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Warranting the decision-maker, not the decision: How healthcare practitioners evaluate the legitimacy of patients' unprompted requests for risk-reducing mastectomy

Brown, SL, Beesley, H, Holcombe, C, Saini, P and Salmon, P (2019) Warranting the decision-maker, not the decision: How healthcare practitioners evaluate the legitimacy of patients' unprompted requests for risk-reducing mastectomy. PATIENT EDUCATION AND COUNSELING, 102 (8). pp. 1446-1451. ISSN 0738-3991

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Abstract

Objective: Guidance on shared decision-making (SDM) exists to reconcile healthcare practitioners’ responsibilities to respect patients’ autonomy and to ensure well-made decisions. Patients sometimes make unprompted requests for clinical procedures that carry medical and other dangers, such as risk-reducing mastectomy (RRM) to reduce breast cancer risk. Faced with pre-formed decisions into which they have had little input, it is unclear how practitioners can reconcile respecting autonomy with ensuring well-made decisions.

Methods: Qualitative study of linked patient-practitioner interviews in clinics associated with a breast unit in North-West England. We examined how 10 practitioners addressed 19 patients’ unprompted requests for RRM.

Results: Practitioners empathised with patients’ distress about cancer risk and regarded RRM as a legitimate way to help. However, practitioners were wary of choices that patients had made ‘emotionally’. To resolve this paradox, practitioners warranted patients by satisfying themselves that patients were ‘sensible’ and ‘informed’ decision-makers, and thus their decisions could be trusted, rather than establishing whether their decisions were well-made. Practitioners gave information about RRM, and tested patients’ resolve to obtain it by delaying decisions and presenting ‘what if’ scenarios depicting failure or harm associated with RRM.

Conclusion: Patients who present emotionally and with strong resolve can receive RRM, but without evidence of a well-made decision.

Practice Implications: Using argumentation theory, we propose an ethically robust and clinically practicable approach, whereby practitioners elicit, examine and, where appropriate, challenge the arguments patients make for their decisions.

Item Type: Article
Uncontrolled Keywords: 11 Medical and Health Sciences, 17 Psychology and Cognitive Sciences
Subjects: B Philosophy. Psychology. Religion > BF Psychology
R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine
Divisions: Natural Sciences & Psychology (closed 31 Aug 19)
Publisher: ELSEVIER IRELAND LTD
Related URLs:
Date Deposited: 25 Jul 2019 07:43
Last Modified: 25 Jul 2019 08:00
DOI or Identification number: 10.1016/j.pec.2019.03.007
URI: http://researchonline.ljmu.ac.uk/id/eprint/11108

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