Ethical aspects of risk communication

Clinical decision-making is becoming increasingly complex because of greater patient access to information, more clinical options and the emphasis on patient-centred care with informed decision-making. Risk communication should form part of evidence-based clinical practice, and it is important to think about what happens when clinicians adopt different consultation approaches. In this article, the ethical consequences of risk communication are analysed by looking at how the paternalistic and shared decision-making models of consultation demonstrate different ethical implications, based around a clinical scenario. To do this, we have applied the ethical principles of autonomy, utility and justice to these models. We show that the different models of consultation place varying degrees of emphasis on risk communication, patient autonomy and biomedical utility. This has implications for the way care is delivered both for the individual patient and for the population as a whole

The transition to secondary progressive multiple sclerosis: an exploratory qualitative study of health professionals' experiences

Background: Identifying the transition from relapsing-remitting to secondary progressive multiple sclerosis (SPMS) can be challenging for clinicians. Little previous research has explored how professionals experience working with patients during this specific stage of the disease. We explored the experiences of a group of multidisciplinary professionals who support patients in the transition to SPMS, to describe this stage from a professional perspective. Methods: Qualitative semistructured interview study with 11 professionals (medical, nursing, and allied professionals; both specialists and generalists) working with patients with MS in South Wales, United Kingdom. Thematic analysis of the interview data was performed. Results: Two overarching themes were identified: the transition and providing support. The theme “transition” comprised issues related to recognizing and communicating about SPMS. Uncertainty influenced both recognizing the transition and knowing how to discuss it with patients. “Providing support” included descriptions of challenging aspects of patient care, providing support for carers, utilizing the multidisciplinary team, and working within service constraints. Providing adequate psychological support and engaging patients with self-management approaches were seen as particularly challenging. Conclusions: Caring for patients in the transition to SPMS generates specific challenges for professionals. Further research on health-care interactions and patients'/professionals' experiences around the transition phase may help to identify strategies for professional development and learning, and how to optimize patient experience at this difficult stage of disease

"You are just left to get on with it": qualitative study of patient and carer experiences of the transition to secondary progressive multiple sclerosis

Objectives Although the transition to secondary progressive multiple sclerosis (SPMS) is known to be a period of uncertainty for clinicians, who may find progressive disease challenging to objectively identify, little research has explored the experiences of patients and carers specifically during this transition period. Our objective was to explore what patients and their carers understand about their disease stage and describe their experiences and perspectives on the transition to SPMS. Design Semistructured qualitative interviews and subsequent validation focus groups were analysed using inductive thematic analysis. Setting South East Wales, UK. Participants 20 patients with MS and 13 carers were interviewed. Eight patients and two carers participated in focus groups. Results Four main themes around disease progression were identified. ‘Realisation’ describes how patients came to understand they had SPMS while ‘reaction’ describes their response to this realisation. The ‘realities’ of living with SPMS, including dealing with the healthcare system during this period, were described along with ‘future challenges’ envisaged by patients and carers. Conclusions Awareness that the transition to SPMS has occurred, and subsequent emotional reactions and coping strategies, varied widely between patients and their carers. The process of diagnosing the transition was often not transparent and some individuals wanted information to help them understand what the transition to SPMS meant for them

Shared decision making in the UK: moving towards wider uptake

Shared decision making (SDM) is firmly on the policy agenda in the UK and a recent legal ruling has confirmed its importance. Policymakers, ethicists, professional regulators and societies, patient organisations and now the courts are committed to ensuring that SDM becomes the norm throughout the NHS, but an unfavourable economic climate makes this especially challenging. Considerable progress has been made over the last few years, with new learning from demonstration sites, various initiatives in capacity building and training, wider availability of patient decision aids, and important leadership initiatives. Enthusiasm for this way of working is growing among clinicians, patients and managers, but it could be undermined if SDM comes to be seen primarily as a means of cost control

On a learning curve for shared decision making: interviews with clinicians using the knee osteoarthritis Option Grid

Rational: Tools used in clinical encounters to illustrate to patients the risks and benefits of treatment options have been shown to increase shared decision making. However, we do not have good information about how these tools are viewed by clinicians, and how clinicians think patients would react to their use. Objective: Our aim was to examine clinicians’ views about the possible and actual use of tools designed to support patients and clinicians to collaborate and deliberate about treatment options, namely Option Grid TM decision aids. Method: We conducted a thematic analysis of qualitative interviews embedded in the intervention phase of a trial of an Option Grid decision aid for Osteoarthritis of the knee. Interviews were conducted with six participating clinicians before they used the tool, and again after clinicians had used the tool with six patients. Results: In the first interview, clinicians voiced concern that the tool would lead to an increase in encounter duration, to patient resistance regarding involvement in decision making, and potential information overload. At the second interview, after minimal training, the clinicians reported that the tool had changed their usual way of communicating, and it was generally acceptable and helpful integrate it into practice. Discussion and Conclusions: After experiencing the use of Option Grids, clinicians became more willing to use the tools in their clinical encounters with patients. How best to introduce Option Grids to clinicians and adopt their use into practice will need careful consideration of context, workflow and clinical pathways

