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A qualitative study of clinical decision-making in a multidisciplinary outpatient clinic for patients with atrial fibrillation - from the patient’s perspective

Lars Thrysoee, Lisbeth Birkelund, Regner Birkelund


Background: International studies show that patient involvement in clinical decision-making has a positive effect on patients’ experiences of quality and on their adherence to the initiated treatment. Studies also demonstrate that patients are becoming more interested in engaging in decision-making processes. While patient involvement in decision-making plays an important role in the newest European guidelines for treatment of patients with atrial fibrillation, recent research points to the challenges associated with this ideal. The aim of the present study was to determine how patients with newly diagnosed atrial fibrillation experienced the clinical decision-making process in outpatient treatment courses.

Methods: The study had a qualitative research design. Data were generated by means of fieldwork in which the researcher participated in outpatient consultations with participating patients. Field notes were supplemented with semi-structured individual interviews. Fourteen patients (7 women and 7 men) between the ages of 40 to 82 were included. The empirical data were analyzed and interpreted according to Ricoeur’s interpretation theory.

Results: Three main themes were identified: (1) Lack of prerequisites for patient involvement in decision-making at the first consultation; (2) Limited patient involvement in the anticoagulant choice and (3) Lack of follow-up on the patient’s understanding of illness and treatment.

Conclusion: The data showed that the medical aspects of the patients’ illness were most often the focus of attention, whereas the patients’ own experiences, needs and preferences were not systematically included in the decision-making process.


Anticoagulation, clinical decision-making, newly diagnosed atrial fibrillation, outpatient courses, patient involvement, patient understanding, person-centered healthcare, quality of care, Ricoeur

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Eckman, M.H., Wise, R.E., Naylor, K., Arduser, L., Lip, G.Y., Kissela, B., Flaherty, M., Kleindorfer, D., Khan, F., Schauer, D.P., Kues, J. & Costea, A. (2015). Developing an Atrial Fibrillation Guideline Support Tool (AFGuST) for shared decision making. Current Medical Research and Opinion 31 (4) 603-614.

Chugh, S., Havmoeller, R., Narayanan, K., Singh, D., Rienstra, M., Benjamin, E.J., Gilum, R.F., Kim, Y.H., McAnulty, J.H.Jr., Zheng, Z.J., Forouzanfar, M.H.. Naghavi, M., Mnsah, G.A., Ezzti, M. & Murray, C.J. (2014). Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation 129 (8) 837-847.

Broge, C. (2011). Three times as many have atrial fibrillation in 2011. (In Danish). The Danish Heart foundation.

Berian, J.R. & Livingston, E.H. (2015). Preventing Stroke in PeopleWith Atrial Fibrillation. Journal of the American Medical Association 314 (3) 310.

Clarkesmith, D.E., Pattison, H.M., Lip, G.Y. & Lane, D.A. (2013). Educational intervention improves anticoagulation control in atrial fibrillation patients: the TREAT randomised trial. PLoS One 8 (9) e74037.

Fuster, V., Ryden, L.E., Cannom, D.S., Crijns, H.J., Curtis, A.B., Ellenbogen, K.A. et al. (2006). ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 114 (7) e257-354.

Wirtz, V., Cribb, A. & Barber, N. (2006). Patient-doctor decision-making about treatment within the consultation--a critical analysis of models. Social Science & Medicine 62 (1) 116-124.

Ruland, C.M. (2005). Shared decision making and nursing informatics research in Norway. Applied Nursing Research 18 (2) 70-72; discussion 2-3.

Whitney, S.N. (2003). A New Model of Medical Decisions: Exploring the Limits of Shared Decision Making. Medical Decision Making 23 (4) 275-280.

Epstein, R.M. & Gramling, R.E. (2013). What is shared in shared decision making? Complex decisions when the evidence is unclear. Medical Care Research and Review 70 (Supplement 1) 94S-112S.

Entwistle, V.A. & Watt, I.S. (2006). Patient involvement in treatment decision-making: the case for a broader conceptual framework. Patient Education and Counseling 63 (3) 268-278.

