How do physicians influence patient and family decision making regarding treatment options?

How Physicians Influence Patient and Family Treatment Decision-Making

Physicians exert the most direct and powerful influence on patient treatment choices through their recommendations, communication style, and the information they choose to present—even when evidence is equivocal or multiple reasonable options exist. 1

The Physician's Central Role in Decision-Making

Physicians remain the principal influencer in medical decision-making despite the shift toward shared decision-making models. 1 Research demonstrates that physician recommendations significantly alter patient choices, even pulling patients away from decisions they would otherwise prefer or that maximize health outcomes. 2 This influence operates through several mechanisms:

• Direct recommendations carry disproportionate weight: When physicians make explicit treatment recommendations, patients follow them even when those recommendations contradict what objectively maximizes health or what patients would choose independently. 2
• Physicians' own treatment preferences differ from what they recommend: Physicians choose higher-risk options for themselves (with higher mortality but fewer adverse effects) more often than they recommend these same options to patients, suggesting they frame information differently when advising others. 3
• The framing of information shapes decisions: How physicians present benefits versus harms, use numerical versus verbal descriptions of risk, and emphasize certain outcomes over others fundamentally alters patient choices. 1

Essential Communication Practices That Shape Decisions

Information Provision and Framing

Physicians must provide complete, honest, unbiased information about diagnosis, prognosis, and all treatment options—including the option of not pursuing aggressive treatment. 1 This includes:

• Numerical likelihoods when available: Words like "rarely" and "frequently" are variably interpreted and often misunderstood; absolute risks presented with visual aids are most effective. 1
• Both occurrence and non-occurrence probabilities: Present both the likelihood of events happening and not happening to avoid positive or negative framing bias. 1
• Patient-centered communication reduces inappropriate care: Physicians who provide patient-centered communication successfully reduce medically inappropriate services and mitigate requests for inappropriate treatment. 1

Distinguishing Preference Elicitation from Decision-Making

A critical but often overlooked distinction exists between eliciting patient preferences and making the actual treatment decision. 1 The process should follow this sequence:

1. Inform patients of the need for a decision and explain the medical facts comprehensively. 4
2. Elicit patient preferences and goals only after the individual is sufficiently informed—premature preference elicitation leads to uninformed choices. 1
3. Identify outcomes that matter to the patient (e.g., living as long as possible, maintaining function, minimizing pain) rather than focusing solely on disease-specific metrics. 1
4. Make the actual decision through the patient's preferred model—some want to decide themselves, others want the physician to decide, but virtually all want their opinion to guide the process. 1

Partnership Models and Cultural Considerations

Respecting Autonomy While Maintaining Clinical Judgment

Patient and family partnership does not mean the patient is always right. 1 Physicians must balance respect for patient preferences with their clinical judgment and ethical standards:

• Clinicians should listen to and understand patients' healthcare needs in their particular situation while being willing to navigate differing health beliefs and values. 1
• Patients do not have the right to demand any available treatment without reasonable expectation of benefit. 1
• Partnership is achieved when patients receive necessary information and are invited to make decisions, not when physicians simply acquiesce to requests. 1

Cultural Variations in Decision-Making Models

The North American norm of individual patient autonomy must be adapted when caring for ethnically diverse patients. 1 Alternative models include:

• Family-based decision-making: Cultures valuing beneficence and nonmaleficence over autonomy have traditions where relatives receive information and make treatment choices, often without direct patient input. 1 Koreans, Mexican-Americans, and some Black families view decision-making as family-centered even with acculturation. 1
• Physician-based decision-making: Eastern European, Russian, and some Bosnian immigrant communities prefer physicians make independent decisions to reduce burden on patients and families. 1
• Shared physician-family models: Asian, Indian, and Pakistani cultures may adopt physicians into the family unit, sanctioning their involvement in intimate discussions. 1, 5

Specific Strategies to Optimize Physician Influence

Use of Decision Aids and Structured Approaches

Decision aids increase patients' knowledge of options, help them reach decisions consistent with their values, and foster collaboration with healthcare professionals. 1 A 2018 Cochrane review of 87 studies confirmed these benefits. 1

• Videos demonstrating treatment options help patients recall information and become more actively involved in decision-making. 1
• Decision trees identifying all potential outcomes of each treatment option allow comparison using patient-specific values. 1
• The "teach back" technique assesses patient understanding of presented information. 1

Timing and Reassessment of Decisions

Preferences change over time and must be reexamined, particularly with changes in health status. 1 For patients with progressive conditions:

• Begin discussions early: For chronic kidney disease, discuss life expectancy and quality of life as early as possible and continue as disease progresses. 1
• Reassess with major complications: When complications substantially reduce survival or quality of life, discuss and reassess treatment goals. 1
• Document discussions: Record and date conversations about prognosis, expressed wishes, unresolved issues, and team recommendations. 1

Addressing Conflicts and Tensions

Three key tensions arise during treatment decision-making that physicians must actively address: 6

1. Information balance: Providing enough information to set expectations without overwhelming patients
2. Cure versus consequences: Balancing highest likelihood of cure with physical, emotional, social, and financial consequences
3. Data versus personalization: Making data-driven decisions while maintaining personalized treatment plans

When disagreements exist between physicians and patients/families, a systematic conflict resolution approach is essential. 1 Interdisciplinary meetings and ethics consultation services can help navigate these situations. 1

Common Pitfalls to Avoid

• Narrowing options prematurely: Surgeons who present only surgical options based on age and physiological status create misconceptions about other treatments. 1
• Assuming understanding: Never assume families understand that symptoms (such as behavioral changes in dementia) are disease-related rather than intentional. 7
• One-time conversations: Families need ongoing support and repeated discussions as disease progresses, not single encounters. 7
• Ignoring caregiver burden: Physicians must address caregiver mental health and relationship dynamics that contribute to decision-making stress. 7
• Treating all patients identically: Cultural context, health literacy, and family dynamics require individualized communication approaches. 1

The Pediatric Context

In pediatric care, parents are generally regarded as best able to appreciate the child's best interests, which forms the central framework for decision-making about life-sustaining treatment. 1 However:

• Children have the right to age-appropriate information about their illness, treatments, and outcomes within the context of family decisions. 1
• Children should be given opportunities to participate in decisions according to their age, understanding, capacity, and parental support. 1
• Physicians must balance providing complete information to families with managing the flow when the care team is divided, which can be stressful to family decision-makers. 1