Patients' views on the use of an Option Grid for knee osteoarthritis in physiotherapy clinical encounters: an interview study

Background: Patient decision support tools have been developed as a means of providing accurate and accessible information in order for patients to make informed decisions about their care. Option GridsTM are a type of decision support tool specifically designed to be used during clinical encounters. Objective: To explore patients’ views of the Option Grid encounter tool used in clinical consultations with physiotherapists, in comparison to usual care, within a patient population who are likely to be disadvantaged by age and low health literacy. Methods: Semi-structured interviews with 72 patients (36 who had been given an Option Grid in their consultation and 36 who had not). Thematic analysis explored patients’ understanding of treatment options, perceptions of involvement, and readability and utility of the Option Grid. Results: Interviews suggested that the Option Grids facilitated more detailed discussion about the risks and benefits of a wider range of treatment options for osteoarthritis of the knee. Participants indicated that the Option Grid was clear and aided their understanding of a structured progression of the options as their condition advanced, although it was not clear whether the option grid facilitated greater engagement in shared decision making. Discussion and Conclusion: The Option Grid for osteoarthritis of the knee was well received by patient participants who reported that it helped them to understand their options, and made the notion of choice explicit. Use of Option Grids should be considered within routine consultations

Communicating risk

Risk communication is the open two way exchange of information and opinion about harms and benefits; it aims to improve understanding of risk and promote better decisions about clinical management Strong evidence suggests that the format in which risk information is presented affects patients’ understanding and perception of risk There is emerging evidence that effective risk communication can lead to more informed decision making in screening Decision aids can be an effective adjunct to risk communication and can improve knowledge, awareness, and decision making The presentation of data uncertainty is one of the most difficult aspects of risk communicatio

What innovations help with the recruitment and retention of ambulance staff: a rapid evidence summary

Abstract: Ambulance waiting times across the UK have increased in recent years. The numbers of ambulance staff leaving services across the UK is increasing every year. Strategies to help recruit and retain all ambulance staff, including paramedics are important. This rapid evidence summary aimed to investigate what innovations can help with their recruitment and retention. Eight primary studies were identified: Recruitment: Evidence from a UK survey suggests that factors negatively influencing paramedic recruitment include competitive job market, lack of locally trained professionals, and newly qualified professionals starting with higher debt. Evidence from the US suggests that factors supporting recruitment concern future paramedics wanting to enter a caring profession or an exciting job. Additionally, strategies to recruit emergency medical technicians need to include the motivational aspects of growth, advancement, recognition, and responsibility. Evidence indicates that factors hindering recruitment of emergency medical technicians and/ or paramedics include rural working, and ambulance services not seen as a primary career path. Retention: Evidence from a UK survey suggests that pay, reward, stress and workload are factors that hinder paramedic retention. Evidence recommends retention strategies for paramedics, such as reviewing banding, improving work conditions and career progression, changing the way ambulances are dispatched to calls, and providing retention premiums. Evidence from the US suggests that pay, benefits, opportunities for advancement, continuous professional development, burnout, stress, workload, nearing retirement and career change are factors that influence retention of emergency medical technicians and/ or paramedics. Evidence from Thailand suggests that remuneration and professionalism are factors supporting paramedic retention. More up-to-date information is needed on the recruitment and retention of ambulance staff in UK settings. Further research providing a more detailed investigation of factors influencing recruitment and retention may be useful. The development or implementation of future strategies to help the recruitment and retention of paramedics and emergency medical technicians should be accompanied by a planned impact evaluation

Thyroid markers and body composition predict LDL-cholesterol change in lean healthy women on a ketogenic diet: experimental support for the lipid energy model

Introduction: There is a large heterogeneity in LDL-cholesterol change among individuals adopting ketogenic diets. Interestingly, lean metabolically healthy individuals seem to be particularly susceptible, with an inverse association between body mass index and LDL-cholesterol change. The lipid energy model proposes that, in lean healthy individuals, carbohydrate restriction upregulates systemic lipid trafficking to meet energy demands. To test if anthropometric and energy metabolism markers predict LDL-cholesterol change during carbohydrate restriction. Methods: Ten lean, healthy, premenopausal women who habitually consumed a ketogenic diet for ≥6 months were engaged in a three-phase crossover study consisting of continued nutritional ketosis, suppression of ketosis with carbohydrate reintroduction, and return to nutritional ketosis. Each phase lasted 21 days. The predictive performance of all available relevant variables was evaluated with the linear mixed-effects models. Results: All body composition metrics, free T3 and total T4, were significantly associated with LDL-cholesterol change. In an interaction model with BMI and free T3, both markers were significant independent and interacting predictors of LDL-cholesterol change. Neither saturated fat, HOMA-IR, leptin, adiponectin, TSH, nor rT3 was associated with LDL-cholesterol changes. Discussion: Among lean, healthy women undergoing carbohydrate restriction, body composition and energy metabolism markers are major drivers of LDL-cholesterol change, not saturated fat, consistent with the lipid energy model