Systemic Therapy Decision Making in Advanced Cancer: A Qualitative Analysis of Patient-Oncologist Encounters

PURPOSE: We sought to characterize patient-oncologist communication and decision making about continuing or limiting systemic therapy in encounters after an initial consultation, with a particular focus on whether and how oncologists foster shared decision making (SDM). METHODS: We performed content analysis of outpatient oncology encounters at two US National Cancer Institute–designated cancer centers audio recorded between November 2010 and September 2014. A multidisciplinary team used a hybrid approach of inductive and deductive coding and theme development. We used a combination of random and purposive sampling. We restricted quantitative frequency counts to the coded random sample but included all sampled encounters in qualitative thematic analysis. RESULTS: Among 31 randomly sampled dyads with three encounters each, systemic therapy decision making was discussed in 90% (84 of 93) encounters. Thirty-four (37%) broached limiting therapy, which 27 (79%) framed as temporary, nine (26%) as completion of a standard regimen, and five (15%) as permanent discontinuation. Thematic analysis of these 93 encounters, plus five encounters purposively sampled for permanent discontinuation, found that (1) patients and oncologists framed continuing therapy as the default, (2) deficiencies in the SDM process (facilitating choice awareness, discussing options, and incorporating patient preferences) contributed to this default, and (3) oncologists use persuasion rather than deliberation when broaching discontinuation. CONCLUSION: In this study of outpatient encounters between patients with advanced cancer and their oncologists, when discussing systemic therapy, there exists a default to continue systemic therapy, and deficiencies in SDM contribute to this default.

The relationship between vitality and the level of subjectivity in future pedagogues

The article presents the results of a study of subjectivity and vitality among students – future pedagogues. Topicality of the research is determined by the need to increase the subjectivity of students as one of the predictors that determine the vitality of a person. The theoretical analysis of the concepts of "subjectivity", "vitality" is carried out. The authors examine the results of the study of the ratio of the components of subjectivity and indicators of vitality in students. The purpose of the study is to identify the relationship between indicators of viability and the level of subjectivity and its components among students – future pedagogues. It was found that the indicators of subjectivity (activity, ability to reflect, freedom of choice, awareness of uniqueness, understanding and acceptance of another as well as self-development) in this sample are at the average value. Analysis of the data of the study of viability and its indicators, it was found that in this sample of subjects self-motivation, social competency, self-esteem and adaptive ways of behaviour are most pronounced. The author has established significant correlations between the indicators of vitality and the components of subjectivity. The empirical data obtained in the study and described in the article can be used in the development of programmes in the formation of professional competences in first-year students.

Choice awareness and manipulation blindness: A cognitive semiotic exploration of choice-making

Within cognitive science, “blindness” to choice is commonly treated as typical of human cognition, implying unreliable agents who essentially lack any awareness of their own choices (e.g. Johansson et al., 2005, 2008; Hall et al., 2010, 2013). Within cognitive semiotics, however, choice awareness is seen as a continuous phenomenon, which is susceptible to the influence of a variety of factors. Manipulation blindness is proposed as a more adequate term for what is known in the literature as “choice blindness”, referring to participants’ tendency to accept a choice as if it were their own. This suggests that “blindness” is strictly limited to the level of detection (of the switch of the preferred choice to a non-chosen one), and not to the level of choice. Using a cognitive-semiotic framework, I examine manipulation blindness as an “indicator” of choice awareness by employing the factors of memory, consequence, and affectivity, and introduce a two-level hierarchy of choice-making. 43 participants were assigned two tasks combining choices with a) two degrees of consequence (more/less) – based on task instructions, and b) two degrees of affectivity (high/low) – based on stimuli with different degrees of abstractness. Participants were first asked to state their preference for one of two alternatives (choice) . After that they were shown chosen as well as non-chosen pictures and asked to confirm whether the picture presented was the one of their choice (memory). Lastly, they were asked to justify their choice, although some of the trials had been manipulated (i.e. the chosen card was switched with the non-chosen one) (manipulation) . Half of the manipulations were detected, and 75% of these detections occurred for the choices participants remembered correctly. While the consequential impact of the choice did not seem to influence detection, affectivity did. Unlike other experiments that investigate “choice blindness”, the results indicate that manipulation blindness is subject to memory and affectivity, suggesting that we are aware of our choices and that we have, to various degrees, access to our intentional acts.

