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Who Should Choose – 2

This is another side discussion focused on the decisions we make as patients, families, providers, and care givers – as we continue on long healthcare journeys. I used the first “chapter” of “Who Should Choose” to illustrate the challenges that come up right away. While the story is appropriate I’m not sure I’ve used it in the right way.   So let’s backtrack just a bit and think about what makes a successful decision – the “right” decision.  I’m guessing that ultimately we’ll end up with two or more dimensions. (That will make this economist happy – he’ll be able to draw a graph or at least put spots on a two dimensional surface.)

So, that takes us into the realm of preferences – what I want maybe the same as what you want – or not. I’m going to use my own preferences to think this through so they may not work with others.

So – some possible criteria that would define success might be:

  • Quality of daily life. This includes moving comfortably, reasonably free from pain, and having as much independence as possible.
  • Life expectancy – pretty straightforward, though there is a hitch. Life expectancy is colored how that time is spent. There’s good time and not so good time. It gets wrapped around the quality of life criterion. That’s what we may need a two dimensional graph.

So far I’ve used these two criteria as we wrestled with my cancer. They helped drive the decision to stop at the basic treatment protocol. I bet there are more considerations lurking around. I’ll add those back here if/when they occur. And I should think how to incorporate them in the stories from chapter 1 and those that follow.

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2 comments to Who Should Choose – 2

  • Doug Gentry

    A friend, Melanie, left this comment over on Facebook – about this posting…

    “This is interesting. I can only imagine that the “logic” under-girding such choice models gets blurred quite a bit by the emotions and the intuitions — the non-logical planes and webs — of what you and your family are facing. Do you remember the High Risk / Low Risk, High Gain / Low Gain model we used at SEED? The idea is to plot the decision in the low risk / high gain quadrant (assuming that you have the information you need)? I’ve used that over and over in decision-making, and sometimes I just end up thinking: forget it! It may be lowest risk and highest gain, but it just doesn’t feel like the best approach.”

    My thought(s) about it next…

  • Doug Gentry

    Melanie hits at least two important issues in her comment. (Typically inciteful for her.) She refers to a high/low risk and high/low gain used at Saint Mary’s College in California. How does that stand up to the stresses of a life or death health decision? Quite well, actually. First, we implicitly assign a value to risk. How much risk are we willing to take when making a decision? If we are risk averse we are cautious, take lots of diagnostic tests, yield decision authority to experts, and often engage in more treatments. While we don’t look at a probability curve directly we act to place ourselves on the low risk end.

    On the reward/gain side we tell ourselves that less risky behavior gives us better outcomes. This is perhaps we feel buttressed by the authority-backed evidence. In the investment world it is backwards from this – we assume better returns when undertaking greater risks. (I can’t connect that approach to the healthcare decision for the moment – need to mull it over.)

    But in any case, the first point is that we assign values to risk and reward. To make a “logical” decision that we assign the place on the graph where we think we are – how risky; how much reward – but then those need to be weighted by the value assign them. No wonder that kind of decision making hurts! But, but I think that’s what happens deep in some cortex.

    “deep in some cortex…” Melanie’s comment also brought up something to mull over. It’s how we actually make those decisions. I think there is some kind of measure or score or description about how we apply multiple criteria to complicated decisions – on a personal level. Maybe those will show up here.

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