Intended for healthcare professionals

Rapid response to:

Learning In Practice

How doctors discuss major interventions with high risk patients: an observational study

BMJ 2005; 330 doi: (Published 20 January 2005) Cite this as: BMJ 2005;330:182

Rapid Response:

Decision-making in Critical Clinical Cases

Patients at times may find it difficult to make a decision about the
management of their illness. As treatment options become more technical,
the consequences of a given treatment choice become more difficult for a
layperson to understand. Decision-making especially becomes a dilemma
where choices have to be made among different therapeutic options for
critical or life threatening illnesses and the degree of uncertainty of
the outcome is high. The question for the patient usually is to either
decide alone (sometimes with family input), let the doctor decide alone,
or make a shared decision. In the case of major illness, patients feel
that they should be involved but ultimately the physician’s opinion is
considered more important. [1] Research evidence also shows that patients
who are women, born abroad, older, and less educated, tend to leave
decisions to the doctor alone. [2] On the other hand, most patients also
prefer that the decision be shared equally between them and their
physician. [3] The situation however, becomes increasingly complex when
there is a decision conflict and serious when either the patient or the
physician declines to discuss their preferences for treatment outcomes and
leave the decision in the hands of each other. [4]

Patients deserve a clear and complete understanding of the proposed
therapies and their effects on health outcomes. Some patients will want
to know all the details, while others will prefer to forego the details
and rely solely on their physician’s advice. This places a heavier
responsibility on the physician to help the patient comprehend what
options are possible and the implications of all the given choices.
Sometimes physicians’ lack of knowledge or inexperience may drive them to
avoid giving a specific advice, hence place heavier responsibility on the
patient. More disturbing is the reality that consequences of litigation
and liability [5,6] and patients’ unrealistic expectations, have markedly
severed physicians’ clinical decision making abilities.

In today's health care systems, though doctors have become
therapeutically more potent in large measure, they have ceased to give the
patient what they want. There's a need to go back to practicing medicine
by the principles of great physicians and scholars, whereby the duty of a
doctor is to diagnose and explain, with explanation being the real
business of medicine. [7] What the patient wants to know is the name of
the illness, what caused it, how is it likely to turn out, and, most
important of all, the efficacy of the medicine/therapy being prescribed.
It is certainly not enough to prescribe pills/treatment in a way of
avoiding a more time consuming analysis and treatment. Physician’s
attitude has been shown to strongly influence patients’ decision making
about their diseases, to the extent that many patients prefer that their
physician make the actual treatment decision. [8] Regardless of the
seriousness of the illness and the degree of uncertainty of outcomes, the
challenge remains to develop and implement shared decision making models
that incorporate both physician’s expertise as well as patient’s values
and preferences. [9]


1. Ende J, Kazis L, Ash A, Moskowitz MA. Measuring patients' desire
for autonomy: decision making and information-seeking preferences among
medical patients. J Gen Intern Med. 1989 Jan-Feb;4(1):23-30.

2. Chamot E, Charvet A, Perneger TV. Women's preferences for doctor's
involvement in decisions about mammography screening. Med Decis Making.
2004 Jul-Aug;24(4):379-85.

3. Steginga SK, Occhipinti S. The application of the Heuristic-
Systematic Processing Model to treatment decision making about prostate
cancer. Med Decis Making. 2004 Nov-Dec;24(6):573-83.

4. Corke CF, Stow PJ, Green DT, Agar JW, Henry MJ. How doctors
discuss major interventions with high risk patients: an observational
study. BMJ 2004; 0: bmj.38293.435069.DEv1

5. Eisenberg H. Malpractice pressure: dirty tricks lawyers play. Med
Econ. 1982; 3:132-51.

6. Merrill RE, Wiggins J. On physicians and litigation. J Okla State
Med Assoc. 1991 Apr;84(4):165-9.

7. Roy Porter. Medicine and the People. In: The Greatest Benefit to
Mankind. 1st American Ed. New York, NY: WW Norton & Company. 1998:668

8. DiMatteo MR, Sherbourne CD, Hays RD, et al. Physicians'
characteristics influence patients' adherence to medical treatment:
results from the Medical Outcomes Study. Health Psychol 1993;12:93-102.

9. Whitney SN. A new model of medical decisions: exploring the limits
of shared decision making. Med Decis Making. 2003 Jul-Aug;23(4):275-80.

Competing interests:
None declared

Competing interests: No competing interests

18 January 2005
Memoona Hasnain
Director of Research & Assistant Professor of Public Health in Family Medicine
Dept of Family Medicine, College of Medicine, University of Illinois at Chicago, IL 60612 USA