Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

When Decision-Making Isn’t Clear: A Patient-Centered Approach


When faced with a difficult choice, making a Punnett's square decision-making tool with your patient might help.

Although I’m a laryngologist who cares for voice and swallowing disorders, one of my more memorable patient encounters recently concerned a patient struggling to decide whether or not to go forward with a risky retinal procedure to try to save his eyesight. He came to me in follow-up of a stable chronic throat complaint, for which no change in treatment plan was needed, but as we spoke, it became clear that he had other things on his mind.


Though he had serviceable vision at the time, he was aware that he was losing his vision in a progressive, inexorable fashion. As he explained it to me, there was a procedure that he had been offered—it had a moderate chance that it might stabilize his vision at current levels, but also carried with it risk of complete loss of vision in that eye. He didn’t know what to do.


While I couldn’t offer him any medical knowledge concerning the procedure he was considering with the Ophthalmologic surgeons, I did review with him the following:


1.) Often, the risk-benefit analysis for a procedure makes the course of action clear to the patient and to the physician, as they make a treatment decision together.


2.) When the decision is not clear, it’s often because the outcome is uncertain.


3.) While we can’t promise a result, we can help the patient go through a process that can inform decision-making. This process recognizes uncertain outcomes, and encourages the patient to make the best decision they can with the information that they have


4.) By imagining the best and worst case outcomes for both having the procedure and not having the procedure, then choosing among these outcomes which emotional narrative feels best, the patient can reach the decision that is best for them—“Well, the negative outcome happened, but at least I did my best to choose a course of action that had the potential to ….”


5.) A 2×2 Punnett square can help in this analysis.


Best Case Worst Case
Surgery Thrilled to preserve vision!  

Lose vision quickly – and (1.) be frustrated that your decision ‘sped up’ the vision loss, or (2.) accept this outcome gracefully knowing that you had chosen surgery to be able to try save vision.


No Surgery  

Slowly lose vision, but know you made what you thought was the best decision at the time.


Slowly lose vision, and be very frustrated that you had missed an opportunity to try to save it.


In the case of my patient with retinopathy, we developed this 2×2 grid and reviewed his options.


Both the best case and worst case for not having surgery was progressive inexorable vision loss.


If he had surgery, the best case was stabilization of vision; the worst case was immediate loss of the remaining vision in that eye.


When viewed through the lens of this best/worst case analysis, the real decision he had to make was between the following possible emotional narratives:  “I don’t have the surgery, I lose my vision slowly, but at least I am glad that I preserved it as long as I could,” versus, “I have the surgery, I lose my vision quickly, but at least I did my best to try to preserve it for the rest of my life.”


By choosing which of these alternate realities he could best live with should a negative outcome occur, his decision became more clear—and the emotional struggle he’d been having in the absence of clarity became less frustrating.