Shared Decision Making

Learning Objectives - describe various models of clinical decision making - discuss potential benefits of shared decision making - outline a process to follow when incorporating shared decision making into your practice

What are the different models of decision making in health care?

• Paternalistic

  • clinician’s opinion → patient

  • maybe most historically used

• Informative

  • clinician provided info → patient

  • more modern

  • after considering all information given, patient will make a decision

• Shared decision making

  • clinician ← opinion and information → patient

  • arrive at a decision together

What are some pros/cons about the paternalistic method?

• one direction

• doesn’t take into account how the patient feels about it

• some people may not want to have to make a decision and think “Dr knows best”

What are some pros/cons for the informative method?

• one direction

• improvement on paternalistic

  • letting patient make the decision

• patient might want the dr’s opinion

What are the pros/cons of shared decision making?

• two directions

• takes into account how the patient feels and their values on their condition, prognoses and treatment options

  • have an ethical obligation to do so !

When are decision aids best to use?

• ideal when a condition does not have a clear best option

  or

• when individual patient preferences or values may lead to divergent treatment choices

What are the benefits of decision aids?

• Cochrane review showed that patients given decision aides:

  • were more knowledgeable

  • had better perception of risk estimates

  • had a greater likelihood of receiving care that aligned with their values

  • were less likely to be passive in the decision-making process

• potential cost savings

• potential improved adherence/outcomes

• potential improved satisfaction

How often is shared decision being used in out-patient clinical encounters?

• < 9%

• on average, physicians spent ~1 out of 20 minute visit discussing treatment and planning

Steps to shared decision making

• understand a patient’s experience

• develop a relationship/partnership

• provide evidence

  • including uncertainty

• present recommendations

• check for understanding and agreement

How to go about understanding the patient’s experience?

• take a thorough patient history

  • helps you frame certain risk/benefits to them specifically

• Can ask patient’s directly to get further information

  • to learn about their goals

  • to see what they want in the future

  • to see how they feel about medication use

  • to see where they stand on risk/benefit

How to develop a relationship/partnership?

• be patient focused and not medication focused

• ask questions about their background

  • employment, family, recreational interests

• focus on patient’s reason for being there

  • start with issue/problem/concern instead of their bag of meds

• avoid rapid fire, check list-type questions

  • a patient may feel like you don’t care and aren’t listening

How to properly provide evidence to a patient?

• define everything

  • don’t assume the patient understands terms like “stroke” or “heart attack”

• provide baseline risk with no therapy

  • using validated risk tool

  • if not, use the event rate in a placebo arm to give rough approx

• provide benefits and harms of therapy

• provide information in several ways

  • verbal

  • pictures/diagrams

  • written

  • decision aids

How to discuss if there is any uncertainty?

Indicate when there is any uncertainty in the estimates of benefit and/or harm.

• It is unclear, but this is my view of the dilemma…

• even though evidence is divided on this issue, i think we can still make a reasonable decision…

How to present your recommendations?

• straight forward and include your evidence, and the patients wants.

How to assess for understanding?

• ask the patient to repeat the information back to you

• give the patient time to reflect and schedule a follow-up

  • can give supplemental information

  • especially helpful in terms of preventative medications

• Ask:

  • does that make sense to you?

  • do you see things differently?

Shared decision making caveats?

• always be aware of pre-existing relationships with other health-care providers

  • could you be damaging their therapeutic relationship with the patient?

• recognize when patients prefer a more direct approach