Eliciting patients' values and treatment preferences is an essential element in models of shared decision making, yet few studies have investigated the interactional realizations of how physicians do this in authentic encounters. Drawing on video-recorded encounters from Norwegian secondary care, the present study uses the fine-grained empirical methodology of conversation analysis (CA) to identify one conversational practice physicians use, namely, formulations of patients' stance, in which physicians summarize or paraphrase their understanding of the patient's stance towards treatment. The purpose of this study is twofold: (1) to explore what objectives formulations of patients' stance achieve while negotiating treatment and (2) to discuss these objectives in relation to core requirements in shared decision making. Our analysis demonstrates that formulating the patient's stance is a practice physicians use in order to elicit, check, and establish patients' attitudes towards treatment. This practice is in line with general recommendations for making shared decisions, such as exploring and checking patients' preferences and values. However, the formulations may function as a device for doing more than merely checking and establishing common ground and bringing up patients' preferences and views: Accompanied by subtle deprecating expressions, they work to delegitimize the patients' stances and indirectly convey the physicians' opposing stance. Once established, these positions can be used as a basis for challenging and potentially altering the patient's attitude towards the decision, thereby making it more congruent with the physician's view. Therefore, in addition to bringing up patients' views towards treatment, we argue that physicians may use formulations of patients' stance as a resource for directing the patient towards decisions that are congruent with the physician's stance in situations with potential disagreement, whilst (ostensibly) avoiding a more authoritarian or paternalistic approach.
Despite pharmacists' extensive knowledge in the optimization of patients' medical treatments, community pharmacies are still fighting to earn patients' trust with respect to medicinal counselling at the counter.
The aim was to investigate how patients perceive pharmacy counselling at the present time, in order to develop the patient-pharmacy relationship for the benefit of both patients and pharmacies.
Short semi-structured interviews were carried out with pharmacy customers by pharmacy internship students.
One hundred and eight customers in 35 independent pharmacies across Denmark were interviewed during the spring of 2011.
Customers were interviewed about their expectations of pharmacies in general and their experiences with medical counselling in particular.
Customers perceive community pharmacies very differently in terms of both expectations of and positive experiences with counselling. They appear to be in favour of pharmacy counselling with respect to over-the-counter medicine and first-time prescription medicine in contrast to refills. Customers find it difficult to express the health-care role of pharmacies even when experiencing and appreciating it.
Lack of appreciation of pharmacy counselling for refill prescription medicine and the difficulty in defining the role of pharmacies might stem from the difficulties that customers have in understanding medicine and thus the role of counselling services with respect to medicine. The pharmacy staff does not seem to realize these barriers.
For pharmacies to encourage customer interest in pharmacy counselling, the staff should start taking the identified barriers into account when planning communication strategies.
Use of an intrauterine contraceptive device (IUD) has not been recommended to nulliparous women in the past. There is now good evidence that there is no increased risk of pelvic inflammatory disease or infertility in nulliparas who use IUDs and the recommendations have changed. Our objective was to understand more about the motivations and experience of nulliparous women using IUDs.
This was a mixed method study. First, we asked 44 nulliparous women who had had an IUD inserted within the previous six months about their reasons for seeking the IUD, their history with other forms of contraception, their perception of the insertion experience, and their feelings after insertion. Questionnaires were then distributed to 154 nulliparous women presenting for IUDs, asking about their past experience with hormonal contraception.
The main theme arising from the interviews was a desire to avoid hormonal contraception. Other reasons for choosing the IUD were greater contraceptive effectiveness than other methods, convenience of use, and lower cost. Responses to the questionnaire indicated that 138 women (89.7%) had used hormonal contraception in the past and, of those, 98 (63.0%) complained of mood side effects, 64 (41.6%) of sexual side effects, and 64 (41.6%) of physical side effects.
The most important motivation for nulliparous women in this study to choose IUDs was to avoid the potential or actual side effects of hormonal contraception. Despite experiencing some discomfort at the time of insertion, this group of nulliparous women was very positive about using IUDs for contraception.
