Medical Treatment Decisions

In the past, doctors often made decisions for their patients without their input and without explaining the risks and benefits of all available treatments. This approach has become generally unacceptable.

Because the goal of medical treatment is to improve outcomes, as defined by a person’s own goals and values (see Defining Goals), health care professionals now try to share medical decision making with their patients. Information is exchanged in 2 ways:

• Doctors provide patients with information about available treatments and the benefits and risks of those treatments.

• Patients share personal information about their lifestyle, preferences, and values with their doctor.

The doctor and patient discuss treatment options and agree on the best treatment plan. Shared decision making does not mean that doctors leave people completely on their own to decide among various, sometimes confusing treatment options. Doctors still make recommendations based on standards of care and the best medical evidence, but they present the reasons behind those recommendations and how they think those recommendations meet the individual's needs and goals. In shared decision making, doctors help guide people through the decision process, neither dictating to them nor abandoning them.

In some cases, people need to work with their doctors to make decisions that take into account quality of life. Aggressive cancer therapy may prolong life but have severe negative effects that greatly reduce quality of life. The person's preference for quality of life versus duration of life and tolerance for risk and uncertainty help inform health care goals and determine what medical interventions to pursue. Quality-of-life issues may be particularly important to older people (see Therapeutic Objectives in Older People).

Sometimes, people are unable to make decisions on their own behalf because they have illnesses, such as dementia, that affect their ability to understand information. Sometimes, they have severe illnesses such as delirium or coma that affect their level of consciousness. In such cases, a doctor will ask the person’s next-of-kin or other holder of a health care power of attorney to help make treatment decisions.

Health care professionals use their education, experience, and the results of clinical trials to provide information regarding the risks and benefits of available treatments.

Risk is the likelihood that a harmful outcome will occur, such as worsening of the disease or developing a side effect from the treatment. How risks are described can make a big difference. For example, suppose that there was a clinical trial that compared a new medication to prevent stroke against an established medication. Now suppose the results of the trial showed that the new medication caused the side effect of bleeding in 2% of people but the established medication caused bleeding in 1% of people.

• One way to state the results would be to say that the new medication caused "twice as much bleeding" (the relative risk increase).

• But it would be equally correct to say that the new medication "increased the possibility of bleeding by only 1 percentage point" (the absolute risk increase).

In this example, the relative risk being twice as high makes the new medication sound extremely dangerous, whereas the absolute risk increase of 1 percentage point makes the danger sound minimal. And people who are for or against something typically quote only the risk description that best fits their opinion. Doctors can help people understand risk estimates and make a reasoned decision.

The benefit of treatment could be any of the following:

• Cure of the disease (the greatest benefit and ultimate goal)

• Decreased symptoms (for example, reduced pain)

• Improved function (for example, being able to walk farther)

• Decreased likelihood of disease complications (for example, heart attack in people with diabetes)

After weighing the risks and benefits of treatment and taking into account a person’s goals and preferences, the doctor might make a recommendation for a specific treatment plan. However, this process can sometimes be complicated, because

• There may not be one best treatment for a disease

• The tradeoffs between the risks and benefits may be numerous and confusing to sort through

Because medical information can be complex, health care professionals should provide perspective on the potential risks and benefits. For example, in the United States, advertisements for various medications are accompanied by a long list of potential side effects that range from mild to disastrous, but these advertisements do not provide information on any of the following topics:

• How many people will experience these side effects

• The consequences of these side effects

• The consequences of not treating the disease

As a result, a person who might benefit greatly from a treatment might refuse the medication for fear of experiencing any number of the advertised side effects (which may occur in, for example, 1 out of 100 people).

For example, many people who have high blood pressure stop treatment because they have side effects from the medication they were given. Doctors can explain to people that even though they feel fine now, treating high blood pressure is important because it significantly reduces their chance of heart attack, stroke, and kidney failure, which are leading causes of death and disability in the United States. If people understand that side effects might be avoided or minimized by using a different medication or a different dose, they might be more willing to assume the risks of treatment. By contrast, the effects of a heart attack or stroke are often serious, irreversible, and life-threatening, meaning that the potential benefit of taking a blood pressure medication greatly outweighs the potential risks for most people.

Doctors can also provide perspective by comparing the person's circumstances with the circumstances of the people in whom a medication or treatment was originally studied in a clinical trial. For example, a person who is sicker than the people in whom the medication was originally studied might benefit less from the medication and perhaps experience more risk. On the other hand, a person who is healthier than the people in whom the medication was originally studied might have better outcomes than those of the study group.