Diabetes Management: Facing Tough Decisions
I was intrigued by an article ("Grave Decisions" written by David J. Craig) in my winter medical school alumni news (Columbia Magazine, Winter 2010-2011, pages 21-25). The article focused on decision- making and that contrary to what one might infer, too many choices may not be in one's best interest. The article discussed the work of Columbia University's Dr.Sheena Iyengar in regard to human decision-making. Her landmark article in The Journal of Consumer Research, Volume 36, October 2009, discussed the cultural differences between the United States and France in regard to decision-making in critical medical situations. In the study, the authors looked at end-of-life decisions with premature infants and how parents arrived at the final choice. Interestingly enough, the authors found crucial differences in terms of decision-making in the two countries. In the United States, physicians have embraced parental decision- making autonomy requiring parents to decide their child's treatment, whereas in France, physicians have adopted a more "paternalistic" approach leaving treatment decisions to the physicians. Iyengar wanted to know how parents coped emotionally afterwards. Did the parents have better adaptation if they personally made the decision or if the physician had the final decision? Did they wish that a physician had given them more or less advice?
The study demonstrated that 3 months after the death of their infant, American parents struggled with more anxiety, guilt, and depression. The French parents were coping better and believed their child's death was inevitable. According to Iyengar, the conclusion was "that it's comforting to receive guidance from an expert in a stressful situation." How does this information relate to decision-making in diabetes management?
Decision-making is a complex process. Given too many choices, many individuals choose not to make a choice due to the overwhelming possibilities. In one of Iyengar's earlier studies as a graduate student at Stanford University, she noted that when an individual was given an overwhelming amount of jam choices (40), they often left the gourmet store without any jam. If they were given only 6 choices, more often than not, they made a choice and actually purchased the jam. That leaves the simple notion that when given fewer choices, many individuals are more comfortable. In addition, most individuals are more comfortable making choices in which they are more familiar in terms of experience, which may not necessarily be the appropriate response.
When confronted with a new diagnosis of diabetes, it is often overwhelming. There is an enormous amount of information taught at the beginning (one of our patient's lamented that they could only retain 1 percent of the information that was "thrown" at them and that there were TOO many choices). Families (and medical personnel) go directly to the Internet and "google" diabetes with millions of hits!
Which site is best?
Which applies to MY situation?
Which meter should I use?
Is there a best one?
Which treatment plan is best? For type 2 DM, for type 1 DM?
Do I start a low-carb diet?
Do I carbohydrate count?
Do I demand an insulin pump (because that must be the best)?
I could write 100 more questions that plague parents/children and adults. In essence, too many choices may be paralyzing!
What were the final comments of Dr. Iyengar in her Journal of Consumer Research Study? Both the autonomy and paternalistic approaches appeared to be extreme and that a more nuanced approach was suggested in decision-making. Once again, this is directly applicable to diabetes management. As I have reiterated in many blogs, diabetes management is a team approach. By reverting to the autonomy approach in which families are personally responsible for making choices with little input from their diabetes team, it is my belief that there are significant "missed opportunities." Families often walk into their appointments with reams of Internet papers and articles strongly suggesting a certain form of treatment. On the other hand, the paternalistic approach in which the physician and team reverts to the "father knows best" mantra also is inappropriate. The key for the diabetes team is to sift through the many treatment decisions and offer a limited sampling of the best options. In this manner a "dance of sorts' can occur in which the family/person with diabetes or the diabetes team may take the lead at different times during the course of their therapeutic relationship.