Decision Conflicts in Clinical Care during COVID-19: A Patient Perspective

Abstract

(1) Background: Uncertainty is typical for a pandemic or similar healthcare crisis. This affects patients with resulting decisional conflicts and disturbed shared decision making during their treatment occurring to a very different extent. Sociodemographic factors and the individual perception of pandemic-related problems likely determine this decisional dilemma for patients and can characterize vulnerable groups with special susceptibility for decisional problems and related consequences. (2) Methods: Cross-sectional data from the OnCoVID questionnaire study were used involving 540 patients from 11 participating institutions covering all major regions in Germany. Participants were actively involved in clinical treatment in oncology or psychiatry during the COVID-19 pandemic. Questionnaires covered five decision dimensions (conflicts and uncertainty, resources, risk perception, perception of consequences for clinical processes, perception of consequences for patients) and very basic demographic data (age, gender, stage of treatment and educational background). Decision uncertainties and distress were operationalized using equidistant five-point scales. Data analysis was performed using descriptive and various multivariate approaches. (3) Results: A total of 11.5% of all patients described intensive uncertainty in their clinical decisions that was significantly correlated with anxiety, depression, loneliness and stress. Younger and female patients and those of higher educational status and treatment stage had the highest values for these stressors (p < 0.001). Only 15.3% of the patients (14.9% oncology, 16.2% psychiatry; p = 0.021) considered the additional risk of COVID-19 infections as very important for their disease-related decisions. Regression analysis identified determinants for patients at risk of a decisional dilemma, including information availability, educational level, age group and requirement of treatment decision making. (4) Conclusions: In patients, the COVID-19 pandemic induced specific decisional uncertainty and distress accompanied by intensified stress and psychological disturbances. Determinants of specific vulnerability were related to female sex, younger age, education level, disease stages and perception of pandemic-related treatment modifications, whereas availability of sufficient pandemic-related information prevented these problems. The most important decisional criteria for patients under these conditions were expected side effects/complications and treatment responses.

Keywords: COVID-19; decision conflicts; moral distress; oncology; psychiatry; uncertainty.

Figure 1

Perception of (A) decisional uncertainty and (B) distress due to uncertainty in oncology (blue) and psychiatry (orange) patients; (C) mean ± SD for general, treatment-related decisional uncertainty and resulting distress during own treatment decisions; (D) required treatment modification due to pandemic conditions from patients’ perspectives (Percentage histograms of all respondents).

Figure 2

(A) Perception of anxiety, depression, stress, loneliness and hope within two weeks before questionnaire; (B) reflection of own pandemic risk during data-capture period; (C) modification requirement for treatment and patients’ criteria for treatment decisions; (D) burden due to additional risk for treatment by COVID-19 (Percentages of all respondents).

Figure 3

Influence of information availability on (A) decisional uncertainty and (B) decisional distress.