Temporal characteristics of decisions in hospital encounters: A threshold for shared decision making? A qualitative study

• Patients are the focus of a large number of decisions in hospital encounters.
• Decisions are connected to past, present or future medical actions or judgment.
• Preformed decisions are made prior to the encounter and conveyed as information.
• Conditional decisions prescribe future actions given a certain course of events.
• The temporal nature of decisions may serve as a threshold for patient involvement.

ObjectiveTo identify and characterize physicians’ statements that contained evidence of clinically relevant decisions in encounters with patients in different hospital settings.MethodsQualitative analysis of 50 videotaped encounters from wards, the emergency room (ER) and outpatient clinics in a department of internal medicine at a Norwegian university hospital.ResultsClinical decisions could be grouped in a temporal order: decisions which had already been made, and were brought into the encounter by the physician (preformed decisions), decisions made in the present (here-and-now decisions), and decisions prescribing future actions given a certain course of events (conditional decisions). Preformed decisions were a hallmark in the ward and conditional decisions a main feature of ER encounters.ConclusionClinical decisions related to a patient–physician encounter spanned a time frame exceeding the duration of the encounter. While a distribution of decisions over time and space fosters sharing and dilution of responsibility between providers, it makes the decision making process hard to access for patients.Practice implicationsIn order to plan when and how to involve patients in decisions, physicians need increased awareness of when clinical decisions are made, who usually makes them, and who should make them.