La loi du 04 mars 2002 relative aux droits des malades et à la qualité et à la qualité du système de santé et la loi HPST (Hôpital, Patients, Santé et Territoires) de 2009 qui accorde un cadre légal à l’éducation thérapeutique ont promu l’autonomie du patient en favorisant sa participation aux décisions médicales. L’autogestion de la maladie chronique voulue par les pouvoirs publics en fournissant ces outils juridiques pour améliorer la qualité de soins, a suscité notre intérêt pour programme d’éducation thérapeutique destiné à des patients insuffisants rénaux en pré-dialyse. L’un des objectifs est de favoriser la liberté des patients à choisir une méthode de dialyse. Dans notre travail de thèse, nous avons voulu montrer comment les déterminants sociaux des décisions médicales et ceux liés aux choix d’une méthode de dialyse sont construits. Si en France, les patients semblent davantage se tourner vers une prise en charge à l’hôpital, dans certains pays, c’est le pluralisme médical qui est de mise. L’exercice de l’auto-analyse a montré le poids de l’économique, de la culture, de la famille dans les choix de santé.Par ailleurs, la place de l’éducation thérapeutique dans le processus décisionnel n’est pas figée : l’éducation thérapeutique peut être complémentaire à la pratique médicale, être un outil d’aide à la décision pour certains patients insuffisants rénaux ou être utilisée par les médecins pour favoriser l’observance décisionnelle des patients. Nous avons montré que les patients et les médecins se basent sur plusieurs facteurs qui peuvent influencer la nature de la délibération.Cette étude a montré que le choix est réseauté et que les décisions sont construites car elles sont basées sur des interactions et des stratégies médicales. Ces déterminants permettent également de comprendre comment la confiance est construite dans le processus décisionnel. Tantôt distribuée, tantôt déplacée, la confiance est explicative du type d’information que le patient priorise. Le choix réseauté du patient amène finalement à la relativisation du modèle de décision médicale partagée qui semble de plus en plus avoir un caractère normatif dans la relation entre professionnels de santé et patients. / The law of March 04th, 2002 on the rights of patients and the quality of the health system and the law HPST (Hôpital, Patients, Santé et Territoires) of 2009 that grants legal framework for patients’ education, have promoted the patient’s autonomy by encouraging his participation in medical decisions. Self-management of chronic illness as favoured by public authorities in providing the legal tools to improve the quality of care has aroused our interest in patient education programs for patients with renal failure in pre-dialysis. One of the objectives of this program is to allow patients free choice when deciding on the method of dialysis.Our thesis aims to underline how the social determinants at work in medical decisions and those involved in the choice of a dialysis method are constructed.In France, patients seem to favor hospital patient care, but in some countries, medical pluralism is more frequent. The exercise of self-analysis has revealed the significant part played by economy, culture and family in health choices.Moreover, the part played by patient education in the decision-making process is neither fixed nor pre-determined: patient education can complement medical practice, can be a decision support tool for some kidney patients or be used by doctors to promote patient decision-making compliance.We have shown that patients and physicians rely on several factors that may influence the nature of the discussion.This study reveals that the choice is networked and that the decisions that are made are the outcome of several interactions and medical strategies. These determinants also help to understand how trust develops and leads to decision-making.Sometimes distributed, sometimes shifted, trust accounts for the type of information prioritized by the patient. The networked choice of the patient finally puts the shared decision-making model into perspective as it increasingly seems to have a normative character in the relationship between health professionals and patients.

Purpose. To systematically develop and field test an intervention to engage families and healthcare teams in the decision-making process about life support for critically ill patients in the Intensive Care Unit (ICU). Setting. Adult medical-surgical ICU at a Canadian academic teaching hospital. Methods. The International Patient Decision Aid Standards (IPDAS) criteria and the Interprofessional Shared Decision Making (SDM) model guided the study of families facing decisions about life support for their relative in ICU that involved:1) systematic review; 2) qualitative descriptive study; 3) mixed methods field test of a novel patient decision aid (DA). Systematic review findings. Of 3162 citations, four trials evaluated interventions to improve communication between health professionals and patients/families. One intervention met eight of nine criteria for SDM but did not evaluate its effect on the benefit to communication. Qualitative study findings. Six family members and nine health professionals identified two options (life support or comfort care) and values associated with these options. Values included maintaining quality of life, surviving critical illness, minimizing pain and suffering, not being attached to machines, giving the family enough time to adapt emotionally to the patient’s health situation, and the judicious use of healthcare resources. Families were unlikely to become engaged without healthcare professionals making the decision explicit and minimizing other barriers across the decision-making process. Field test findings. Family members and health professionals for eight patients indicated that the DA was feasible to use, acceptable to users, had the potential to do what was intended, and did not seem to present adverse consequences to users. An enhanced delivery strategy is needed for future evaluation of its effect on facilitating patient/family involvement in decisions. Conclusions. Limited involvement of families in the process of decision-making about life support in the ICU reinforced the need for effective interventions to facilitate SDM. These studies validated the operationalization of the IPDAS criteria, as part of a systematic process for developing and field testing DAs. However, IPDAS criteria stop short of elements necessary to consider when implementing the DA in the processes of care.

