Qualitative analysis of how patients decide that they want risk-reducing mastectomy, and the implications for surgeons in responding to emotionally-motivated patient requests

Brown, Stephen L.; Whiting, Demian; Fielden, Hannah G.; Saini, Pooja; Beesley, Helen; Holcombe, Christopher; Holcombe, Susan; Greenhalgh, Lyn; Fairburn, Louise; Salmon, Peter

Abstract

Objective: Contemporary approaches to medical decision-making advise that clinicians should respect patients' decisions. However, patients' decisions are often shaped by heuristics, such as being guided by emotion, rather than by objective risk and benefit. Risk-reducing mastectomy (RRM) decisions focus this dilemma sharply. RRM reduces breast cancer (BC) risk, but is invasive and can have iatrogenic consequences. Previous evidence suggests that emotion guides patients' decision-making about RRM. We interviewed patients to better understand how they made decisions about RRM, using findings to consider how clinicians could ethically respond to their decisions. Methods: Qualitative face-to-face interviews with 34 patients listed for RRM surgery and two who had decided against RRM. Results: Patients generally did not use objective risk estimates or, indeed, consider risks and benefits of RRM. Instead emotions guided their decisions: they chose RRM because they feared BC and wanted to do 'all they could' to prevent it. Most therefore perceived RRM to be the 'obvious' option and made the decision easily. However, many recounted extensive post-decisional deliberation, generally directed towards justifying the original decision. A few patients deliberated before the decision because fears of surgery counterbalanced those of BC. Conclusion: Patients seeking RRM were motivated by fear of BC, and the need to avoid potential regret for not doing all they could to prevent it. We suggest that choices such as that for RRM, which are made emotionally, can be respected as autonomous decisions, provided patients have considered risks and benefits. Drawing on psychological theory about how people do make decisions, as well as normative views of how they should, we propose that practitioners can guide consideration of risks and benefits even, where necessary, after patients have opted for surgery. This model of practice could be extended to other medical decisions that are influenced by patients' emotions.

Citation

Brown, S. L., Whiting, D., Fielden, H. G., Saini, P., Beesley, H., Holcombe, C., …Salmon, P. (2017). Qualitative analysis of how patients decide that they want risk-reducing mastectomy, and the implications for surgeons in responding to emotionally-motivated patient requests. PLoS ONE, 12(5), e0178392. https://doi.org/10.1371/journal.pone.0178392

• Journal Article Type: Article
• Acceptance Date: May 14, 2017
• Online Publication Date: May 26, 2017
• Publication Date: May 26, 2017
• Deposit Date: Jul 25, 2017
• Publicly Available Date: Jul 25, 2017
• Journal: PLoS one
• Print ISSN: 1932-6203
• Electronic ISSN: 1932-6203
• Publisher: Public Library of Science
• Peer Reviewed: Peer Reviewed
• Volume: 12
• Issue: 5
• Article Number: ARTN e0178392
• Pages: e0178392
• DOI: https://doi.org/10.1371/journal.pone.0178392
• Keywords: General Biochemistry, Genetics and Molecular Biology; General Agricultural and Biological Sciences; General Medicine
• Public URL: https://hull-repository.worktribe.com/output/453761
• Publisher URL: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0178392
• Additional Information: This is a copy of an open access article published in PLoS one, v.12 issue 5.