abnormal uterine bleeding patients : how to decide...
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PIERRE PANEL CENTRE HOSPITALIER DE VERSAILLES
ABNORMAL UTERINE BLEEDING Clinical problems and desire of
patients : how to decide ?
FRANCE
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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
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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
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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
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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”…
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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?
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! 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
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! 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
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info.k4health.org/pr/prf/fj48/elements.shtml
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Raise self-esteem
Open ended Questions
Reflect
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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?
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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
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Anatomy of a decision
Evidence Research data
Preferences (experience) of the patient
DECISION
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Versailles
Versailles
Versailles