Shared Decision Making Notes

Shared Decision Making

Introduction

• Shared decision making is a collaborative process between patients and healthcare providers.
• Objectives:
  • Understand the nature of shared decision making.
  • Explain the importance of shared decision making.
  • Understand the challenges involved.
  • Describe the main steps in shared decision making.
• Refer to Chapter 14 of Hoffman et al.'s "Evidence Based Practice Across the Health Professions" for more details.

Three Approaches to Decision Making

1. Paternalistic Care (Traditional Model)

• Physicians make decisions considered best for the patient.
• Patients are passive recipients with little involvement.
• The healthcare professional is in control and provides information selectively.
• The physician makes decisions and expects patient compliance.

2. Patient-Centered Approach

• Places the patient at the center of healthcare.
• Clinicians gather comprehensive information about the patient, including their conditions and circumstances.
• Information about diagnosis and management is shared to enable informed choices.
• Effective communication is crucial for shared decision making.

3. Informed Patient (Independent Patient Approach)

• The health professional presents the facts, and the decision rests solely with the patient.

Summary of Decision-Making Approaches

• Decision can be made:
  • Solely by the patient.
  • Solely by the physician.
  • Jointly (shared decision making).
• Evidence-based practice requires patient involvement and consideration of their preferences.
• Informed decisions require patients to know the benefits, risks, and uncertainties of their options.

Core Elements of Shared Decision Making

• Partnership.
• Respect.
• Choice.
• Empowerment.
• Focus on the patient, not just their clinical condition.

Value of Shared Decision Making

• Most valuable when:
  • There's a tradeoff between different benefits and risks.
  • Evidence is uncertain.
  • Patient values and preferences are important.

Clinician's Role in Enabling Informed Decisions

• Provide clinically relevant information in an understandable way.
• Patients need to know:
  • The natural history of their condition.
  • What happens if they choose to do nothing.
  • Possible options.
  • Benefits and harms of each option (quantified wherever possible).

Steps in Shared Decision Making

1. Determine the Patient's Desired Level of Involvement:
   • Not all patients want to be actively involved.
2. Explain the Options:
   • Include the option of doing nothing.
   • Explain likely outcomes of each option.
3. Explain Benefits and Harms:
   • Quantify benefits and harms.
   • Refer to Module 10 (communicating risks and benefits).
4. Use Clinical Decision Support Tools:
   • If available, use tools to communicate information effectively.
5. Assess Patient's Perspective:
   • Ask how the patient weighs benefits and risks.
   • Determine which choice the patient is most comfortable with.
6. Ensure Sufficient Information:
   • Check if the patient has enough information.
   • Ask if there's anything else they want to know.
7. Address Misconceptions:
   • Patients often overestimate benefits and underestimate harms.
   • Shared decision making helps align expectations with evidence.
8. Promote Conservative Choices:
   • Informed patients tend to choose more conservative options.
   • Reduces inappropriate use of tests and treatments, and over-diagnosis and over-treatment.

Decision Support Tools

• Risk calculators.
• Evidence summaries.
• Communication frameworks.

Decision Aids

• Comprehensive tools designed to facilitate shared decision making.

PREDICT (New Zealand Risk Calculator)

• Developed by Professor Rod Jackson.

• Online cardiovascular risk calculator based on the GATE framework.

• Uses data from New Zealand general practice patients, updated continually.

• Includes hospitalization and mortality data.

• Variables:

  • Gender, age, ethnicity, family history, smoking status, diabetes status.
  • Systolic blood pressure.
  • Ratio of total cholesterol to HDL cholesterol.
  • Atrial fibrillation.
  • Use of antihypertensive, lipid-lowering, and antithrombotic medications.
  • Modified index of social deprivation.

• Estimates individual cardiovascular risk and calculates the impact of interventions (e.g., stopping smoking, statins).

Other Risk Calculators

• Generally less sophisticated, using checklists of risk factors.

Guidelines and Communication Frameworks

• Summarize evidence for investigations and treatments.
• Help patients ask appropriate questions.

Australian Ask, Share, Know

• Guide for patients:
  • What are my options (including waiting and watching)?
  • What are the benefits and harms of each option?
  • How likely are each of those benefits and harms to happen to me?

