This study revealed several themes relating to older adults' perception of patient involvement in medication decision making. There was variability in perceptions on whether it was possible or desirable for patients to participate in any aspect of prescribing decisions. While some participants expressed attitudes and beliefs that were congruent with the paternalistic model,37
deferring decisions completely to the physician, others supported a more participatory role for the patient. For those who considered it possible for patients to participate, knowledge, communication, confidence, trust, time constraints, the expanding number of medications available, the focus on treating numbers, and multiple physicians prescribing for the same patient were recurring themes that facilitated or impeded patient involvement in medication decision making. Participants also expressed views on participating in different aspects of decision making.24,25,30
For some interviewees, involvement was limited to the physician providing drug-specific information to the patient, which, while a necessary step, is not the same as sharing decisions.24,25
Others mentioned discussing treatment options. Only 1 participant expressed the idea that medication prescribing should be based on individual patients' health preferences and goals, a key component of shared decision making.24,25
Many of our findings are consistent with previous studies addressing medication related and other health care decision making. Prior investigations have shown, for example, that some patients do not want to be involved in decision making.26–29,38
Of those who do want to be involved, the spectrum of involvement ranges from sharing information to active participation in the final decision.24,25,30,31
Many of the views and issues mentioned by our participants were similar to those reported for decisions ranging from cancer screening and treatment to asthma management,27–29
suggesting that many of the important considerations are not unique to older adults or to medication decision making.
One advantage of qualitative research is the opportunity to uncover unexpected themes.34–36
One such unexpected theme in the present study was that both presence and absence of trust in the physician could serve to either facilitate or impede participation. This complex relationship between trust and patient involvement requires further exploration and hints at the difficulties confronting an evolution to a shared decision-making model of medication prescribing.
The limitations of this study are several. We did not attempt to prioritize the responses in this qualitative study. We cannot comment, therefore, on the relative importance of the themes. Participation was limited to English-speaking adults who were able to go to medical appointments or to senior centers, and in the case of participants recruited from physicians' offices, be able to participate in a telephone interview. We do not know how many, or who, did not chose to participate or whether nonparticipants might have perceptions different from those expressed by participants. Finally, the number of minority participants was small although they raised themes similar to those raised by Caucasian participants. In this qualitative study, we could not determine the prevalence of the various responses or the differences in prevalence across participant characteristics such as age, gender, ethnicity, or health status. Further research is needed to quantify the perceptions expressed by participants and to determine the spectrum of desired participation. In the meantime, our findings suggest areas that need to be addressed.
While evolution to greater patient involvement may be possible, and desirable to some older patients, findings suggest that the transition will be challenging. Several different strategies likely will be necessary to encourage older patients to participate in medication decision making. As a simple first step, physicians need to directly ask patients how involved they would like to be in making decisions. The shared decision-making model involves various aspects including exchange of information between patient and physician, discussing treatment options, and making the treatment decisions.24,25,30
The physician should elicit which aspects the patient wishes to be involved in. For those patients not wishing to be involved, further exploration may be needed. Because fear, perceived lack of knowledge, and low self-efficacy were frequently mentioned reasons for the reluctance to participate, strategies to enhance patient knowledge and to increase confidence in interacting with physicians should be used before accepting that patients do not wish to be involved.
For those patients who express interest in being involved, the study highlights ways to encourage greater patient participation. The communication skills of both patient and physician were frequently mentioned determinants of patient involvement. Although the concept of patient centeredness has influenced recent teaching practices, training in communication skills remains largely focused on history taking and diagnosis.15
Less attention has been paid to decisionmaking tasks.39
The reference to prescribing by multiple physicians as a barrier indicates that communication between providers is as important as patient-physician communication. Physicians must not only communicate with each other but must agree on the medication regimen that best meets individual patients' goals and preferences.
Another physician-related issue was the perception of several participants that physicians are focused on “treating numbers.” Such a focus is an expected consequence of guideline-driven medication prescribing.40,41
Successful implementation of shared decision making, however, will require a resolution of the inherent conflict between appropriate treatment of individual diseases and goal-directed care of older adults with multiple conditions.6
Eliciting patient goals and preferences is a fundamental aspect of decision making and is particularly important given the variability in health outcome priorities among older patients with multiple conditions. The rare mention of goals and preferences in this study suggests that training in, and encouragement of, elicitation of preferences will be essential to shared decision making.13–15
Shared decision making between physicians and patients would seem integral to dealing with the uncertainty and variability inherent in medication prescribing for older patients with multiple conditions. The perceptions and views expressed by interviewees in this study can help inform movement toward greater involvement of older patients in medication decision making.