THINKING FORWARD: THE TIME ORIENTATION OF PATIENTS MAKING TREATMENT DECISIONS

Purpose: To develop a conceptual framework of how patients integrate future considerations into their appraisal of equally valid treatment options.

Methods: We conducted 18 scenario-based semi-structured interviews among outpatients for whom one of two decisions would be medically relevant: (1) patients with severe chronic obstructive lung disease who may face the decision of whether to elect for mechanical ventilation or palliative care in the event of respiratory failure, and (2) patients meeting lung cancer screening recommendations who may face the decision of whether to pursue a biopsy or watchful waiting in response to a lung nodule.  Using grounded theory methods, we developed a framework to understand the time-orientation and dominant future-focused considerations of patients facing these challenging decisions.

Results:   Understanding, acceptance, and familiarity of the medical decision and possible management choices increase the degree to which patient decision makers are future-orientated during deliberation.  Older patients and those who perceive worse health more easily imagine poor health outcomes and limited future life.  Certain patients reject the possibility of imagining the future or are intentionally avoidant of future-oriented thought.  Patients report concern over the quality of the information used to form views of the future and rely heavily on  past experiences to guide formulations of potential outcomes.  Patients also express the desire to select a choice that minimizes future uncertainty.  Many patients struggle to engage the future due to inability or unwillingness to imagine negative outcomes.  Patients’ concrete constructions of the future include (1) potential effects on family members (e.g., the need to facilitate preparation of the family and concern for family members’ ability to cope); (2) personal emotional expectations (e.g., coping with the treatment itself or a loss of self and, for some, anticipating a positive emotional state regardless of outcome), and (3) prognostic considerations (e.g. predicted mental and physical function and likelihood of death).

Conclusions:   Future-orientation during patient decision making includes attempts to imagine many relevant implications for self and family.  However, decision makers express greater uncertainty and are more limited in future-oriented thinking when expressing a lack of personal familiarity with a potential outcome.  Therefore, decision makers focus on rejecting or accepting the option or options they are able to relate to past experiences rather than fully engaging in choice deliberation.