PIERRE PANEL CENTRE HOSPITALIER DE VERSAILLES

ABNORMAL UTERINE BLEEDING Clinical problems and desire of

patients : how to decide ?

FRANCE

Heavy menstrual bleeding NICE clinical guideline 44

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NICE clinical guideline 44

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Heavy menstrual bleeding: pharmaceutical treatment

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Heavy menstrual bleeding: surgical treatment

Heavy menstrual bleeding: surgical treatment

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Anatomy of decision making 7

D’après Bitzer J. 2011 Service de Gynécologie-Obstétrique, Bâle, Suisse

Subjective : wishes, values, perceptions

Objective : risks, capacities, resources

Social and cultural context

Childbearing age

Relationships

Invasiveness

Evidence based

Pharmacokinetic profile

Standard, Guidelines, options

!  Standard !  Generally accepted patient-care strategy !  Implies Level 1 evidence !  Accurate knowledge of the risks and benefits !  Few or no alternative therapies offering an equivalent risk-

benefit ratio !  Virtual unanimity (99% of acceptability)

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!  Guidelines !  Assess the level of evidence !  Assess the degree of uncertainty !  Engagement in all stages of the process !  Implies Level 2 or 3 Evidence !  Outlines also what “is not required to…”

Standard, Guidelines, options 9

Standard, Guidelines, options

!  Evidence based options !  Accurate knowledge of the risks and benefits !  Existence of alternative therapies with different but acceptable

levels of efficiency and risks !  Even distribution of the patients’ choices

!  Random options !  Inaccurate knowledge and uncertain clinical use !  Insufficient, inconclusive or conflicting evidence/experts

opinions. !  Patients’ preference

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Eliciting patient’s preferences

!  Clear statement of the patient in favour of an option !  Refusal to choose

!  Reformulate in order to obtain the patient’s point of view !  Eliciting of constituent elements of a preference

!  Help the patient to make connections between the risks/benefits and family, social, philosophical, religious preferences

!  Reformulate and assess the consistence of the chosen option

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Beliefs or representations that may affect the behaviour of patients facing treatment choice

!  Absence of periods is bad for your health and can be fattening !  Loss of uterus can be synonymous with loss of femininity !  Hormones are “bad for your health”, “fattening”, they “give

cancer”, “reduce libido”… !  Artificial hormones are “bad for the planet”…

Replacing beliefs

!  On any topic, it is not easy to leave opinions and beliefs behind

!  As a first step, it is important to explore and respect them

« "It is not so much that people are unaware that causes problems, it is all they know and that is not true" »

Mark Twain

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A few questions to explore the patient’s knowledge and beliefs

!  Would the absence of periods trouble you? !  Do you prefer any method in particular?

If yes, which one? And why? !  Are you reluctant to use any methods?

If yes, which ones? And why? !  What would be the optimum method for you? !  Would you rather use a simple but less efficient method or a

more invasive but 100% efficient method?

!  Paternalistic !  Physician: Guardian !  Values: objective and shared by physician !  Patient’s autonomy: assenting to objective values

!  Informative !  Patient: choice of, and control over, medical care !  Values: defined, fixed, and known to the patient !  Physician: competent technical expert

!  Interpretative !  Values: inchoate and conflicting, requiring elucidation !  Physician: Counselor or adviser (elucidate or interpret) !  Patient’s autonomy: self-understanding relevant to medical care

!  Deliberative !  Values: open to development and revision through moral discussion !  Patient’s autonomy: moral self-development relevant to medical care !  Physician: friend or teacher (reveal patient’s values and preferences)

Emanuel EJ, Emanuel LL. JAMA 1992 ; 267 : 2221-6.

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Physician-patient relationship 16

!  Discussion about patient’s autonomy in decision making (BIC)

!  Discussion of the clinical issue and nature of the decision to be made (BIC)

!  Discussion of the alternatives (IC)

!  Discussion of the risks and benefits of the alternatives (IC)

!  Discussion of uncertainties (limits) associated with the decision (C)

!  Assessment of patient’s understanding (C)

!  Asking the patient to express a preference (C)

BraddockCH III &col. JGenInternMed.1997;12:339-345.

B = basic I = intermediate C = complex

Elements of Informed Decision Making 17

info.k4health.org/pr/prf/fj48/elements.shtml

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Raise self-esteem

Open ended Questions

Reflect

Transform closed-ended questions into open-ended questions

•  Are you reluctant to use a hormone treatment?

•  Are you uncomfortable with the idea of not having a uterus anymore?

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How do you feel about not having a uterus anymore?

What do you think of a hormone treatment?

Few formulas to start reformulation (reflect)

•  If I understand you correctly…

•  So, in your opinion…

•  What you mean is that…

•  In other words…

•  So, according to you…

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Raising self-esteem

•  Reinforce the feeling of personal efficiency, enhance patient’s resources

•  Direct formulas to raise self-esteem,

to appreciate the efforts and to be supportive

« I sincerely realize that you have always been very consistent in your gynecological follow-up, so I have total confidence in your ability to take your treatment consistently »

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This encourages the patient to continue

Anatomy of a decision

Evidence Research data

Preferences (experience) of the patient

DECISION

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Versailles

Versailles

Versailles