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ACPN Edinburgh
Shared Decision Making Workshop
WelcomeSandra Winterburn
Associate Professor
08/07/2020
Plan
Begin with a short presentation on why Shared Decision Making is so integral to the future of the NHS
Use activities to aid reflection on your own practice –How often you engage in SDM? What are the Myths?Experience Decision Making for yourself
Describe the COD (Choice, Option, Decision) framework for SDM
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Working definition Shared Decision Making (SDM) is a collaborative process in which clinicians and patients work together to select tests, treatments & management, based on clinical evidence and patients’ informed preferences and values.
It explicitly acknowledges the fact that there is usually more than one way to treat a problem, including ‘no treatment’ and patients may require help to weigh up the benefits and harms of the options in order to determinethe best choice for them.
Choosing wisely UK
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BRAN for SDM- What could be more fitting?
The Choosing Wisely principles encourage patients get the best from conversations with their doctors and nurses by asking four questions.
What are the Benefits?
What are the Risks?
What are the Alternatives?
What if I do...Nothing?
This discussion requires skills in patient centred communication and conveying risk
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Drivers for shared decision making – (why)
Healthcare policy- e.g. Liberating the NHS “All patients should be fully involved in decisions about their own care and treatment so that the principle of shared decision-making – ‘no decision about me, without me’ - becomes the norm across the NHS”
NICE and NHS England are working with the shared decision making collaborative to encourage shared decision making across England
Shift from paternalistic medicine to patient centred care
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Drivers for shared decision making – (why)
Ethical - All clinicians have an ethical duty to inform patients about options and elicit their individual preferences
Patient preference-The personal values of individual patients have a huge part to play in any health related decision. What’s right for one person may not be the best option or choice for another.
The most recent NHS patient survey (2019) highlight that despite patients desire to be involved in the decision making process, just over 50% of those surveyed answered yes to the following question:‘Were you involved as much as you wanted to be in decisions about your care and treatment?’
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Drivers for shared decision making – (why)
Financial-SDM leads to a reduction in healthcare costs.Cochrane review (Stacey, 2014) found that people who use decision aids to support their choice of treatment are more likely to choose less invasive options. (Surgery, Medication and Lifestyle choices)
Outcomes-People who are supported to make an informed decision by a healthcare professional have better outcomes, better experiences, and less regret about their decisions (Coulter, 2011)
Patients involved in SDM are much more likely to commit to the plan & adhere to treatment (Wennberg, 2010)
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Drivers for shared decision making – (why)
Self management and empowermentLinks with increased patient satisfaction and ability to self-manage
How often do you think that you actively engage patients in Shared Decision Making?
A. Frequently
B. Occasionally
C. Rarely
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What factors would make you more likely to engage patients in SDM?
A. If patients ask questions about options available
B. If there are two treatments with equal efficacy
C. If the patient is young
D. If the patient has a high level of ‘health literacy’
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Myth #1 Not every one wants to engage in SDM?
A. Agree
B. Neutral
C. Disagree
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Myth #2 SDM is not possible because patients are always asking me what they should do
A. Agree
B. Neutral
C. Disagree
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Myth #3 In SDM, patients are left to make decisions alone & that’s too much pressure for them
A. Agree
B. Neutral
C. Disagree
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Shared Decision Making is not compatible with Evidence Based Practice
A. Agree
B. Neutral
C. Disagree
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The concept of two experts in the
room
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The nature of the partnership between the clinician and the patient is central to the Shared Decision Making process.
Both partners are experts in their own right and each has their own areas of expertise, which the other needs to acknowledge.
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The clinician as an expert
Diagnosis Published literature
Causes of disease Guidelines & Protocols
Prognosis Previous Experience
Treatment options Interpretation of potential risk
Outcome probabilities for population & individual
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The patient as an expert
Ideas, concerns & expectations
Experience of illness
Social circumstances
Attitude to risk
Values
Preferences
What might work best for them as an individual
Experience the dilemmas of decision making for yourself
Disaster strikes!!
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Choice 1
Choice 2
This route will take
2+ days
What would be your Choice?
A. Go over mountain?
B. Around mountain?
C. Split up?
D. None of above
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Influences on your decision making may have included:
• Level of fitness
• Attitude to risk
• Fear of heights
• Fear of spiders (uncertainty)
• Concern / responsibility for others in your party
• Previous experience of similar situations
• The influence of group members
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A Model for Shared Decision Making (how)
“Were you aware that
there were different
options?”….
