Shared Decision Making in Healthcare

Objectives

Understand the nature of shared decision making.
Explain the importance of shared decision making.
Understand the challenges in sharing clinical decisions with patients.
Describe the main steps in shared decision making.
Reference: Chapter 14, Evidence Based Practice Across the Health Professions by Hoffman et al.

Approaches to Decision Making

1. Paternalistic Care (Traditional Model)

Physicians make decisions considered best for the patient.
Healthcare professional controls intervention and implementation.
Patients are passive recipients.
Physician makes the decision; patient expected to comply.

2. Patient-Centered Approach

Places the patient at the center of healthcare.
Clinicians gather understanding about patient's conditions and circumstances.
Shares information about diagnosis and management.
Effective communication is central to enable shared decision making.

3. Informed Patient or Independent Patient Approach

Health professional presents facts.
The decision rests solely with the patient.

Summary of Decision-Making Models

Decision by patient alone.
Decision by physician alone.
Decision jointly made: shared decision making.
Evidence-based practice requires patient involvement and consideration of preferences.
Patients need to know benefits, risks, and uncertainties of options.
Shared decision-making focuses on partnership, respect, choice, and empowerment.
Focus is on the patient, not the clinical condition.

Value of Shared Decision Making

Most valuable with trade-offs of benefits and risks.
When evidence is uncertain about the best choice.
When patient's values and preferences are important.
Clinicians provide clinically relevant information that patients can understand.
Patients need to know:
- Natural history of their condition.
- What happens if they do nothing.
- Possible options.
- Benefits and harms of each option (quantified where possible).

Steps in Shared Decision Making

Determine Patient Involvement: Degree to which the patient wants to be involved.
Explain Options: Including doing nothing and the likely outcome of each.
Explain Benefits and Harms: Of each option, referencing communication of risks and benefits (Module 10).
Use Clinical Decision Support Tools: To help communicate information.
Assess Patient Preferences: How benefits and risks weigh up for them.
Check Understanding: Ensuring the patient has enough information.
Address Misconceptions: Patients tend to overestimate benefits and underestimate harms.
Promote Conservative Choices: Fully informed patients choose more conservative options.
Reduce Inappropriate Use: Of tests and treatments, reducing 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 using the GATE framework.
Uses data from New Zealand general practice patients, hospitalization data, and deaths.
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 (income, employment, social support, living space).
Estimates cardiovascular risk and calculates the change in risk with intervention.

Other Risk Calculators

Generally less sophisticated, using check boxes for risk factors.

Guidelines and Communication Frameworks

Summaries of evidence for different investigations and treatments.
Communication frameworks assist patients in asking appropriate questions.
- Australian Ask, Share, Know:
  - What are my options (including waiting and watching)?
  - What are the possible benefits and harms of those options?
  - How likely are each of those benefits and harms to happen to me?

Decision Aids

Communication tools for patients facing health management decisions.
Information about options, benefits, and harms.
Exercises to help patients consider preferences.
Formats: paper-based (pamphlet), video, internet.
Giving a decision aid does not guarantee shared decision making.

Example: Decision Aid for Enlarged Prostate

Information on benefits and risks of each option:
- Watchful waiting.
- Medications.
- Surgery (significant consequences; 20% not very satisfied; 2-7% urinary incontinence; 5-10% impotence).
Requires the patient to understand and weigh up potential adverse consequences.

Understanding Probability and Risk

Patients may personalize risk rather than seeing it as applying to the population.
Patients may misinterpret statistical information.

Strategies to Simplify Information Presentation

Probability: chance of an event occurring (values between 0 and 1; e.g., 0.5 = 50%).
- Single probability: chance of a single event (e.g., 20% chance of side effect).
- Conditional probability: chance of an event given another event (e.g., screening test positive 90% of the time if a person has a disease).

Using Natural Frequencies

Example: "Of every 100 patients, 20 will experience this side effect."
Reduces misinterpretation.

Relative Risk

Can be misleading.
Example: Third-generation oral contraceptives associated with twice the risk compared to second-generation contraceptives. The media failed to communicate that the baseline risk was very low (15 cases per year per 100,000 users).

Numbers Needed to Treat

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

Verbal vs. Numerical Presentation

Verbal descriptors (very common, rare) overestimate adverse events.
Numerical presentations lead to greater patient satisfaction and adherence.
Caution against qualitative risk descriptors (low, high, frequent) without clear explanation.

Framing of Information

Positive framing: focuses on benefit or gain (e.g., 80% may benefit).
Negative framing: focuses on who will not benefit or will lose/be harmed (e.g., 20% may experience a side effect).
Positive framing is more effective in promoting prevention behaviours.

Important Considerations

Use the same denominator when presenting risks and benefits.
Nature of the risk influences patient reaction (high-consequence risks invoke strong emotional reactions).
Compare risk numbers with more familiar risks.

Strategies to Improve Communication of Risks and Benefits

Be open about uncertainty.
Present natural frequencies (e.g., 3 out of 100).
Clearly define time scale and denominator (e.g., "in one year, 20 in 100 people will have this side effect").
Use absolute risk rather than relative risk.
Avoid number needed to treat.
Use visual aids (pictographs, bar graphs).
Give information in terms of positive benefit and negative harm outcomes.
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 risks in perspective by presenting comparative risks.
Less is more - avoid presenting too much information.

Challenges in Shared Decision Making

Insufficient or no evidence about possible benefits and harms.
Patients cannot be involved (medical emergency, lack of cognitive capacity, or unwillingness).
Health professionals may be frustrated if patients make choices they perceive as wrong.

Differences Between Shared Decision Making and Informed Consent

Shared decision making: exchanges complex information and negotiates feasible treatment options.
Informed consent: confirms consent to proceed for clinical protection; assesses risks, benefits, and costs.

Conclusion

Shared decision making is central to patient-centered care and evidence-based practice.
Steps include explaining options, benefits, harms, discussing patient experiences, and incorporating preferences.
Benefits: greater knowledge, more realistic expectations, choices that reflect personal values, improved communication, and reduced decisional conflicts.
Challenges and myths can hinder shared decision making.
Decision support tools can help, but do not guarantee shared decision making.
Communicate statistical information clearly using natural frequencies, visual displays, and absolute risks.
Consider patient preferences, health literacy, and the suitability of the format.