Toward a Conceptual Model of Affective Predictions in Palliative Care.

CONTEXT: Being diagnosed with cancer often forces patients and families to make difficult medical decisions. How patients think they and others will feel in the future, termed affective predictions, may influence these decisions. These affective predictions are often biased, which may contribute to suboptimal care outcomes by influencing decisions related to palliative care and advance care planning. OBJECTIVES: This study aimed to translate perspectives from the decision sciences to inform future research about when and how affective predictions may influence decisions about palliative care and advance care planning. METHODS: A systematic search of two databases to evaluate the extent to which affective predictions have been examined in the palliative care and advance care planning context yielded 35 relevant articles. Over half utilized qualitative methodologies (n = 21). Most studies were conducted in the U.S. (n = 12), Canada (n = 7), or European countries (n = 10). Study contexts included end of life (n = 10), early treatment decisions (n = 10), pain and symptom management (n = 7), and patient-provider communication (n = 6). The affective processes of patients (n = 20), caregivers (n = 16), and/or providers (n = 12) were examined. RESULTS: Three features of the palliative care and advance care planning context may contribute to biased affective predictions: 1) early treatment decisions are made under heightened emotional states and with insufficient information; 2) palliative care decisions influence life domains beyond physical health; and 3) palliative care decisions involve multiple people. CONCLUSION: Biases in affective predictions may serve as a barrier to optimal palliative care delivery. Predictions are complicated by intense emotions, inadequate prognostic information, involvement of many individuals, and cancer's effect on non-health life domains. Applying decision science frameworks may generate insights about affective predictions that can be harnessed to solve challenges associated with optimal delivery of palliative care.

Trajectories of Current and Predicted Satisfaction With One's Life Following a Cancer Diagnosis.

Background: Poor physical and mental health is common among cancer survivors, but little is known about how cancer influences life satisfaction and expectations about one's future, both of which may subsequently influence health decisions and outcomes. Purpose: The current study examined how a cancer diagnosis influences current and predicted future life satisfaction in seven domains, including family, finances, work, and health. Methods: We leveraged data from three waves of the Midlife in the United States study (N = 6,389) and examined the relation between new and past cancer diagnoses on satisfaction using generalized estimating equations. We also compared participants' predicted satisfaction to the actual satisfaction they reported at later waves of data collection, and examined whether concordance between the two differed by cancer history. Results: A cancer diagnosis was associated with a decline in satisfaction about one's present health and sex life, ps < .05, but satisfaction with all other domains remained steady or improved. In contrast, predictions about the future became and remained less optimistic than the predictions of those without cancer across all life domains except relationships with children, ps < .05. Within-subjects comparisons of predicted and actual satisfaction suggest those without a cancer history were optimistic in their predictions across all life domains except health whereas survivors were more accurate in their predictions. Conclusions: Given the many ways in which expectations about the future can influence decision making, behavior, and health, survivors' attenuated optimistic outlooks may influence their health and well-being.

Interventions to Engage Affective Forecasting in Health-Related Decision Making: A Meta-Analysis.

Background: People often use affective forecasts, or predictions about how a decision will make them feel, to guide medical and health decision making. However, these forecasts are susceptible to biases and inaccuracies that can have consequential effects on decision making and health. Purpose: A meta-analysis was performed to determine the effectiveness of intervening to address affective forecasting as a means of helping patients make better health-related choices. Methods: We included between-subjects experimental and intervention studies that targeted variables related to affective forecasting (e.g., anticipated regret, anticipated affect) as a means of changing health behaviors or decisions. We determined the overall effect of these interventions on targeted affective constructs and behavioral outcomes, and whether conceptual and methodological factors moderated these effects. Results: A total of 133 independent effect sizes were identified from 37 publications (N = 72,020). Overall, affective forecasting interventions changed anticipated regret, d = 0.24, 95% confidence interval (CI) (0.15, 0.32), p < .001, behavior, d = 0.29, 95% CI (0.13, 0.45), p < .001, and behavioral intentions, d = 0.19, 95% CI (0.11, 0.28), p < .001, all measured immediately postintervention. Interventions did not change anticipated positive and negative affect, and effects on intentions and regret did not extend to follow-up time points, ps > .05. Generally, effects were not moderated by conceptual model, intervention intensity, or behavioral context. Conclusions: Affective forecasting interventions had a small consistent effect on behavioral outcomes regardless of intervention intensity and conceptual framework, suggesting such constructs are promising intervention targets across several health domains.

