Autonomy-related behaviors of patient companions and their effect on decision-making activity in geriatric primary care visits
Introduction
While an estimated 20–50% of geriatric primary care patients are accompanied by a companion during their medical visits (Beisecker, 1989; Botelho, Lue, & Fiscella, 1996; Brown, Brett, Stewart, & Marshall, 1998; Prohaska & Glasser, 1996; Schilling et al., 2002), there has been relatively little descriptive study of how their presence or actions may influence the medical decisions patients make or the care they receive (Beisecker, 1989; Greene, Majerovitz, Adelman, & Rizzo, 1994; Prohaska & Glasser, 1996; Schilling et al., 2002). Based on the limited information available on companions that accompany elderly patients to routine medical visits, it seems that most are the patient's spouse or an adult child (Glasser, Prohaska, & Roska, 1992; Fortinsky, 2001; Hasselkus, 1988; Haug, 1994; Silliman (1989), Silliman (2000)). The roles played by the companion are not necessarily apparent; fewer than half of geriatric patients in Prohaska and colleagues’ study who were accompanied to a medical visit felt that the presence of a companion was necessary, although over 60 percent indicated that it was welcomed (Prohaska & Glasser, 1996).
Some researchers fear that the intrusion of a third party into the doctor–patient relationship may result in a loss of patient autonomy and jeopardize confidentiality (Greene et al., 1994; Kapp, 1992). Indeed, there is some evidence that patients tend to be more passive in their medical visits and decision-making when a companion is present (Greene et al., 1994). Physicians may direct information toward the companion, rather than the patient (Beisecker, 1989; Greene et al., 1994), and both the physician and companion may ignore or exclude the patient in care discussions (Beisecker, 1989; Coe & Prendergast, 1985; Greene et al., 1994). However, others suggest that the presence of a companion is beneficial to the care process (Jecker, 1990): physicians both give more information when family members are present than when patients are alone (Labrecque, Blanchard, Ruckdeschel, & Blanchard, 1991; Prohaska & Glasser, 1996) and report that the presence of a companion increases both patient and physician understanding (Schilling et al., 2002). Moreover, many patients want companions present during their medical visits (Botelho et al., 1996). These preferences, however, should be viewed within the context of personal values and culture, such as familial obligation and loyalty (Dworkin, 1998; Jecker, 1990). Nevertheless, ethicists have voiced the concern that family members and health care providers may assume that patients have delegated decision-making authority to others when they have not (Kapp, 1992).
It is within this context that the investigation of patient autonomy in primary care visit decision-making may be viewed. In pioneering work on decision-making, Braddock and colleagues developed a coding system to examine whether decisions that were made in primary care fit the criteria for informed consent (Braddock III, Edwards, Hasenberg, Laidley, & Levinson, 1999; Braddock III, Fihn, Levinson, Jonsen, & Pearlman, 1997). Their research found that only 9% of decisions met their criteria for informed decision-making. As patient autonomy is a major concern for some researchers, there is surprisingly little written about the impact of companions on patient decision-making autonomy during the primary care visit.
The current study was designed to investigate this question and explores the nature and consequences of companion behaviors on patient decision-making activity during geriatric primary care visits.
Section snippets
Overview
This sample includes 93 primary care visits with elderly patients and companions, collected as part of a larger study that included 432 videotaped geriatric primary care visits. The larger study was designed to study doctor–patient communication among the elderly and to compare several coding systems that are used in doctor–patient communications. Videotapes of visits were collected at outpatient clinics associated with three different academic medical centers in Missouri, New Mexico, and Ohio.
Description of study population
Characteristics of both patients and companions are seen in Table 2. Patients ranged in age from 65 to 95 years, and 45% of the patients were 80 years of age or older. Most patients were white (79%) and female (72%). Of those patients reporting educational level , 32 (38%) had less than a high school education. The mean scaled score on the physical functioning scale of the SF-36 for the patients in this study was 45 (range 0–100, SD=28), substantially lower than the US average for people
Discussion
It is reassuring to note that companion activity in decision-making did not diminish patients’ decision-making activity. Furthermore, companion behaviors that were autonomy-detracting occurred less frequently than those that were autonomy-enhancing. When these detracting behaviors do occur, they did not adversely affect patients’ engagement in informed decision-making. The fear of the negative impact an overbearing companion might have on a patient's autonomy was not borne out in this study.
Acknowledgments
This research is supported by the National Institutes of Health Grant number NIA R44-AG15737, Mary Ann Cook, PI. Dr. Clayman was supported during her doctoral training by Grant number 5T32HL97180, David Levine, PI. In addition to Drs. Cook and Levine, the authors wish to thank Dr. Peter Rabins, Ms. Lori Hamby, and the study participants for their contributions to this research.
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