How do we deal with multiple goals for care within an individual patient trajectory? A document content analysis of health service research papers on goals for care

Berntsen, Gro; Gammon, Deede; Steinsbekk, Aslak; Salamonsen, Anita; Foss, Nina; Ruland, Cornelia M.; Fønnebø, Vinjar

doi:10.1136/bmjopen-2015-009403

Cited by 47 publications

(63 citation statements)

References 43 publications

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“…This finding strengthens the importance of community-based care services, such as ambulant nursing services in COPD care,66 but also of informal caregivers. Cooperation between informal caregivers and health care professionals can be challenged by different perspectives on a conditions’ severity and unclear areas of responsibility 67,68. Our findings indicate that GPs can face similar challenges in cooperation with other health care professionals.…”

Section: Discussionmentioning

confidence: 78%

How do general practitioners implement decision-making regarding COPD patients with exacerbations? An international focus group study

Laue

Melbye

Halvorsen

et al. 2016

COPD

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PurposeTo explore the decision-making of general practitioners (GPs) concerning treatment with antibiotics and/or oral corticosteroids and hospitalization for COPD patients with exacerbations.MethodsThematic analysis of seven focus groups with 53 GPs from urban and rural areas in Norway, Germany, Wales, Poland, Russia, the Netherlands, and Hong Kong.ResultsFour main themes were identified. 1) Dealing with medical uncertainty: the GPs aimed to make clear medical decisions and avoid unnecessary prescriptions and hospitalizations, yet this was challenged by uncertainty regarding the severity of the exacerbations and concerns about overlooking comorbidities. 2) Knowing the patient: contextual knowledge about the individual patient provided a supplementary framework to biomedical knowledge, allowing for more differentiated decision-making. 3) Balancing the patients’ perspective: the GPs considered patients’ experiential knowledge about their own body and illness as valuable in assisting their decision-making, yet felt that dealing with disagreements between their own and their patients’ perceptions concerning the need for treatment or hospitalization could be difficult. 4) Outpatient support and collaboration: both formal and informal caregivers and organizational aspects of the health systems influenced the decision-making, particularly in terms of mitigating potentially severe consequences of “wrong decisions” and concerning the negotiation of responsibilities.ConclusionFear of overlooking severe comorbidity and of further deteriorating symptoms emerged as a main driver of GPs’ management decisions. GPs consider a holistic understanding of illness and the patients’ own judgment crucial to making reasonable decisions under medical uncertainty. Moreover, GPs’ decisions depend on the availability and reliability of other formal and informal carers, and the health care systems’ organizational and cultural code of conduct. Strengthening the collaboration between GPs, other outpatient care facilities and the patients’ social network can ensure ongoing monitoring and prompt intervention if necessary and may help to improve primary care for COPD patients with exacerbations.

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Section: Discussionmentioning

confidence: 78%

How do general practitioners implement decision-making regarding COPD patients with exacerbations? An international focus group study

Laue

Melbye

Halvorsen

et al. 2016

COPD

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“…The three‐goal model could be relevant for individualized management or care plans. In case of multimorbidity, a dynamic individualized care plan is recommended . Core elements of these plans are “optimizing quality of life, eliciting preferences and goals, weighing risks and benefits of implementing recommendations from single disease guidelines, addressing trade‐offs, setting priorities, stopping potentially harmful or unnecessary medications and starting beneficial medications while simplifying regimens, integrating care, and minimizing treatment burden” .…”

Section: Discussionmentioning

confidence: 99%

“…Berntsen et al developed a goal typology with a distinction between professionally defined and personally defined goals. Personally defined goals are goals which “honor the patient's right to make decisions about his/her personal matters”.…”

