, [https://oregonstate.edu/instruct/theory/sjt.html]  Cognitive continuum theory The theory suggests that reasoning is neither purely intuitive nor purely analytical but is rather a continuum between the two poles, with judgements located at points somewhere in between. It relies upon three principles, namely: – the complexity of the task to be undertaken – the clarity of the task, and – the way in which the task is presented.  Cognitive continuum theory Using cognitive continuum theory we can answer the question: How did the healthcare professional get it (i.e. the judgement) right? The cognition mode to use should depend on the task structure, number of cues and time available to complete the task. Caution: over-reliance on intuition to the exclusion of analysis can severely limit the use of knowledge and evidence [Kahneman et al., 1982] The cognitive continuum  Stages in decision analysis Decision analysis uses a structured framework which enables decision making to be shared with colleagues and patients. 1. Defining the problem: At the heart of the decision is the problem to be solved. 2. Rational models: The aim of rational models is to maximize the ‘payoff ’; i.e. to choose the best strategy. 3. Certainty, uncertainty and probability: The idea is employ a technique that reassigns uncertainty so that the result is close to certainty  Classes of probability 1. logical or classical probability work out all the possible outcomes of a process and to count them, then we can logically work out with exactitude the probability of an event. This is then an exact, objective quantity (if possible) 2. frequentist or observed probability most events that clinicians encounter may not be easily countable or logically decomposable 3. subjective probability. it may not be possible to collect survey data.  The decision tree For complex, multi-stage decision problems, it is often helpful to represent the options, uncertainties and outcomes in the form of a decision tree. Decision tree example: Physiotherapy Elements of rational decision making  Clinical decision support systems Clinical decision support systems (CDSS) are computer systems that integrate cues from medical and patient information sources with the aim of helping clinicians make decisions. Studies it was reported that CDSS may have a future role as a diagnostic aid in the decision- making process. Factors affecting clinical decision making Hagbaghery, M. A., Salsali, M., & Ahmadi, F. (2004). The factors facilitating and inhibiting effective clinical decision-making in nursing: a qualitative study. BMC nursing, 3(1), 1-11.  In a recent study in Ethiopia, nurses suggested…. Facilitating factors Inhibiting factors Continuous supervision and Working feedback from immediate environment supervisors. Maintenance and replacement Professional freedom non-functional equipments Team work and collaboration Authority for decision Continuous professional Management of development resource for care Commitment Nurse-bed ratio  Role of patient in clinical decision making There is growing consensus that patients ought to be more involved in their own care The patient’s position is moving towards being a customer; evident in an increasing degree of personal choice and personal rights, care guarantee, and a right to self determination (Nordgren 2004). Participation is linked to the concepts of power and empowerment.  Power: is seen as extra personal, indicating that an increase in one’s power must be balanced with a decrease in someone else’s power Empowerment is an individual process in which the person is interacting with the environment pursuing impact on his/her life (Kuokkanen & Leino-Kilpi 2000)  A patient must be an active participant in his/her empowerment, indicating that health workers cannot empower patients: the role is to facilitate and support the empowerment (Laverack 2005). It is the health practitioners major responsibility is to invite patients as active partners in decision making in health since the patient is in a subordinate position and cannot be expected to take the lead  Patient participation involves several dimensions, including collaboration, partnership, and involvement, sometimes used interchangeably (Cahill 1998; Kirk & Glendinning 1998) Although these dimensions do not necessarily indicate genuine participation (Ashworth et al., 1992)  Factors that facilitate/inhibit patient participation The same factors both facilitate or work against patient participation in decision making. – Access to information and knowledge, – Quality of professional-patient relationship, – Time, – Actual medical situation, and – Personal characteristics of health practitioners and patients.  The autonomy of patients in the final phase of life could be categorized on a scale from self- determination to non-participation (Sahlberg Blom , 2001) Hence, the involvement of relatives to patients in the final phase of life using the categories to know, to be, and to do (Andershed , 1998) Approaches to involving patient in health care  SUMMARY In this lecture….. 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