Charles, C., Gafnia, A. & Whelana, T. (1999). Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Social Science & Medicine 49 (9) 651-661.

Elwyn, G., Coulter, A., Laitner, S., Walker, E. & Watson, P.R.T. (2010). Implementing shared decision making in the NHS. British Medical Journal 341, c5146.

Elwyn, G., Frosch, D., Thomson, R., Joseph-Williams, N., Lloyd, A., Kinnersley, P., Cording, E., Tonson, D., Dodd, C., Rollnick, S., Edwards, A. & Barry, M. (2012). Shared Decision Making - A Model for Clinical Practice. Journal of General Internal Medicine 27 (10) 1361-1367.

Chewning, B., Bylund, C.L., Shah, B., Arora, N.K., Gueguen, J.A. & Makoul, G. (2012). Patient preferences for shared decisions: a systematic review. Patient Education and Counseling 86 (1) 9-18.

Burton, D., Blundell, N., Jones, M., Fraser, A. & Elwyn, G. (2010). Shared decision-making in cardiology: do patients want it and do doctors provide it? Patient Education and Counseling 80 (2) 173-179.

Borg Xuereb, C., Shaw, R.L. & Lane, D.A. (2012). Patients' and health professionals' views and experiences of atrial fibrillation and oral-anticoagulant therapy: a qualitative meta-synthesis. Patient Education and Counseling 88 (2) 330-337.

Camm, A.J., Kirchhof, P., Lip, G.Y., Schotten, U., Savelieva, I., Ernst, S. et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). European Heart Journal 31 (19) 2369-2429.

Kirchhof, P., Benussi, S., Kotecha, D., Ahlsson, A., Atar, D., Casadei, B. et al. (2016). 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS: The Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC)Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESCEndorsed by the European Stroke Organisation (ESO). European Heart Journal 33 (38) 2893-2962.

Borg Xuereb, C., Shaw, R.L. & Lane, D.A. (2016). Patients' and physicians' experiences of atrial fibrillation consultations and anticoagulation decision-making: A multi-perspective IPA design. Psychology & Health 31 (4) 436-455.

Murray, E., Charles, C. & Gafni, A. (2006). Shared decision-making in primary care: tailoring the Charles et al. model to fit the context of general practice. Patient Education and Counseling 62 (2) 205-211.

Clarkesmith, D.E., Lip, G.Y. & Lane, D.A. (2017). Patients' experiences of atrial fibrillation and non-vitamin K antagonist oral anticoagulants (NOACs), and their educational needs: A qualitative study. Thrombosis Research 153, 19-27.

Kirchhof, P., Breithardt, G., Aliot, E., Al Khatib, S., Apostolakis, S., Auricchio, A., et al. (2013). Personalized management of atrial fibrillation: Proceedings from the fourth Atrial Fibrillation competence NETwork/European Heart Rhythm Association consensus conference. Europace 15 (11) 1540-1556.

Siouta, E., Muhli, U., Hedberg, B., Brostrom, A., Fossum, B. & Karlgren, K. (2015). Patients' experiences of communication and involvement in decision-making about atrial fibrillation treatment in consultations with nurses and physicians. Scandinavian Journal of Caring Sciences 30 (3) 535-546.

Thrysoee, L., Stromberg, A., Brandes, A. & Hendriks, J.M. (2017). Management of Newly Diagnosed Atrial Fibrillation in an Outpatient Clinic Setting - Patient's perspectives and experiences. Journal of Clinical Nursing 27 (3-4) 601-611.

Chokshi, D.D., Rugge, J. & Shah, N.R. (2014). Redesigning the Regulatory Framework for Ambulatory Care 2014. The Millbank Quarterly 92 (4) 776-795.

Preatorius, C.L. & Preatorius, H. (2014).The hospital with no beds in 2013. In: The Hospital of the future. (In Danish). Pedersen, K.M. & Petersen, N.C. (Eds), pp. 105-134. Copenhagen: Munksgaard.

