Decision Conflicts in Clinical Care during COVID-19: A Patient Perspective

Abstract

(1) Background: Uncertainty is typical for a pandemic or similar healthcare crisis. This affects patients with resulting decisional conflicts and disturbed shared decision making during their treatment occurring to a very different extent. Sociodemographic factors and the individual perception of pandemic-related problems likely determine this decisional dilemma for patients and can characterize vulnerable groups with special susceptibility for decisional problems and related consequences. (2) Methods: Cross-sectional data from the OnCoVID questionnaire study were used involving 540 patients from 11 participating institutions covering all major regions in Germany. Participants were actively involved in clinical treatment in oncology or psychiatry during the COVID-19 pandemic. Questionnaires covered five decision dimensions (conflicts and uncertainty, resources, risk perception, perception of consequences for clinical processes, perception of consequences for patients) and very basic demographic data (age, gender, stage of treatment and educational background). Decision uncertainties and distress were operationalized using equidistant five-point scales. Data analysis was performed using descriptive and various multivariate approaches. (3) Results: A total of 11.5% of all patients described intensive uncertainty in their clinical decisions that was significantly correlated with anxiety, depression, loneliness and stress. Younger and female patients and those of higher educational status and treatment stage had the highest values for these stressors (p < 0.001). Only 15.3% of the patients (14.9% oncology, 16.2% psychiatry; p = 0.021) considered the additional risk of COVID-19 infections as very important for their disease-related decisions. Regression analysis identified determinants for patients at risk of a decisional dilemma, including information availability, educational level, age group and requirement of treatment decision making. (4) Conclusions: In patients, the COVID-19 pandemic induced specific decisional uncertainty and distress accompanied by intensified stress and psychological disturbances. Determinants of specific vulnerability were related to female sex, younger age, education level, disease stages and perception of pandemic-related treatment modifications, whereas availability of sufficient pandemic-related information prevented these problems. The most important decisional criteria for patients under these conditions were expected side effects/complications and treatment responses.

Differences in Stakeholders’ Perception of the Impact of COVID-19 on Clinical Care and Decision-Making

“…Questionnaire data were used to obtain perspectives of the different stakeholder groups regarding pandemic-related decisional uncertainties and the impact of COVID-19 on clinical care as previously described [ 5 ]. Briefly, the qualitative results were aggregated into dimensions covering conflicts/uncertainty, resources, risk perception, perception of consequences for clinical processes, and in clinical care with 3–5 questions for each dimension.…”

“…The COVID-19 pandemic has been connected with numerous changes in treatment of many patient groups, such as for cancer [ 1 ] and psychiatry patients [ 2 ]. These pandemic effects on the availability and accessibility of healthcare appears to very intensively induce challenges in shared-decision-making (SDM) [ 3 , 4 ], moral distress for healthcare providers, and decisional problems for patients [ 5 ]. Healthcare professionals were confronted with complex decisions and ethical dilemmas about the provision of care and their implicit judgements about access for patients [ 6 ].…”

“…This uncertainty and moral distress is inherent in sudden healthcare crises [ 8 ], but may not be solely determined by objective pandemic indicators. It seems to be intensively influenced by individual perceptions of the pandemic situation and the related consequences [ 5 , 9 ]. The personal reflection of the pandemic consequences appears to be of high relevance since the individual perception of risk guides response and health-related decision-making [ 10 , 11 ].…”

“…Previously published results from our group [ 5 ] suggested that the clinical setting appears to influence the extent of decisional conflicts and impact on SDM. Distinct perception profiles of changes in oncology care processes due to COVID-19 were previously identified and more than 20% of the healthcare professionals, but only ~11% of the patients reported severe decisional conflicts during the pandemic [ 5 ]. Therefore, it seems to be interesting to compare the perception of decisional conflicts and the impact on SDM between different stakeholder groups.…”

A pyramid model to describe changing decision making under high uncertainty during the COVID-19 pandemic

“…Interestingly, the individual perception of moral distress was not related in any group to objective pandemic trends, such as defined by regional incidences. 9 Furthermore, decisional uncertainty was identified as important factor determining patients' trust in healthcare during the pandemic. 10 Alternative criteria and frames of reference gain a differentiating importance during decision making with regard to the direct and concrete process organisation.…”