Achieving home death is often seen as an important endpoint in palliative care, but no studies of the preferred place-of-death have yet been conducted in Scandinavia. Furthermore, we do not know if professionals' report on deceased patients' preference of place-of-death is a valid information. The aim of this study was to describe where terminally ill Danish cancer patients prefer to die and to determine if their preference changed during the palliative period, as reported retrospectively by bereaved relatives, general practitioners (GPs) and community nurses (CNs) and to assess the agreement of their accounts. The study was a population-based, cross-sectional combined register and questionnaire study in Aarhus County, Denmark. The population comprised 599 deceased adult cancer patients who had died from 1 March to 30 November 2006 and were identified through merging of health registers. Relatives returned 198 questionnaires about patients' preferred place-of-death, GPs 333 and CNs 201. The study showed that most terminally ill cancer patients preferred home death (up to 80.7%). The reported preference for home death weakened as death approached (down to 64.4%). A better congruence was seen between relatives' and GPs' accounts of preference for place of death at the end of the palliative period (? 0.71) than between relatives' and CNs' accounts (? 0.37). In conclusion, bereaved relatives (and GPs and CNs) report retrospectively that most terminally ill cancer patients wish to die at home. The preference weakened significantly as death approached. The agreement between relatives' and GPs' accounts on patients' preferences at the end of the palliative period was 'substantial', whereas the agreement between relatives' and CNs' accounts at the same time was significantly less outspoken. This indicates that CNs may be facing a problem in assessing their patients' wishes retrospectively.
While complementary and alternative medicine (CAM) can improve quality of life at end of life, little research exists on hospice residents' interest in using and sharing CAM experiences with a partner/friend/other family member. A pilot study conducted in British Columbia, Canada explored the extent of hospice residents' interest and openness to CAM use. A convenience sample of 48 hospice residents from 9 hospice sites completed questionnaire-based interviews. The majority of participants were Caucasian women over 60 years old. 81 percent expressed interest in receiving CAM; 79 percent used CAM prior to entering the hospice setting. 50 percent of those interested in using CAM felt their partner/friend/other family member would also be interested in receiving CAM, and half of that 50 percent reported personal interest in sharing the experience. Reasons reported for CAM interest were to enhance well-being, relaxation, and for pain relief. Further research could explore how resident-caregiver dyads may benefit from shared CAM experiences over the illness trajectory.
To estimate the association between delivery preferences during pregnancy and actual delivery mode.
This was a prospective cohort study using data from the Norwegian Mother and Child Cohort Study (N=65,959). We analyzed predictors of birth outcome by means of women's preferences for mode or delivery and a range of medical and socioeconomic factors with multivariable logistic regression models. The term "elective" cesarean delivery includes cesarean deliveries planned 8 hours or more before delivery and performed as planned.
When asked about delivery preference at 30 weeks of gestation, 5% of the women reported a preference for a cesarean delivery, 84% had a preference for vaginal delivery, and 11% were neutral. Among those with a cesarean delivery preference, 48% subsequently had a cesarean delivery (12% acute and 36% elective), and of those with a vaginal preference 12% delivered by cesarean (8.7% acute and 3.1% elective). When adjusting for maternal characteristics and medical indications, the odds for an acute cesarean delivery among nulliparous women with a cesarean delivery preference was almost two times higher (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.49-2.62) and for elective cesarean delivery the preference was 12 times higher (OR 12.61, 95% CI 9.69-16.42) than for women with a vaginal preference. For multiparous women, the corresponding figures were OR 3.13 (95% CI 1.39-7.05) and OR 10.04 (95% CI 4.59-21.99). When multiparous women with previous cesarean deliveries were excluded, the OR for an elective cesarean delivery was 26 times higher given a cesarean delivery preference compared with a vaginal delivery preference (OR 25.78, 95% CI 7.89-84.28). Based on a small subset of women with planned cesarean delivery on maternal request (n=560), we estimated a predicted probability of 16% for nulliparous women (25% for multiparous women) for such cesarean delivery.
Pregnant women's expressed preferences for delivery mode were associated with both elective and acute cesarean deliveries.
While many countries have increased the opportunities for patient choice of provider, there is debate to what extent this has had positive effects on efficiency and quality of healthcare provision. First, some conditions should be met to exercise such choice, of which the most important is the provision of reliable data on providers' performance to both patients and physicians as their agents, as well as increasing primary health care (PHC) providers' involvement in realization of patient choice. Second, expanding patient choice does not always lead to efficient allocation of resources in a healthcare system. This article explores these controversial developments by using empirical evidence from the Russian Federation. It shows that choice indeed has value for patients, but there are many areas of inefficient choice, which leads to misallocation of healthcare recourses. Thus, health policy in this area should be designed to ensure a reasonable balance between objectives of expanding choice and promoting more efficient organization of healthcare provision. Political rhetoric about unlimited patient choice may be useless and even risky unless supported by well-balanced programmes of supporting and managing choice.