Decision Aids

• Communication tools that assist patients in making health decisions.
• Contain information on options, benefits, and harms.
• May include exercises to help patients clarify preferences.
• Formats: pamphlets, videos, internet resources.
• Decision aids alone do not guarantee shared decision making, and shared decision making can occur without decision aids.

Example: Decision Aid for Enlarged Prostate

• Provides information on:
  • Watchful waiting.
  • Medications.
  • Surgery (benefits and risks).
• Highlights potential adverse consequences of surgery: $20\%$ dissatisfied, $2-7\%$ urinary incontinence, $5-10\%$ impotence or erectile problems.
• Requires patients to weigh risks against potential gains.

Understanding Probability and Risk

• Health professionals and patients may understand probability differently.
• Patients may personalize risk rather than see it statistically.
• Patients may misinterpret statistical information.

Strategies for Simplifying Information

• Probability: The chance of an event occurring (values between 0 and 1).
  • Example: $0.5 = 50\%$.
• Single Probability: The probability of a single event.
  • Example: $20\%$ chance of a side effect.
  • Misinterpretation: Patients may think they will experience the side effect $20\%$ of the time.
• Conditional Probability: The probability of an event given another event has occurred.
  • Example: $90\%$ chance of a positive screening test if a person has a disease.
• Natural Frequencies: Overcome misleading interpretations.
  • Example: "Out of 100 patients, 20 will experience this side effect."
• Relative Risk: Can be misleading; for example, a warning about third-generation oral contraceptives doubling the risk compared to second-generation contraceptives.
  • The media failed to communicate that the baseline risk was very low.

Numbers Needed to Treat

• Clinically useful for professionals but difficult for patients to understand.

Verbal vs. Numerical Presentation

• Meta-analysis showed verbal descriptors (e.g., "very common") overestimated adverse event probability.
• Numerical presentations led to more satisfaction and adherence.
• Caution against using qualitative descriptors (e.g., "low risk") without clear explanations.

Framing of Information

• Positive Framing: Focuses on benefits or gains.
  • Example: $80\%$ of patients will benefit.
• Negative Framing: Focuses on who will not benefit or who will be harmed.
  • Example: $20\%$ may experience a side effect.
• Positive framing is more effective for promoting prevention behaviors.
• Use the same denominator when presenting information.

Nature of the Risk

• High consequence risks (e.g., being struck by lightning) invoke strong emotional reactions.
• Compare risks with more familiar risks to help patients put them into perspective (e.g., risk of dying from any cause in the next year).

Strategies for Improving Risk Communication

• Be open about uncertainty.
• Present natural frequencies (e.g., 3 out of 100 people).
• Define the time scale and denominator for single probabilities.
• Use absolute risk (e.g., absolute risk reduction) instead of relative risk.
• Avoid "number needed to treat."
• Use visual aids to assist understanding.
• Present information in terms of both positive benefits and negative harms.
• Use multiple formats (verbal, written, visual).
• Use the same denominator for positive and negative outcomes.
• Avoid qualitative risk descriptors or supplement with quantitative information.
• Put the risk in perspective by comparing it to other events.
• Avoid presenting too much information.

Challenges to Shared Decision Making

• Insufficient or no evidence about benefits and harms.
• Patients cannot be involved (e.g., medical emergency).
• Patients do not wish to be involved.
• Health professionals may be frustrated if patients make choices they perceive as wrong.

Shared Decision Making vs. Informed Consent

• Shared decision making is an exchange of information and negotiation of treatment options, integrating patient preferences and medical expertise.
• Informed consent is primarily for clinical protection, confirming consent to proceed after assessing risks, benefits, and costs.

Conclusion

• Shared decision making is central to patient-centered care and evidence-based practice.
• It involves collaboration and joint decision-making.
• Steps include:
  • Communicating the need for a decision.
  • Explaining options, benefits, and harms.
  • Eliciting understanding.
  • Discussing patient experiences, expectations, preferences and values.
  • Incorporating these elements into the decision-making process.
• Shared decision making leads to:
  • Greater knowledge of options.
  • More realistic expectations.
  • Choices that reflect personal values.
  • Improved communication.
  • Reduced decisional conflicts.
• Decision support tools, like decision aids, can help, but do not guarantee shared decision making.
• Communicate statistical information in an understandable way using natural frequencies and visual aids.
• Consider the patient's preferences, health literacy, and suitability of the format for their needs.