Section: Discussionmentioning

confidence: 99%

A three‐goal model for patients with multimorbidity: A qualitative approach

Vermunt

Harmsen

Elwyn

et al. 2017

Health Expectations

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BackgroundTo meet the challenge of multimorbidity in decision making, a switch from a disease‐oriented to a goal‐oriented approach could be beneficial for patients and clinicians. More insight about the concept and the implementation of this approach in clinical practice is needed.ObjectiveThis study aimed to develop conceptual descriptions of goal‐oriented care by examining the perspectives of general practitioners (GPs) and clinical geriatricians (CGs), and how the concept relates to collaborative communication and shared decision making with elderly patients with multimorbidity.MethodQualitative interviews with GPs and CGs were conducted and analyzed using thematic analysis.ResultsClinicians distinguished disease‐ or symptom‐specific goals, functional goals and a new type of goals, which we labelled as fundamental goals. “Fundamental goals” are goals specifying patient's priorities in life, related to their values and core relationships. These fundamental goals can be considered implicitly or explicitly in decision making or can be ignored. Reasons to explicate goals are the potential mismatch between medical standards and patient preferences and the need to know individual patient values in case of multimorbidity, including the management in acute situations.ConclusionBased on the perspectives of clinicians, we expanded the concept of goal‐oriented care by identifying a three‐level goal hierarchy. This model could facilitate collaborative goal‐setting for patients with multiple long‐term conditions in clinical practice. Future research is needed to refine and validate this model and to provide specific guidance for medical training and practice.

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“…Giving primacy to patient autonomy over biomedical beneficence appears as a defining value in recovery-oriented practices [23]. Interestingly, the epidemic growth of multiple long-term conditions in aging populations has prompted the biomedical literature to revisit similar ethical premises in efforts to resolve conflicting health and professional goals and their underlying values [72, 73]. Arguably, chronic care and recovery researchers could benefit from joining forces towards a values-based, alternative health outcome paradigm [72], accompanying measures [39–41] and required changes to support systems [74, 75].…”

Section: Discussionmentioning

confidence: 99%

Transitions from biomedical to recovery-oriented practices in mental health: a scoping review to explore the role of Internet-based interventions

Strand

Gammon

Ruland

2017

BMC Health Serv Res

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BackgroundThe Internet is transforming mental health care services by increasing access to, and potentially improving the quality of, care. Internet-based interventions in mental health can potentially play a role in transitions from biomedical to recovery-oriented research and practices, but an overview of what this may entail, current work, and issues that need addressing, is lacking. The objective of this study is to describe Internet-based recovery-oriented interventions (referred to as e-recovery) and current research, and to identify gaps and issues relevant to advancing recovery research and practices through opportunities provided by the Internet.MethodsFive iterative stages of a scoping review framework were followed in searching and analyzing the literature. A recovery framework with four domains and 16 themes was used to deductively code intervention characteristics according to their support for recovery-oriented practices. Only Internet-based interventions used in conjunction with ongoing care were included.ResultsTwenty studies describing six e-recovery interventions were identified and originated in Australia, Finland, the Netherlands, Norway and USA. The domain supporting personal recovery was most clearly reflected in interventions, whereas the last three domains, i.e., promoting citizenship, organizational commitment and working relationship were less evident. Support for the formulation and follow-up of personal goals and preferences, and in accessing peer-support, were the characteristics shared by most interventions. Three of the six studies that employed a comparison group used randomization, and none presented definitive findings. None used recovery-oriented frameworks or specific recovery outcome measures. Four of the interventions were specific to a diagnosis.ConclusionResearch about how technologies might aid in illuminating and shaping recovery processes is in its formative stages. We recommend that future e-recovery research and innovation attend to four dimensions: evidence-supported interventions, new knowledge about personal recovery, values-based approaches and Internet as a facilitator for organizational transformation. The incremental changes facilitated by e-recovery may help propel a shift in mental health care toward recovery-oriented practices.

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How do we deal with multiple goals for care within an individual patient trajectory? A document content analysis of health service research papers on goals for care

Cited by 47 publications

References 43 publications

How do general practitioners implement decision-making regarding COPD patients with exacerbations? An international focus group study

How do general practitioners implement decision-making regarding COPD patients with exacerbations? An international focus group study

A three‐goal model for patients with multimorbidity: A qualitative approach

Transitions from biomedical to recovery-oriented practices in mental health: a scoping review to explore the role of Internet-based interventions

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