Challenges In Understanding And Respecting Patients' Preferences.

Area of Science:

• Medical Ethics
• Health Services Research
• Decision Science

Background:

• The Institute of Medicine's "Dying in America" report emphasizes honoring end-of-life treatment preferences.
• Shared decision-making and advance care planning (ACP) are recommended for seriously ill patients.
• Decision science highlights difficulties in specifying patient preferences for complex or unfamiliar future choices.

Purpose of the Study:

• To identify factors influencing the effectiveness of advance care planning.
• To examine the role of local provider practice norms in shaping ACP conversations and patient decisions.
• To propose strategies for improving the fidelity of ACP in reflecting patient preferences.

Main Methods:

• Conceptual analysis of decision science research and healthcare practice norms.
• Discussion of how local practice norms influence the timing, content, and interpretation of ACP discussions.
• Identification of provider influence as a key, yet overlooked, factor in ACP.

Main Results:

• Advance care planning may not fully capture patient preferences due to inherent complexities and unfamiliarity of future scenarios.
• Local provider practice norms significantly shape how ACP discussions occur and how patient choices are influenced.
• Provider influence, stemming from evolving norms, can subtly guide patient decisions.

Conclusions:

• Local provider practice norms are a powerful, underrecognized influence on advance care planning.
• Strategies to improve ACP include increasing provider awareness of their influence through audit, feedback, and coaching.
• Systematizing ACP processes can help mitigate the impact of unexamined practice norms and better honor patient preferences.