Decisional Conflict

Every day, people face healthcare decisions involving trade-offs between potential benefits and risks. Which birth control method should I use? Are my symptoms (acne, attention deficit/hyperactivity disorder, hot flashes, chronic pain) bad enough to warrant stronger medication with potentially more serious side effects? Should I have surgery for poorly controlled benign uterine bleeding, back pain, benign prostatic hyperplasia, obesity, osteoarthritis? Should my relative receive care for dementia or terminal illness at home or at a care facility?

Decision making is the process of choosing between alternative courses of action (including inaction). Generally, people choose the option that they perceive will be effective in achieving valued outcomes and in avoiding undesirable outcomes. However, many decisions are choice dilemmas or conflicted decisions. No alternative will satisfy all personal objectives and none is without its risk of undesirable outcomes.

Among the 2,500 healthcare interventions evaluated by the Clinical Evidence group, 13% were classified as “beneficial,” 23% as “probably beneficial,” 8% as “need to weigh benefits versus risks,” 6% as “probably nonbeneficial,” 4% as “probably useless or dangerous,” and 46%, the largest number, as having insufficient evidence of usefulness. Consequently, patients need help in resolving uncertainty when facing clinical decisions. They may express uncertainty or difficulty in identifying the best alternative due to the risk or uncertainty of outcomes, the need to make value judgments about potential gains versus potential losses, and anticipated regret over the positive aspects of rejected options.

The aim of this entry is to briefly review what has been learned on how patients make difficult decisions by highlighting the value of screening for decisional conflict. The first section summarizes research on patient decisional conflict. It also reviews tools for assessing and addressing decisional needs. The second section reports on the effects of decision support interventions on decisional conflict. The last section highlights the gaps in knowledge and areas needing further research.