Background: Management of atrial fibrillation (AF) is complex and requires active patient engagement in shared decision making to achieve better clinical outcomes, greater medication adherence, and increased treatment satisfaction. Efficacy in patient-physician interactions is a critical component of patient engagement, but factors associated with efficacy in older AF patients have not been well-characterized. Methods: We performed a cross-sectional analysis of baseline data from the ongoing Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF) study, a cohort study of older adults (age ≥ 65) with non-valvular AF and CHA2DS2-VASc score ≥ 2. Participants were classified according to their Perceived Efficacy in Patient-Physician Interactions (PEPPI-5) score (lower: 0-44; higher: 45-50). Logistic regression analysis was used to identify sociodemographic, clinical (AF type, AF treatment, medical comorbidities), and geriatric (cognitive impairment, sensory impairment, frailty, independent functioning) factors associated with lower reported efficacy. Results: Participants (n = 1209; 49% female) had a mean age of 75. A majority (66%) reported higher efficacy in their interactions with physicians. Lower efficacy was associated with persistent AF (adjusted odds ratio [aOR] = 1.52; 95% confidence interval [CI] = 1.13-2.04) and with symptoms of depression (aOR = 1.67; CI = 1.20-2.33) or anxiety (aOR = 1.40; CI = 1.01-1.94). Decreased odds of lower efficacy were observed in participants with chronic kidney disease (aOR = 0.68; CI = 0.50-0.92) and those classified as pre-frail compared to those classified as not frail (aOR = 0.71; CI = 0.53-0.95). Conclusion: Older patients with persistent AF or symptoms of depression or anxiety have decreased efficacy in patient-physician interactions. These individuals merit greater attention from physicians when engaged in shared decision making.

Le dépistage du cancer de la prostate est largement controversé de par l’équilibre de la balance bénéfices-risques de cette procédure. L’enjeu de santé publique est alors d’accompagner au mieux les hommes susceptibles de se faire dépister pour qu’ils puissent être informés et participer au choix. L’objectif de ce doctorat est de contribuer à comprendre pourquoi les hommes participent au dépistage du cancer de la prostate, pour pouvoir améliorer dans un second temps leur accompagnement. Nous avons tout d’abord interrogé des hommes sur leurs connaissances, leurs sources d’informations et leur rôle dans le choix de participer au dépistage du cancer de la prostate. Ces entretiens ont abouti à la nécessité de concevoir un nouvel outil d’information pour améliorer les connaissances des hommes, en particulier sur les risques de la procédure de dépistage. Enfin, nous avons estimé comment les bénéfices et les risques étaient intégrés dans le choix des individus selon si ces derniers avaient eu accès à notre outil d’information. Les résultats de ce travail montrent que les hommes semblent moins favorables à une proposition de dépistage après avoir eu accès à notre outil d’information. Cependant, cela ne modifie pas leur appréciation des bénéfices et des risques du dépistage. Il est nécessaire de poursuivre les efforts pour permettre aux hommes de faire un choix éclairé. / Prostate cancer screening is highly controversial because of the benefit risk ratio. An issue is to support men susceptible to perform this screening towards informed choice and shared decision-making. The aim of this doctorate is to understand why men adhere to prostate cancer screening, and in a second time to improve their support. We interviewed men about their knowledge, their information seeking behaviour, and their implication in prostate cancer screening decision. This highlighted the necessity to create a new information tool to improve men’s knowledge, in particular regarding risks of the screening procedure. Finally, we investigate benefit risk trade-off with and without our information tool access. Results of this work shows that men are less favourable to a screening option after taking into account our information tool. However, benefit and risk of this screening appreciation was not changed. We need to continue efforts to allow men to make an informed choice.

Each year millions of people face the medical decision-making cycle that comes with a diagnosis of cancer. For patients and their families, this can be a rollercoaster of confusion and fear. Researchers have indicated that the complexity of the decision-making process is underrepresented in the current approach of informed decision-making. The purpose of this study was to add to scientifically-validated research expanding the identification of factors that influence decision-making for individuals diagnosed with cancer. Fuzzy trace theory (FTT) is the dual process memory theory used as the framework for this study. Qualitative data were collected using semistructured interviews with 10 participants. The sampling strategy included purposeful sampling and snowball or chain sampling. The audio-recorded interviews were transcribed and analyzed. Software tools were used to aid in the creation of word mapping and clusters and a naming structure emerged. A comprehensive thematic analysis was completed. Participants detailed experiences with family and social dynamics, psychological or emotional stress, external influencing factors to the decision-making process, and experiences with cancer advertising. This research can create positive social change through the advancement of scientifically-validated research to support patients during the decision-making process.

