More than half of the patients discharged from hospital identified a medical decision that was made during the hospital stay. According to patient reports, the decision-making process was globally in conformity with current expert opinions.1–5,14,30
Most respondents gave positive ratings to the decision that was reached; only few conveyed negative feelings through their responses. A shared decision-making approach led to the highest scores for both the process and decision evaluation of the decision-making. Both scores were also predictive of a more favourable assessment of the hospital stay.
According to our observations, a decision that the patient will be satisfied with requires explanations that are easy to understand, covering all options available to the patient as well as risks. Furthermore, a good decision requires patient involvement to the level desired, and absence of pressure into the decision. These empirical findings provide a solid support to experts’ opinions about the ingredients of appropriate decision-making. The association between process and outcome suggests that satisfaction with the decision is not only a consequence of low expectations (but as we did not measure expectations, we cannot assess the impact of this variable directly).
Only one finding was contrary to experts’ opinions: involving the patient more
than he or she wanted had a positive effect on the global satisfaction. Possibly, some patients interpreted “more than I wanted” to mean “exceeding my initial expectations”, rather than “too much”. If so, a more explicit wording of this item may be warranted. Alternatively, some patients do not know in advance how much involvement they would want, and realize in retrospect that greater involvement was a good thing. The finding that being involved “more than preferred” was associated with higher satisfaction than being involved “less than preferred” has been observed previously.35
Our study also confirms that the patient’s perception of shared decision-making is associated with the highest ratings of the decision. That process scores should be high for shared decision-making is in part tautological, since the process score gives high marks to the exchange of information and to the active involvement of the patient. However, the same cannot be said of the decision satisfaction score, which is not predicated on any type of process. Our results support shared decision-making as the preferable model for most patients.36,37
Other findings deserve comment. The prevalence of recalled decision-making appears to be low at 58.8%. Studies conducted in ambulatory settings typically identified several decisions made during a single visit.13,14,16
It is likely that even more decisions are made during a hospital stay. Some patients may be unaware that decisions are made repeatedly, believing instead that their care is a sequence of pre-determined steps. Unless the doctor brings the decision to the patient’s attention, the patient may never realise that several courses of action were possible. That older patients, who are more likely to prefer a doctor-centred decision-making style, were less likely to report a medical decision is consistent with this hypothesis. However, incomplete or selective recall remains a possibility.
Patient reports of decision-making process were more favourable than we anticipated based on previous descriptive studies. For each of the 11 process-related items, more than half of the respondents gave the most desirable answer, and one out of six rated all of these 11 elements at the highest level. Several caveats are in order. Firstly, patients who were not involved in decisions may have skipped this section of the questionnaire. Secondly, given that for most patients several decisions were made in the hospital, respondents may have focused on the decision for which the process was the most explicit, and which therefore conformed best with current standards. Thirdly, patient opinion surveys tend to produce globally positive ratings. Finally, the moderate response rate raises the possibility that patients who were more satisfied with decision-making were also more likely to participate. Thus both selection bias and information bias may have contributed to the globally favourable findings.
This study was based on an unselected large sample of patients discharged from a general hospital. However, only one hospital was involved, and it remains unclear whether the results that we observed are applicable to other hospitals, particularly to hospitals in other cultural contexts, where both the doctors’ approaches to medical decision-making and the patients’ expectations in this area may differ.
Another limitation is the lack of a precise description of the decision discussed by the respondent. This was tried in pre-tests, but the responses that we obtained were too heterogeneous and the idea was abandoned. This limits the interpretability of the results. Furthermore, we only collected patients’ perceptions, with no corroborating evidence from the doctor. Finally, all limitations of self-report, such as imperfect memory and social desirability bias, apply to our results as well.
While not a specific goal of this study, a useful by-product is the development of two scales that allow the patient to evaluate the process and the outcome of medical decision-making. Both scales had good internal consistency. Their validity is supported by the associations between process items and decision satisfaction scores, and vice versa (Tables and ). However, a more extensive validation of these scales is advisable. In particular, measurement of the outcome of decision-making is challenging, as satisfaction with the decision may be high when the patient’s expectations are low, and may decrease when more extensive information about available options causes discomfort or decisional conflict.
In conclusion, our results indicate that decision-making in a general hospital is globally satisfactory, though several areas for improvement exist, and provide an empirical confirmation of expert opinions about the desirable features of medical decision-making.