Palliative and Supportive Care cambridge.org/pax Editorial Cite this article: Yan H, Kukora SK, Arslanian- Engoren C, Deldin PJ, Pituch K, Yates JF (2019). Aiding end-of-life medical decision- making: A Cardinal Issue Perspective. Palliative and Supportive Care,1–3. https://doi.org/ 10.1017/S1478951519000981 Received: 27 September 2019 Accepted: 27 October 2019 Author for correspondence: Haoyang Yan, Department of Psychology, University of Michigan, 3071 East Hall, 530 Church Street, Ann Arbor, MI 48109. E-mail: haoyangy@umich.edu © Cambridge University Press 2019 Aiding end-of-life medical decision-making: A Cardinal Issue Perspective Haoyang Yan, M.S. 1 , Stephanie K. Kukora, M.D. 2 , Cynthia Arslanian-Engoren, PH.D., R.N., A.C.N.S.-B.C., F.A.H.A., F.A.A.N. 3 , Patricia J. Deldin, PH.D. 1,4 , Kenneth Pituch, M.D. 2 and J. Frank Yates, PH.D. 1 1 Department of Psychology, University of Michigan, Ann Arbor, MI; 2 Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI; 3 Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, MI and 4 Department of Psychiatry, University of Michigan, Ann Arbor, MI Many challenges exist in bridging communication gaps between clinicians and patients in end-of-life decision-making in which there is a continuum of treatment possibilities (Breen et al., 2001; Pochard et al., 2005; White et al., 2007). The shared decision-making approach has demonstrated the potential for improving decisions to achieve better quality of care (Teno et al., 2004; Thompson et al., 2004; Dowling and Wang, 2005; Makoul and Clayman, 2006). However, sharing of end-of-life decisions in practice happens infrequently due to factors such as time constraints, inadequate communication, clinical situations (e.g., sensitive topics, including end-of-life discussions), and patient characteristics (e.g., older age and poor health condition; White et al., 2007; Joseph-Williams et al., 2014). Additionally, debate regard- ing exactly what shared decision-making entails and how it can and should be adopted into practice has likely also hindered its acceptance by medical providers (Makoul and Clayman, 2006). We propose a new approach — using the Cardinal Issue Perspective on decision- making as a checklist for routinely performing shared decision-making in end-of-life situa- tions. The Cardinal Issue Perspective has the potential to streamline and address important decision-making considerations that may not be fully attended to in current clinical shared decision-making models and practice. The Cardinal Issue Perspective (Yates, 2003), based on the existing extensive literature in decision science, is a comprehensive and well-recognized framework for managing decision processes and ensuring quality. Its utility has been demonstrated in a variety of practical set- tings, including understanding the decision-making of elderly people in value-laden healthcare decisions (Bynum et al., 2014). It theorizes that a decision process must address all 10 cardinal issues in some way, e.g., by deliberation, habit, or social norm. The more adequate the resolu- tions are, the more likely it is that the decision at hand will be successful. A lack of awareness or poor understanding of all 10 cardinal issues by decision makers, however, may result in problematic resolutions. For instance, a patient or a surrogate decision maker who is unaware of palliative medicine options and long-term implications of life-sustaining treatments may later find that the decision is in conflict with personal values and the outcomes not as expected (Teno et al., 2000; Nelson et al., 2005). Therefore, we suggest using the 10 cardinal issues checklist (Yates, 2003) for clinicians, patients, and surrogate decision makers to scrutinize decision-making at each phase to smooth the communication process and maximize the chance of making an effective decision (Table 1 for an end-of-life decision example). Current models (e.g., Makoul and Clayman, 2006) may not fully address all of the cardinal issues, suggesting opportunities to improve shared decision-making. The first three cardinal issues are devoted to setting the stage for decision-making efforts. Need emphasizes bringing up the decision problem at the right time and discussing the urgency of the decision, giving clinicians, patients, and surrogate decision makers opportu- nities to discuss the benefits and risks of watchful waiting vs. actively making a decision, e.g., continuing current treatments and withdrawing life support. In addition to determining decision makers and their preferred level of involvement, Mode encourages not only provid- ing resources to support decision-making (e.g., consultants, decision guide worksheets, and websites) but also discussing the content together to help patients and surrogate decision makers understand issues pertinent to decision-making. Investment refers to kinds and amounts of resources stakeholders contribute in the decision-making process itself. It is not often discussed in shared decision-making models. Quantifying the resources, such as material (time and money) and emotional efforts (stress and pressure), that decision makers can afford to invest in making a decision, will help them manage the decision process and balance other aspects of life. Excessive devotion of resources may result in decision-making burnout and potentially undermine decision makers’ well-being. The next five cardinal issues are regularly reflected in shared decision-making models (Makoul and Clayman, 2006). In current practice, Options (reasonable options), Possibilities https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1478951519000981 Downloaded from https://www.cambridge.org/core. IP address: 104.144.208.66, on 04 Dec 2019 at 13:31:38, subject to the Cambridge Core terms of use, available at