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Shared Decision-Making: Empowering Patients in Healthcare

Explore the concept of shared decision-making in healthcare, why it is important, and its relevance to NICE guidance. Understand the tasks involved and the benefits it offers to patients and healthcare professionals.

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Shared Decision-Making: Empowering Patients in Healthcare

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  1. Making decisions with patients Andy Hutchinson

  2. Thought experiment • Imagine an ‘ideal’ tablet • No side-effects, doesn’t cost you anything (£), needs no prescription or medical supervision and can be started or stopped at any point without problem • All you have to do is take one every day for the rest of your life • Without saying anything aloud, write down how much extra lifespan this tablet would have to give you for you to be prepared to take it

  3. Medicines disutility: what’s the trade-off? Fontana M, et al. (2014) Circulation 129: 2539-46 360 members of the general public in north-west London Equal number of men and women, 1% had a history of cardiovascular disease and 22% were currently taking regular medication of some kind. Mean age 38 years Median increase in lifespan required was 6 months (IQR 1 to 36 months) 34% people would take the medicine if it would increase their lifespan by <1 month 12% would take it only if it would increase their lifespan by 10 years or more The authors calculate that 99% of the population would gain <2 years extra lifespan by lifelong statin prophylaxis

  4. What I’m going to cover • Shared decision-making – what it is and what it isn’t • Why should we do shared decision-making? • Shared decision-making and NICE guidance • Your thoughts

  5. What is shared decision-making?

  6. What is shared decision-making? A process in which clinicians and patients work together to select tests, treatments, management or support packages, based on clinicalevidenceand the patient’s informed preferences It includes providing evidence-based information about options, outcomes and uncertainties decision support counselling to clarify options and preferences a system for recording and implementing patients’ informed preferences Coulter A, Collins A, Kings Fund report 2011

  7. Preference-sensitive decisions More than one clinically reasonable and cost-effective treatment or care option exists (including the possibility of no treatment) The choice between options involves the individual person concerned weighing up significant trade-offs according to their preferences and values Wennberg D, Marr A, Lang L, et al (2010) NEJM 363: 1245–55

  8. SDM – Two sources of expertise Coulter A, Collins A, Kings Fund report 2011

  9. What is shared decision-making not? SDM is not • Just ‘being nice’ or just giving information • Handing decisions entirely to the patient or service user • It is a 2-way process that includes supporting the person to think what their priorities are and make a choice consistent with these • A means of saving money • Although some potential efficiencies have been noted • A free-for-all in terms of patient/service user choice

  10. Tasks in shared decision-making The first task of shared decision-making is to ensure that individuals are not making decisions in the face of avoidable ignorance Healthcare professionals and patients generally overestimate the likely benefits of treatments and underestimate the risks Healthcare professionals may ‘misdiagnose’ the patient’s priorities The second task is to support people to deliberate about their options by exploring their reactions to information Some people feel surprised or unsettled by the offer of options and uncertainty about what might be best if all responsibility for decision making is transferred to patients they may feel abandoned Elwyn G, et al. J Gen Intern Med 2012; 27:1361–7

  11. Why should we do SDM?

  12. Consent and the Montgomery judgment Healthcare professionals must take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments The test of materiality is a risk to which a reasonable person in the patient’s position would be likely to attach significance or a risk that the healthcare professional knows — or should reasonably know — would probably be deemed of significance by this particular patient Sokol D (2015) BMJ 350: h1481

  13. SDM is recommended in professional guidance • GMC consent guidance • ‘…you must work in partnership with your patients to ensure good care… • …maximise patients’ opportunities, and their ability, to make decisions for themselves…’ • GPhC standards for pharmacy professionals • ‘give the person all relevant information in a way they can understand, so they can make informed decisions and choices’ • ‘ask questions and listen carefully to the responses, to understand the person’s needs and come to a shared decision about the care [you] provide’ • NMC professional standards • ‘encourage and empower people to share decisions about their treatment and care’

  14. NICE quality standards for SDM (being refreshed) • QS15: Patient experience in adult NHS services (February 2012) • Quality statement 4: Patients have opportunities to discuss their health beliefs, concerns and preferences to inform their individualised care. • Quality statement 5: Patients are supported by healthcare professionals to understand relevant treatment options, including benefits, risks and potential consequences. • Quality statement 6: Patients are actively involved in shared decision making and supported by healthcare professionals to make fully informed choices about investigations, treatment and care that reflect what is important to them. • Quality statement 7: Patients are made aware that they have the right to choose, accept or decline treatment and these decisions are respected and supported.

  15. SDM, guidelines and NICE

  16. NICE guidance on SDM • Patient experience in adult NHS services (CG138, 2012) • Enabling patients to actively participate in their care, tailoring healthcare services for each patient • Service-user experience in adult mental health (CG136, 2011) • Promoting active participation by service-users in treatment decisions and supporting self‑management • Multimorbidity (NG56, 2016) • Individualised care in discussion with the patient • Medicines adherence (CG76, 2009) • Patient involvement in decisions about medicines • Medicines optimisation (NG5, 2015) • Use of patient decision aids NICE guideline on shared decision-making coming 2021

  17. NICE: Guidelines, not tramlines Every NICE guideline states, on its landing page: • The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users • It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

  18. Supporting SDM in NICE guidelines • Updated our guidelines process and methods manuals, to better support shared decision-making through evidence. • Asking guideline developers to: • identify preference-sensitive decision points - those where patients’ values and preferences are likely to be the primary determinant of choice of treatment • publish a summary table of harms and benefits in the guideline to aid discussions about choice of treatments (clinician facing) • NICE decision aids • Additional tools to support shared decision-making (patient facing)

  19. Summary tables in guidelines Brain tumours and brain metastases in adults: NG99, July 2018 Table 2: Factors to take into account when deciding on frequency of follow-up for people with glioma

  20. Antipsychotics and dementia NG97, June 2018

  21. Surgery for stress urinary incontinence orpelvic organ prolapse

  22. Implementing SDM: Lessons from MAGIC Joseph-Williams N et al, BMJ 2017; 357: j1744 ‘We do it already’ ‘We don’t have the right tools’ ‘Patients don’t want shared decision-making’ ‘How can we measure it?’ ‘We have too many other demands and priorities’

  23. Quick discussion How would you respond to a colleague who says • We are doing this already or • Patients don’t want shared decision-making, and anyway, quite a lot of them just aren’t well educated enough

  24. Implementing SDM: Lessons from MAGIC Joseph-Williams N et al, BMJ 2017; 357: j1744 ‘We do it already’ How can we help you do it (even) better? ‘We don’t have the right tools’ Skills trump tools, and attitudes trump everything ‘Patients don’t want shared decision-making’ Many patients feel unable rather than unwilling to share in decision-making Does this statement really reflect reticence on behalf of health professionals? ‘How can we measure it?’ A challenge, but tools do exist ‘We have too many other demands and priorities’ A challenge to leaders and managers

  25. Reflection • Has this session challenged your previous thinking on this topic, or confirmed it? In what ways? • What would ‘good care’ look like in your area of practice? • What will have to change? • What will you need to stop doing? • What will you need to start doing? • What will you need to do more of? • What will you do first?

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