US Consumers' Understanding of Nutrition Labels in 2013: The Importance of Health Literacy.

INTRODUCTION: We examined US adults' understanding of a Nutrition Facts panel (NFP), which requires health literacy (ie, prose, document, and quantitative literacy skills), and the association between label understanding and dietary behavior. METHODS: Data were from the Health Information National Trends Survey, a nationally representative survey of health information seeking among US adults (N = 3,185) conducted from September 6, 2013, through December 30, 2013. Participants viewed an ice cream nutrition label and answered 4 questions that tested their ability to apply basic arithmetic and understanding of percentages to interpret the label. Participants reported their intake of sugar-sweetened soda, fruits, and vegetables. Regression analyses tested associations among label understanding, demographic characteristics, and self-reported dietary behaviors. RESULTS: Approximately 24% of people could not determine the calorie content of the full ice-cream container, 21% could not estimate the number of servings equal to 60 g of carbohydrates, 42% could not estimate the effect on daily calorie intake of foregoing 1 serving, and 41% could not calculate the percentage daily value of calories in a single serving. Higher scores for label understanding were associated with consuming more vegetables and less sugar-sweetened soda, although only the association with soda consumption remained significant after adjusting for demographic factors. CONCLUSION: Many consumers have difficulty interpreting nutrition labels, and label understanding correlates with self-reported dietary behaviors. The 2016 revised NFP labels may address some deficits in consumer understanding by eliminating the need to perform certain calculations (eg, total calories per package). However, some tasks still require the ability to perform calculations (eg, percentage daily value of calories). Schools have a role in teaching skills, such as mathematics, needed for nutrition label understanding.

Decision making and cancer.

We review decision making along the cancer continuum in the contemporary context of informed and shared decision making in which patients are encouraged to take a more active role in their health care. We discuss challenges to achieving informed and shared decision making, including cognitive limitations and emotional factors, but argue that understanding the mechanisms of decision making offers hope for improving decision support. Theoretical approaches to decision making that explain cognition, emotion, and their interaction are described, including classical psychophysical approaches, dual-process approaches that focus on conflicts between emotion versus cognition (or reason), and modern integrative approaches such as fuzzy-trace theory. In contrast to the earlier emphasis on rote use of numerical detail, modern approaches emphasize understanding the bottom-line gist of options (which encompasses emotion and other influences on meaning) and retrieving relevant social and moral values to apply to those gist representations. Finally, research on interventions to support better decision making in clinical settings is reviewed, drawing out implications for future research on decision making and cancer.

Precancer risk perceptions predict postcancer subjective well-being.

OBJECTIVE: The present study used longitudinal data to explore whether subjective well-being in cancer survivors was related to predisease judgments of their likelihood of getting cancer. METHOD: Subjective well-being was assessed in terms of affective well-being (frequency of positive and negative affective states) and satisfaction with one's life overall. The sample consisted of 158 participants in the National Survey of Midlife Development in the U.S. (MIDUS) who developed cancer during the 8-10 years between the first and second waves of the survey (average time since diagnosis = 3.37 years; SD = 2.48), and 3,243 control participants who reported no history of cancer at either wave. RESULTS: Controlling for demographic variables and well-being at Wave 1, the effect of cancer on well-being depended on whether, prior to being diagnosed, people judged themselves to be at low or high risk of cancer. For those perceiving a high risk, a cancer diagnosis had a modest but significant negative impact on affect and life satisfaction, whereas no negative impact emerged for those perceiving a low risk. Similar effects were not observed for heart attack risk perceptions, or for measures of trait optimism or depression, suggesting that the effect was domain-specific. CONCLUSIONS: Low precancer risk perceptions were associated with long-term benefits for subjective well-being in people who developed cancer.

Just blowing smoke? Social desirability and reporting of intentions to quit smoking.

