--- module: 100-03 language: en chapter: 100 title: "Social Psychology, Communication, Culture, and the Behaviour of Health" module_title: "Adherence, placebo and nocebo, risk, consent, and shared decisions" source_sha256: f2c994a5cac6ed1378fbb8455703ae5341f82f0285305165c946e0c94ad39afd --- # Adherence, placebo, risk, consent, and decisions ## Adherence ### Correspondence with an agreed plan ### Plans fail from cost, burden, confusion, goals ### Nonadherent label becomes character judgment ### Initiation, implementation, persistence ### Refill shows possession, container shows opening #### Self-report needs safe disclosure ### Unintentional: forgetting, dexterity, access ### Intentional: side effects, mistrust, preference #### Categories overlap over time ### Ask normalisingly about missed doses ## Regimen design ### Regimen design is a clinical intervention ### Fewer doses, stable routines, fewer medicines ### Usable packaging, supply, missed-dose plan ### Reminders fix memory, not cost or side effects ### Monitoring must not become punitive ### Reliable benefit with minimum burden ## Placebo and nocebo ### Meaning, expectation, learning, context ### Alters symptoms, autonomic, endocrine function #### Illness is not imaginary ### Trial placebo response is broader #### Spontaneous change, regression to the mean ### Nocebo from negative expectation ### Neutral frequency and severity, action to take ### Report affected and unaffected proportions ### Open-label placebo is condition-specific #### Deception undermines trust and consent ### Ethical contextual healing #### Rationale, proportionate confidence, follow-up ## Communicating risk ### Specify outcome, population, period, comparator ### Relative risk versus absolute difference ### Number needed is reciprocal of difference #### Varies with baseline risk, not fixed ### Natural frequencies clarify conditional probability ### Keep denominators consistent ### Icon array design shapes perception ### Verbal labels need numbers ### Framing: survival feels better than mortality #### Avoid relative benefits with absolute harms ### Precision should match evidence ## Shared decision-making ### Recognise, exchange, deliberate, agree or defer ### Key when outcomes similar but burdens differ ### Not a menu without guidance ### Clinician: options and evidence ### Patient: values, circumstances, trade-offs ### Time-critical choices change the form ### Strong recommendation compatible with autonomy #### Clear reasons, refusal not punished ### Inaccessible options transfer burden ### Decision aids support, not replace, talk #### Current evidence, conflicts disclosed, update date ## Decisional capacity ### Specific to decision and time ### Understand, appreciate, reason, communicate ### Not set by diagnosis, age, or disagreement ### Fluctuates with delirium, pain, fear, drugs ### Support and treat reversible causes first ### Stricter threshold for higher stakes #### Not reserved for those who agree ### Substitute uses known values, else best interests ### Restrictions no broader or longer than needed ## Informed consent and emergencies ### Disclosure, comprehension, voluntariness, capacity ### Signed form is evidence, not the process ### Material: purpose, benefits, risks, alternatives #### Reasonable person and personal concerns ### Consent can be withdrawn, not transferred ### Emergency exception is narrow #### Convenience or time pressure is no emergency ### Advance directives preserve autonomy ### Separate clinical, ethical, legal questions ## Trust and integrated practice ### Trust is input and outcome ### Competence, honesty, reliability, care ### Trustworthy practice welcomes questions ### Mistreatment makes scepticism rational #### Rebuild through changed behaviour and systems ### Define the decision and later behaviour ### Elicit understanding, values, constraints, role ### Absolute risks, proportionate recommendation ### Follow outcomes and revisit the choice