Key components of shared decision making models: a systematic review

ObjectivesTo (1) provide an up-to-date overview of shared decision making (SDM)-models, (2) give insight in the prominence of components present in SDM-models, (3) describe who is identified as responsible within the components (patient, healthcare professional, both, none), (4) show the occurrence of SDM-components over time, and (5) present an SDM-map to identify SDM-components seen as key, per healthcare setting.DesignSystematic review.Eligibility criteriaPeer-reviewed articles in English presenting a new or adapted model of SDM.Information sourcesAcademic Search Premier, Cochrane, Embase, Emcare, PsycINFO, PubMed, and Web of Science were systematically searched for articles published up to and including September 2, 2019.ResultsForty articles were included, each describing a unique SDM-model. Twelve models were generic, the others were specific to a healthcare setting. Fourteen were based on empirical data, 26 primarily on analytical thinking. Fifty-three different elements were identified and clustered into 24 components. Overall, Describe treatment optionswas the most prominent component across models. Components present in >50% of models were:Make the decision (75%),Patient preferences (65%),Tailor information (65%),Deliberate (58%), Create choice awareness (55%), andLearn about the patient(53%). In the majority of the models (27/40), both healthcare professional and patient were identified as actors. Over time,Describe treatment optionsandMake the decisionare the two components which are present in most models in any time period.Create choice awarenessstood out for being present in a markedly larger proportion of models over time.ConclusionsThis review provides an up-to-date overview of SDM-models, showing that SDM-models quite consistently share some components but that a unified view on what SDM is, is still lacking. Clarity about what SDM constitutes is essential though for implementation, assessment, and research purposes. A map is offered to identify SDM-components seen as key.Trial registrationPROSPERO registration CRD42015019740

Do Shared Decision-Making Measures Reflect Key Elements of Shared Decision Making? A Content Review of Coding Schemes

Background. There is a growing need for valid shared decision-making (SDM) measures. We aimed to determine whether the items of extant SDM observer-based coding schemes assess the 4 key elements of SDM. Methods. Items of SDM coding schemes were extracted and categorized. Except for the 4 key elements of SDM (fostering choice awareness, informing about options, discussing patient preferences, and making a decision), (sub)categories were created inductively. Two researchers categorized items independently and in duplicate. Results. Five of 12 coding schemes assessed all 4 SDM elements. Seven schemes did not measure “fostering choice awareness,” and 3 did not measure “discussing patient preferences.” Seventy of 194 items (36%) could not be classified into one of the key SDM elements. Items assessing key SDM elements most often assessed “informing about options” ( n = 57/124, 46%). Conclusion. Extant SDM coding schemes often do not assess all key SDM elements and have a strong focus on information provision while other crucial elements of SDM are underrepresented. Caution is therefore needed in reporting and interpreting the resulting SDM scores.

Barriers and Recommendations to Innovative Ownership Models for Wind Power

Local ownership models have proven to be an important way to avoid local resistance to onshore wind turbines. As wind power expands into onshore and nearshore wind farms, such ownership models become of increasing importance, while also undergoing further development. This paper uses the Choice Awareness theory to examine some of the barriers connected to the implementation of these new ownership models and presents recommendations to overcome such barriers. Choice Awareness addresses societal aspects (discourse, socioeconomics, and public regulation) mainly related to implementing alternatives to existing technologies. For the theory to be able to embrace the complexity of the transition of the energy system more holistically, we explore and specify the organizational dimension of choice-eliminating mechanisms. Based on the case of an NGO’s attempt to bid for a tender for nearshore wind turbines, it is shown how the central administration prevents new innovative ownership models from entering the tender. A strong path dependency has led to a conscious or unconscious elimination of projects based on organizational structures that do not fit the definition of large energy companies. As a result of this, the paper makes three recommendations for policy changes with the aim to secure equal possibilities for actors involved in nearshore wind power tenders.

Negotiating the hairless ideal in Āotearoa/New Zealand: Choice, awareness, complicity, and resistance in younger women's accounts of body hair removal

Hair removal amongst Western women is ubiquitous, and research continues to highlight the ongoing conformity of almost all women with hair removal practices. Often women are presented as either cultural dupes, following the expectations of the Western hairless ideal without question, or highly engaged participants in the rigours of aesthetic labour, using it for their own agentic purposes. This paper seeks to explore the various ways that younger women (18–35) made sense of their own and others’ hair removal practices. We report on a thematic analysis of data generated from an online (mostly) qualitative survey with 299 female-identified respondents. Four themes were constructed: (1) women should do what they want with their body hair, (2) removing hair is socially shaped, (3) begrudging complicity, and (4) resistance to hair removal norms takes a particular kind of woman. We discuss the ways in which women described their practices and thinking where they seemed simultaneously complicit with and resistant to idealised notions of feminine embodiment.