"What would you do?" and Values Elicitation

How I Practice Video Series 
Brownsyne Tucker Edmonds, MD, MPH, MS, FACOG
Indianapolis, IN

One of the most dreaded questions that a doctor can hear is a patient asking, “what would you do?” It is a question that doctors are really reluctant to answer. In part, I think they don’t want to have undue influence on the patient’s decision making and in part, I think it is just an uncomfortable situation that no one really wants to engage fully. But I think the danger of just avoiding the question is that it can then leave patients feeling abandoned and maybe bearing a degree of responsibility or a load that some research suggests that they are not really prepared to take full responsibility for. Most patients are looking for the opportunity to have some guidance and have sort of a shared decision making model in these settings. When they ask “what would you do,” the advice that I would give to doctors in terms of how to navigate that slightly uncomfortable moment is to first make sure you understand why they ask.  What would you do could be as clear as the question that they articulate but it may actually be something more subtle. This notion of “what would you do for someone that you really cared about, someone in your family, someone that you love?” It may be a question that speaks to issues or concerns about trust. It may be a question about, a request for more support or reassurance. So it is worth taking a moment to clarify the question: “When you ask me what would you do, what are you hoping to learn or what’s it going to help you to understand in my response?” The next thing that I would suggest is to make sure that you figure out what the real question is: “What would I do if I were me? Or what would I do if I were you? understanding that those are two really distinct and different sets of considerations. If the question is what would I do as me, recognizing that my values may be completely different than yours,” then that poses the provider, the physician, with the question how much am I willing to share with the patient about what my values are, the things that I would consider, and what my reasoning would be in drawing the conclusion that I would draw for myself or for my loved one. But often times the more important question in this situation is “what would I do if I were you,” and the reality is we can’t answer that question without having a clear sense or at least a little bit of a conversation with the patient about what their values and what their goals are. So “what would I do if I were you?” begs the question, well it really does depend on what your goals are here and what you value.  And then I think rather than just leaving it there, which is what I have often observed in a lot of the research that I’ve done, it opens the door to actually try to figure out what the patient’s goals are and what they value. It’s an opportunity for values elicitation. One of the strategies that can be useful is to then evoke a hypothetical patient: “well, I’ve taken care of patients that were faced with this resuscitation decision and they feel like they are always going to wonder what if we would have tried maybe they would have made it, maybe we should have given them the chance to fight, and for patients that tell me something like that, rather than carry that anxiety and that burden forward, an attempt at resuscitation is probably the right thing to do. But I’ve also taken care of patient who have told me that ‘I just can’t imagine that if the chances that my baby are going to survive are that low, I’m not sure it’s the right thing to put them through so much potential pain, potential suffering, that just doesn’t seem like right thing that I would want for my child.’ So you know, when I talk to patients who are telling me things like that it makes sense to pursue comfort care and make sure that no matter how short the baby’s life that it is one that is comfortable and that they experience love in it. So both of those decisions are ones that come from a place of compassion and care, from a place of love and concern from a parent. Neither one of them is right or wrong. The really important thing in terms of ‘what would I do if I was you?’ kind of depends on which of those patients sounds more like you. Which kind of concerns are most important to you.”

So those are the kind of strategies that I’d use in terms of navigating the “what would I do?” question, it’s not just to leave it at “it depends on your values, it depends on what is important to you” but to take it one step further and try to use some techniques to understand whether or not you can help the patient to bridge those values to a management strategy that aligns with what it is that is their primary concerns and that’s the way that I practice. 

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