“For us to make the
right decision I would
like you to be
involved in
discussing the
options available”
“It is
possible to
do three
things in this
situation, let
me list them
quickly
before I
describe
each one in
more detail”
Deliberation
Relates
discussion of
decisions to the
patients Ideas,
Concerns and
Expectations
(ICE) elicited in
brief history
taking
“So what is
your thinking
about the
options I
have
outlined?
“What might
suit you
best?”
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COD Step by Step
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Examples of Preference Sensitive decisions
Mr Matsuka, 73 year old retired solicitor. BMI 30, type 2 diabetes
Recently diagnosed with rectal cancer, presented to GP with 2-3 month history change in bowel habit, noticed over the past few weeks, blood mixed within stool.
MRI shows low rectal cancer at 4-5cm from anal verge, less than 1mm from margin, no evidence of lymph node involvement or metastatic disease.
Flexi sig revealed bulky but mobile tumour at 4-5cm, ulcerating and semi-circumferential. Histology confirms moderately differentiated adenocarcinoma/EMVI (extra mural vascular invasion) positive.
Possible decisions: straight to surgery or neoadjuvant chemoradiotherapy
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When should SDM be used?
Shared decision making is most appropriately applied under conditions of uncertainty. Uncertainty can arise when a decision is described as preference sensitive
That is, when medical evidence and clinical expertise suggest that there is more than one medically reasonable option, and the choice of which option is best for a given patient depends on his or her preferences, values, characteristics, and circumstances.
Equipoise
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Shared Decision Making has failed if…
The clinician cannot articulate and contextualise the patient's ideas, expectations, values and beliefs
The patient cannot articulate the options available to them, and the benefits and harms of each option
Lack of mutual understanding has led to more confusion over what direction to take
In summary
Shared decision making requires working with your existing communication skills …..not a completely different set of skills
In order to truly engage in patient partnership you have to be willing to listen to patients’ opinions and be influenced by what you hear
This involves a shift from ‘what is the matter… to what matters most’
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Thank you
Any Questions?
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References
Department of Health. Equity and excellence: Liberating the NHS
Elwyn G, Dehlendorf C, Epstein RM, et al. Shared decision making and motivational interviewing: achieving patient-centered care across the spectrum of health care problems. Ann Fam Med 2014;12(3):270-275.
Elwyn G, Laitner S, Coulter A et al. Implementing shared decision making in the NHS. BMJ 2010;341:c5146
Elwyn G, Durand M A et al A three-talk model for shared decision making: multistage consultation process BMJ 2017;359:j4891
Légaré F, Thompson-Leduc P. Twelve myths about shared decision making. Patient Educ Couns 2014;359:281-6.
O'Connor A, Stacey D, Entwistle V et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD001431.
Say R, Murtagh M & Thompson R. Patients’ preference for involvement in medical decision making: A narrative review. Patient Educ Couns 2006 Volume 60, Issue 2, February 2006, Pages 102-114
Stacey D, Légaré F, Col N, Bennett C, Barry M, Eden K, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2014;1. CD001431.
Wennberg J, Song Y, Skinner J et al. Regional variations in diagnostic practices. N Engl J Med. 2010 Jul 1;363(1):45-53.
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Resources
Better Medicine https://www.bmj.com/bettermedicinercgp
Better Medicine builds on the BMJ’s Too Much Medicine initiative and highlights evidence-based tools for use alongside existing guidelines. Publishes blog posts to deal with the practical and philosophical considerations connected with shared decision making and over diagnosis.
Choosing Wisely https://www.choosingwisely.co.uk/resources/shared-decision-making-resources/
Choosing Wisely UK brings together a range of patient and health related organisations from across the country and is hosted at the Academy of Medical Royal Colleges, the coordinating body for the UK and Ireland’s 24 medical royal colleges and faculties.
Kings Fund https://www.kingsfund.org.uk/publications
Coulter A and Collins A. Making Shared Decision Making a Reality; No decision about me without me.
Winton Centre for Risk and Evidence Communication https://wintoncentre.maths.cam.ac.uk/
To make good decisions, we all need good evidence which is clearly communicated. At the Winton Centre we work with institutions and individuals to improve the way that important evidence is presented to all of us.