INTRODUCTION: Do cigarette smokers really want to quit smoking or do they simply say they do in order to placate others and avoid criticism? In surveys of smokers, stated quit intentions and reports of quit attempts may be biased by social desirability concerns. This makes it difficult to interpret large-scale state and national surveys of smoking behavior that collect data through telephone and face-to-face interviews, methods that tend to evoke high levels of socially desirable responding. METHODS: The 2007 Health Information National Trends Survey used a dual-frame design to query smokers' quit intentions and past quit attempts in 1 of 2 ways: A self-administered mail survey (low pressure for socially desirable responding; n = 563), or an interviewer-administered telephone survey (high pressure for socially desirable responding; n = 499). Estimates derived from the 2 formats were compared to test for social desirability effects. RESULTS: In both survey modes, approximately two thirds of smokers reported seriously considering quitting in the next 6 months (mail: 64.9%; telephone: 68.9%), and approximately half reported making a quit attempt in the past year (mail: 54.9%; telephone: 52.3%). Neither difference approached significance in logistic regressions controlling for demographics (ps > .24). CONCLUSIONS: It appears that a large proportion of smokers in the United States aspire to live smoke-free lives and are not simply responding in a socially desirable manner to deflect criticism in an antismoking social climate. Future research should (1) replicate this study with greater statistical power, (2) examine the possible effects of survey context (e.g., health survey vs. smoking pleasure survey), and (3) explore survey mode effects in specific subpopulations.

New approaches to understand cognitive changes associated with chemotherapy for non-central nervous system tumors.

CONTEXT: Researchers have described a constellation of cognitive deficits (e.g., impairments in executive functions, working memory, attention, and information-processing speed) associated with cancer treatment, and specifically chemotherapy, for non-central nervous system tumors. However, findings have been inconsistent, largely because of measurement and study design issues. OBJECTIVES: To propose ways for researchers to more clearly delineate and characterize the mild cognitive deficits and related outcomes that appear to affect a subset of cancer patients and suggest methods to make more effective use of the existing data to understand risk factors for impaired neuropsychological functioning. METHODS: We examined the literature on the relationship between chemotherapy and cognitive impairment, as well as related literature on neuropsychological measurement, structural and functional neuroimaging, alternative measures of health outcomes, and integrative data analysis. RESULTS: A more comprehensive picture of cognitive functioning might be obtained by incorporating nontraditional ecological measures, self-reports, computational modeling, new neuroimaging methods, and markers of occupational functioning. Case-control and integrative data analytic techniques potentially could leverage existing data to identify risk factors for cognitive dysfunction and test hypotheses about the etiology of these effects. CONCLUSION: There is a need to apply new research approaches to understand the real-world functional implications of the cognitive side effects of chemotherapy to develop and implement strategies to minimize and remediate these effects before, during, and after cancer treatment.

Exploring objective and subjective numeracy at a population level: findings from the 2007 Health Information National Trends Survey (HINTS).

Numeracy is a critical component of decision making in health, and low numeracy may adversely affect risk comprehension, medical treatment, and health outcomes. Health researchers have developed objective and subjective measures of numeracy that potentially could be used for clinical or health research purposes. To examine the association between objective and subjective numeracy at a population level, data were obtained from the 2007 Health Information National Trends Survey, a health communication survey that collects data from a nationally representative sample of the U.S. population. Associations between items from 2 published subjective numeracy measures (STAT-Confidence Scale; Subjective Numeracy Scale) and a single published objective numeracy measure were examined with respect to one another and with respect to sociodemographic characteristics using a multivariate logistic regression model. Controlling for demographic covariates, both subjective numeracy measures were significantly associated with each other (p < .0001) and with objective numeracy (p < .0001). Compared with respondents who regarded themselves as low in subjective numeracy, those who regarded themselves as high in subjective numeracy had significantly higher odds of answering the objective numeracy question correctly (STAT-Confidence Scale OR = 1.42, CI [1.07, 1.90]; Subjective Numeracy Scale OR = 1.71, CI [1.28, 2.28]). However, the subjective measures performed poorly as diagnostic indicators of objective numeracy. Sensitivity and specificity for the STAT-Confidence Scale and the Subjective Numeracy Scale were 67%/49% and 50%/71%, respectively. More work is needed to elucidate the relation between objective and subjective numeracy, at the conceptual and empirical levels, and to develop more robust measures of subjective numeracy that can better discriminate between individuals with low and high objective numeracy.

