Equivocation in patients' decisional preference about life-sustaining treatments.

Abstract

Communication is essential for achieving shared decision-making. We focus on how patients design decisional preferences to allow or decline life-sustaining treatments (LST). We examine "equivocation", a practice through which patients refer to two preferences in response to the physician asking for only one. Conversation analysis of 89 conversations with physicians in which patients allow or decline LST. We identified three types of decisional preference formats. In "unequivocal preferences", patients express a clear-cut preference towards or against an intervention. In "implicitly equivocal preferences" patients express one preference accompanied by a conditional account, conveying an implicit caveat: if the condition is not fulfilled, the preference is not valid. In "explicitly equivocal preferences", patients refer to two contrasting options. These constructions reveal the complexity of decision-making and its granularity, as patients orient to particular scenarios that make relevant specific approaches, instead of confining decisional preferences to the polar request design employed by the physician. Equivocal answers are not always acknowledged by physicians, which means that the documentation of patients' preferences might not adequately capture their wishes and expectations. This pattern of response also raises issues about what patients agree to and understand and, more generally, about patient literacy.