Cancer incidence is high for aging minority and underserved populations, yet research is limited about patient-provider communications with aging racial and ethnic minority populations. Achieving high-quality cancer care is crucial to reducing health disparities for this population. However, potential shortages in professional health personnel, the cost to treat cancer, a strained health care system, and large aging populations contribute to the problem. The purpose of this qualitative study was to understand the personal experiences of aging minorities during cancer treatment decision making when communicating with their cancer care providers. Purposive sampling methods were used to recruit 10 minority women and men born between 1946 and 1964 who had experienced communicating with providers and making cancer treatment decisions. In-depth semi-structured interviews and thematic analysis of qualitative data was conducted. Important findings were barriers related to miscommunication with providers, the need for more time with the cancer doctor, and mistrust of the medical profession. Participants perceived poor interpersonal communication with providers as causing a lack of understanding regarding their cancer treatment options, which affected their decision making regarding their treatment. Barriers to communication included long wait times at public or teaching health care systems for follow up cancer care services. The findings of this study could be useful to assist health care providers in improving communication with their cancer patients, reducing cancer health disparities, and increasing the quality of cancer care for this population.

No description available.

No description available.

Les situations de crise sont fréquentes chez les personnes ayant des troubles de santé mentale. Plusieurs interventions ont été développées pour agir en prévention, dont les plans de crise reconnus comme particulièrement efficaces pour diminuer le recours aux mesures coercitives. Dans la littérature, plusieurs modèles de plans de crise sont proposés et incluent entre autres le plan de sécurité, le plan de crise conjoint et les directives anticipées. Un examen de ces différents plans permet de constater qu’ils ont des buts et des contenus très semblables. Basé sur la méthodologie proposée par le Johanna Briggs Institute (2020), une revue de la portée a été conduite dans l’objectif de dresser l’état des connaissances sur les plans de crise en santé mentale adulte. Une stratégie de recherche documentaire a été conduite sur six bases de données (CINAHL, PubMed, Medline, EMBASE, PsychINFO, and Cochrane) et a permis d’identifier 2435 articles. Parmi ces derniers, 122 textes complets ont été évalués et 78 ont répondu aux critères d’inclusion de l’étude. Ensuite, la qualité méthodologique des articles sélectionnés a été évaluée et les données ont été extraites de façon indépendante par deux étudiantes à la maitrise. L’analyse de contenu a été réalisée, puis les résultats préliminaires ont été présentés, discutés et validés avec un patient partenaire ayant vécu des crises en santé mentale. Une typologie des plans de crise a été identifiée selon 1) les plans de crise légaux et 2) les plans de crise formels. Également, cinq modalités pour la complétion des plans de crise ont été identifiées : les sections, le moment, les étapes de complétion, les personnes impliquées et la formation des acteurs.trices clés. Les retombées de l’intervention sont concordantes avec le but principal des plans de crise, soit la prévention de la crise. Or, les retombées les plus identifiées dans la littérature sont davantage liées au rétablissement de l’usager.ère et semblent indiquer que les plans de crise pourraient représenter une intervention permettant d’opérationnaliser le rétablissement dans les soins en santé mentale. Les futures recherches empiriques devraient cibler le développement des connaissances sur les modalités à privilégier dans l’objectif de guider les milieux cliniques dans l’implantation des plans de crise. / Crisis situations are frequent among people with mental health disorders. Several interventions have been developed to act in prevention, including crisis plans, which are recognized as particularly effective in reducing coercive measures. In the literature, several types of crisis plans have been proposed, including the safety plan, the joint crisis plan and advance directives. A review of these plans suggests that they are very similar in purpose and content. Based on the methodology proposed by the Johanna Briggs Institute, a scoping review was conducted with the objective of mapping the state of knowledge on crisis plans in adult mental health services. A literature search strategy was conducted on six databases (CINAHL, PubMed, Medline, EMBASE, PsychINFO, and Cochrane) and yielded 2435 articles. Of these, 122 full text articles were assessed for eligibility, and 78 met the inclusion criteria. Studies were then critically appraised using the Johanna Briggs Institute appraisal tools, and date were extracted my two master’s students. Content analysis was performed, and preliminary results were presented, discussed, and validated with a patient partner who has experienced mental health crises. A typology of crisis plans was identified according to 1) the legal crisis plan, 2) the formal crisis plan. Five modalities were identified for its completion: sections, timing, creation steps, people involved, and training of key actors in writing a crisis plan. The outcomes of the intervention are consistent with the main objective of crisis plans, which is to prevent a crisis. However, the most identified outcomes focused on the service user’s recovery and indicated that crisis plans could provide an opportunity to operationalize recovery in mental healthcare, thus suggesting an evolution in the aim of the intervention. Future research should further focus on the modalities of crisis plans to guide the implementation in clinical practice.

No description available.