Shared Decision Making Called for by the Situation of Suffering

By Ian Hargraves, Maggie Breslin, Nassim Jafarinaimi

Healthcare, like any care, is the product of what people can do and who they can be for each other in the midst of suffering. The relationship of people attending to suffering finds its most direct expression in contemporary healthcare in the relationship of patient and clinician.  The ways in which these two come together lies at the heart of how we conceive of and organize the healthcare enterprise. If we conceive of the meeting of patient and clinician as rooted in the knowledge and expertise of the medical expert then we may establish paternalistic and patriarchal structures and relationships by which to deploy that knowledge. Beyond this, we may seek to improve and innovate healthcare by heightening the knowledge, technology, and efficiency of the medical expert. Alternatively if, in the coming together of patient and clinician, we focus attention on the demands of the patient who is commissioning and paying for care we may set the suffering person in the role of consumer. Let the buyer beware then becomes the organizing principle, a principle that calls for an empowered patient equipped with authority, information, choice, and control in the face of illness. This is a situation in which we think that if the suffering person would and could only be more—more knowledgeable, more assertive, more discriminating as a purchaser—then illness would be less. There is a third possibility in the coming together of patient and clinician. In this way, the joining of people is called for by the situation of suffering. The reason for healthcare is not the deployment of technical expertise, or the exercise of choice. The reason for healthcare is to attend to the challenges of suffering. This is the reason that in clinic rooms throughout the country and world patients and clinicians sit together, talk, and together take action in attending to suffering or the threat of suffering. In the KER unit, we explore the hypothesis that the medium in which this relationship is made productive and caring is conversation

Overcoming Depth of Field Limitations

Some methods and equipment allow altering the apparent DOF, and some even allow the DOF to be determined after the image is made. For example, Focus stacking combines multiple images focused on different planes, resulting in an image with a greater (or less, if so desired) apparent depth of field than any of the individual source images. Similarly, in order to reconstruct the 3-dimensional shape of an object, a depth map can be generated from multiple photographs with different depths of field. This method is called “shape from focus.”

Other technologies use a combination of lens design and post-processing: Wavefront coding is a method by which controlled aberrations are added to the optical system so that the focus and depth of field can be improved later in the process.

from Wikipedia article which is released under the Creative Commons Attribution-Share-Alike License 3.0.

Butterfly Lighting

Butterfly lighting uses only two lights. The key light is placed directly in front of the subject, often above the camera or slightly to one side, and a bit higher than is common for a three-point lighting plan. The second light is a rim light.

Often a reflector is placed below the subject’s face to provide fill light and soften shadows.

This lighting may be recognized by the strong light falling on the forehead, the bridge of the nose, the upper cheeks, and by the distinct shadow below the nose that often looks rather like a butterfly and thus, provides the name for this lighting technique.

Butterfly lighting was a favourite of famed Hollywood portraitist George Hurrell, which is why this style of lighting is often called Paramount lighting.

From Wikipedia article which is released under the Creative Commons Attribution-Share-Alike License 3.0.

Windowlight Portraiture

Windows as a source of light for portraits have been used for decades before artificial sources of light were discovered. According to Arthur Hammond, amateur and professional photographers need only two things to light a portrait: a window and a reflector. Although window light limits options in portrait photography compared to artificial lights it gives ample room for experimentation for amateur photographers. A white reflector placed to reflect light into the darker side of the subject’s face, will even the contrast. Shutter speeds may be slower than normal, requiring the use of a tripod, but the lighting will be beautifully soft and rich.

The best time to take window light portrait is considered to be early hours of the day and late hours of afternoon when light is more intense on the window. Curtains, reflectors, and intensity reducing shields are used to give soft light. While mirrors and glasses can be used for high key lighting. At times colored glasses, filters and reflecting objects can be used to give the portrait desired color effects. The composition of shadows and soft light gives window light portraits a distinct effect different from portraits made from artificial lights.

From Wikipedia article which is released under the Creative Commons Attribution-Share-Alike License 3.0.

Purposeful SDM: Our new model of shared decision making

There are many situations in which patients and clinicians need to and are making decisions together, arguably these are all instances of Shared Decision Making (SDM). The ways that patients and clinicians make decisions should change according to the problem that is the reason why decisions are being made. For example, how patients and clinicians choose whether or not to take statins to potentially reduce 10-year risk of heart attack may be different from how management decisions are made for a patient living with multiple chronic conditions who is experiencing multiple detrimental life changes. In the first instance patient and clinician might use a weighing approach to weigh the pros and cons of known alternatives (to take or not statins), while in the second they might use a problem-solving approach to uncover possible solutions and judge how they would work in the patient’s life.

In a paper published in the current issue of Patient Education and Counseling, we present the Purposeful SDM model. Purposeful SDM distinguishes different kinds of situations where patients and clinicians need to work out what to do, and different SDM methods for addressing these problems. The model suggests that there is no one way to do SDM, rather we can think of SDM as a range of methods that vary according the problem that the patient is experiencing. I.e. SDM changes according to its purpose.

Kinds of situations that require patients/family and their clinicians to make decisions together and pertinent methods of SDM.

Purposeful SDM extends the predominant focus in SDM research, practice, training, and promotion on the need to involve patients in decision making. The model draws attention to the problem that is the reason why patients and clinicians are involved in making decisions in the first place and the appropriate method of addressing these problems together. The Purposeful SDM model may help explain why many clinicians don’t see current models of SDM as being relevant to the problems that they are dealing with in their practice.

We believe that Purposeful SDM has important implications for what SDM interventions, such as decision aids, should be designed to do and what should be measured when evaluating SDM. Current measures are mostly intended for situations where SDM is used to choose between alternatives. This is only one of the situations and methods that Purposeful SDM describes.

Purposeful SDM: A problem-based approach to caring for patients with shared decision making is available through open access until October 15, 2019.

Authors: Ian G. Hargraves, Victor M. Montori, Juan P. Brito, Marleen Kunneman, Kevin Shaw, Christina LaVecchia, Michael Wilson, Laura Walker, Bjorg Thorsteinsdottir
Download the Purposeful SDM poster presented at ISDM 2019.