Patient Decision Making

Peter A. Shapiro, MD; Philip R. Muskin, MD
JAMA. 1993;270(20):2432. doi:10.1001/jama.1993.03510200038012.
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To the Editor.  —As consultation-liaison psychiatrists, we took interest in the article by Redelmeier et al1 on patients' decision-making processes. The examples of poor reasoning processes are helpful in understanding many cases, and we appreciate that the article is selective in its examination of the "role of emotion in decision making." We were struck, however, by the near-complete absence of any mention, not only of subtle cognitive impairment per se, but also of psychiatric disorders, psychological conflict, and other sources of emotional disturbance that affect decision making. Depending on patients' predominant personality traits, the experience of illness and treatment may arouse various sorts of anxiety.2 Depression, anger, feelings of disappointment in or rejection by family and caretakers, and other emotional states may affect patients' medical decision making, sometimes to the consternation of all concerned.3,4 Fear may be manifest most dramatically by its denial, along with denial of


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