How numeracy influences risk comprehension and medical decision making.

We review the growing literature on health numeracy, the ability to understand and use numerical information, and its relation to cognition, health behaviors, and medical outcomes. Despite the surfeit of health information from commercial and noncommercial sources, national and international surveys show that many people lack basic numerical skills that are essential to maintain their health and make informed medical decisions. Low numeracy distorts perceptions of risks and benefits of screening, reduces medication compliance, impedes access to treatments, impairs risk communication (limiting prevention efforts among the most vulnerable), and, based on the scant research conducted on outcomes, appears to adversely affect medical outcomes. Low numeracy is also associated with greater susceptibility to extraneous factors (i.e., factors that do not change the objective numerical information). That is, low numeracy increases susceptibility to effects of mood or how information is presented (e.g., as frequencies vs. percentages) and to biases in judgment and decision making (e.g., framing and ratio bias effects). Much of this research is not grounded in empirically supported theories of numeracy or mathematical cognition, which are crucial for designing evidence-based policies and interventions that are effective in reducing risk and improving medical decision making. To address this gap, we outline four theoretical approaches (psychophysical, computational, standard dual-process, and fuzzy trace theory), review their implications for numeracy, and point to avenues for future research.

Rethinking the objectives of decision aids: a call for conceptual clarity.

Health decision aids are a potentially valuable adjunct to patient-physician communication and decision making. Although the overarching goal of decision aids--to help patients make informed, preference-sensitive choices--is widely accepted, experts do not agree on the means to achieve this end. In this article, the authors critically examine the theoretical basis and appropriateness of 2 widely accepted criteria used to evaluate decision aids: values clarification and reduction of decisional conflict. First, they argue that although clarifying values is central to decision making under uncertainty, it is not clear that decision aids--as they have been conceived and operationalized so far--can and should be used to achieve this goal. The pursuit of clarifying values, particularly values clarification exercises, raises a number of ethical, methodological, and conceptual issues, and the authors suggest research questions that should be addressed before values clarification is routinely endorsed. Second, the authors argue that the goal of reducing decisional conflict is conceptually untenable and propose that it be eliminated as an objective of decision aids.

Are patient decision aids the best way to improve clinical decision making? Report of the IPDAS Symposium.

This article reports on the International Patient Decision Aid Standards Symposium held in 2006 at the annual meeting of the Society for Medical Decision Making in Cambridge, Massachusetts. The symposium featured a debate regarding the proposition that "decision aids are the best way to improve clinical decision making.'' The formal debate addressed the theoretical problem of the appropriate gold standard for an improved decision, efficacy of decision aids, and prospects for implementation. Audience comments and questions focused on both theory and practice: the often unacknowledged roots of decision aids in expected utility theory and the practical problems of limited patient decision aid implementation in health care. The participants' vote on the proposition was approximately half for and half against.

The uterine sandwich for persistent uterine atony: combining the B-Lynch compression suture and an intrauterine Bakri balloon.

OBJECTIVE: The objective of the study was to evaluate the effectiveness of a combination of surgical interventions for control of postpartum hemorrhage. STUDY DESIGN: At cesarean delivery, patients with persistent bleeding from uterine atony after the administration of oxytonics were treated with the placement of a B-Lynch suture. When the B-Lynch failed, subsequent placement of an intrauterine Bakri balloon followed. This combination is termed the uterine sandwich. RESULTS: The uterine sandwich was successful for all 5 patients undergoing this approach. The median nadir hematocrit was 21.1% (range 20.1% to 28%). The balloon was in place for a median duration of 11 hours (range 10-24 hours). The median volume infused into the balloon was 100 mL (range 60-250 mL). No complications were observed. CONCLUSION: Placing an intrauterine Bakri balloon in conjunction with the B-Lynch uterine compression suture was successful in treating uterine atony.