Spradley, J.P. (1980). Participant Obervation. Belmont, CA: Wadsworth Cengage Learning.

Jorgensen, D. (1989). Participant Observation. A methodology for human studies. Thousand Oaks: Sage.

Körner, M. (2010). Interprofessional teamwork in medical rehabilitation: a comparison of multidisciplinary and interdisciplinary team approach. Clinical Rehabilitation 24 (8) 745-755.

Kvale, S. (2007). Doing Interviews. London: SAGE research methods.

Fridlund, B., Andersson, E.K., Bala, S-V., Dahlman, G-B., Ekwall, A.K., Glasdam, S., Hommel, A., Lindberg, C., Persson, E.I., Rantala, A., Sjöström-Strand, A., Wihlborg, J. & Samuelson, K. (2015). Essentials of Teamcare in Randomized Controlled Trials of Multidisciplinary or Interdisciplinary Interventions in Somatic Care: A Systematic Review. Open Journal of Nursing 5 (12) 1089-1101.

Ricoeur, P. (1976). Interpretation Theory - Discourse and Surplus of Meaning. Fort Worth: Texas Christian University Press.

Ricoeur, P. (1973). The Hermeneutical Function of Distanciation. Philosophy Today 17 (2) 129-142.

Dreyer, P. & Pedersen, B. (2009). Distanciation in Ricoeur’s theory of interpretation: narrations in a study of life experiences of living with chronic illness and home mechanical ventilation. Nursing Inquiry 16 (1) 64-73.

World Medical Association. (2013). Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects. Journal of the American Medical Association 310 (20) 2191-2194.

Thorgård, K. (2012). Patient involvement between expert knowledge and everyday experiences. In Danish: Patientinddragelse mellem ekspertviden og hverdagserfaringer. Nordisk Sygeplejeforskning 2 (2) 96-108.

Larsson, I.E., Sahlsten, M.J., Segesten, K. & Plos, K.A. (2011). Patients' perceptions of barriers for participation in nursing care. Scandinavian Journal of Caring Sciences 25 (3) 575-582.

McCabe, P.J., Rhudy, L.M. & DeVon, H.A. (2014). Patients' experiences from symptom onset to initial treatment for atrial fibrillation. Journal of Clinical Nursing 24 (5-6) 786-796.

Kunneman, M., Montori, V.M., Castaneda-Guarderas, A. & Hess, E.P. (2016). What Is Shared Decision Making? (and What It Is Not). Academic Emergency Medicine 23 (12) 1320-1324.

Butalid, L., Bensing, J. & Verhaak, P. (2014). Talking about psychosocial problems: an observational study on changes in doctor-patient communication in general practice between 1977 and 2008. Patient Education and Counseling 94 (3) 314-321.

Olsson, L.E., Jakobsson Ung, E., Swedberg, K. & Ekman, I. (2013). Efficacy of person-centred care as an intervention in controlled trials - a systematic review. Journal of Clinical Nursing 22 (3-4) 456-465.

Ekman, I., Swedberg, K., Taft, C., Lindseth, A., Norberg, A., Brink, E., Carlsson, J., Dahlin-Ivanoff, S., Johansson, I.L., Kjellgren, K., Lidén, E., Öhlén, J., Olsson, L.E., Rosén, H., Rydmark, M. & Sunnerhagen, K.S. (2011). Person-centered care - ready for prime time. European Journal of Cardiovascular Nursing 10 (4) 248-251.

Miles, A. & Asbridge, J.E. (2016). The chronic illness problem. The person-centered solution. European Journal for Person Centered Healthcare 4 (1) 1-5.

Sabaté, E. (2003). Adherence to long-term therapies. Evidence for action. Geneva:World Health Organization.

Glasdam, S., Oeye, C. & Thrysoee, L. (2015). Patients' participation in decision-making in the medical field-'projectification' of patients in a neoliberal framed healthcare system. Nursing Philosophy 16 (4) 226-238.



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