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Special Article
September 8, 2008

Titrating Guidance: A Model to Guide Physicians in Assisting Patients and Family Members Who Are Facing Complex Decisions

Author Affiliations

Author Affiliations: Hertzberg Palliative Care Institute of the Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York City (Drs Goldstein and Morrison), and the James J. Peters Veterans Affairs Medical Center, Bronx (Drs Goldstein and Morrison), New York; and Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington (Dr Back).

Arch Intern Med. 2008;168(16):1733-1739. doi:10.1001/archinte.168.16.1733

Over the last century, developments in new medical treatments have led to an exponential increase in longevity, but, as a consequence, patients may be left with chronic illness associated with long-term severe functional and cognitive disability. Patients and their families are often forced to make a difficult and complex choice between death and long-term debility, neither of which is an acceptable outcome. Traditional models of medical decision making, however, do not fully address how clinicians should best assist with these decisions. Herein, we present a new paradigm that demonstrates how the role of the physician changes over time in response to the curved relationship between the predictability of a patient's outcome and the chance of returning to an acceptable quality of life. To translate this model into clinical practice, we propose a 5-step model for physicians with which they can (1) determine at which point the patient is on our model; (2) identify the cognitive factors and preferences for outcomes that affect the decision-making process of the patient and his or her family; (3) reflect on their own reaction to the decision at hand; (4) acknowledge how these factors can be addressed in conversation; and (5) guide the patient and his or her family in creating a plan of care. This model can help improve patient-physician communication and decision making so that complex and difficult decisions can be turned into ones that yield to medical expertise, good communication, and personal caring.