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