Toward Shared Decision Making as the Norm: What we All Can Do

1. Toward Shared Decision Making as the Norm: What we All Can Do Thomas Workman, Ph.D., American Institutes for Research

2. How Do We Make Decisions? • We collect information. • We categorize information into reasons for and reasons against. • We weight the list by our likes, dislikes, and values. • We seek advice and opinions of others.

3. How Do We Share Decisions? Clinicians: • Provide information about the benefits and potential harms of options • Connect the evidence to what is known about patient • Offer their professional opinion, recommendation, and reasoning Patients and Caregivers: • Provide information about health history, goals, and lifestyle • Share their thinking about trade offs based on their preferences and values • Offer their personal opinion, concerns, and reasoning

4. The Goals of Shared Decision Making • A patient fully understands the potential benefits and harms of each option. • A patient applies their personal preferences, life circumstances, and values when making a choice. • Both patient and provider reach a mutually satisfying decision in which both have confidence. Informed Decision Making Foundation, (2012, February 12). Introduction to Shared Decision Making & Decision Aids. Available at: http://www.informedmedicaldecisions.org/imdf_provider_tool/an-introduction-to-shared-decision-making-and-decision-aids/

5. What are the benefits of SDM? “Shared decision making has the potential to provide numerous benefits for patients, clinicians, and the health care system, including increased patient knowledge, less anxiety over the care process, improved health outcomes, reductions in unwarranted variation in care and costs, and great alignment of care with patients’ values.” Lee & Emmanuel (2013, NEJM)

6. The SDM Process Informed Decision Making Foundation, (2012, February 12). Introduction to Shared Decision Making & Decision Aids. Available at: http://www.informedmedicaldecisions.org/imdf_provider_tool/an-introduction-to-shared-decision-making-and-decision-aids/

7. Applying Patient Preferences and Values • Length of Life versus Quality of Life • Life Goals and Aspirations • Real Time Goals and Needs • Caregiver Support • Personal Preferences for Treatment Modalities • Fears, Anxieties, and Concerns • Cost Factors

8. Making SDM the Norm PATIENTS/CAREGIVERS CAN: • Clarify the role they wish to take in decision making • Provide the clinician with as much information as possible about their history, interests, values, and preferences • Ask questions when they do not understand or need more information • Communicate openly and honestly when they need more time or information to think about options • Clarify their own criteria for decision making

9. Making SDM the Norm CLINICIANS CAN: • Ensure that the patient/caregiver understands the decision before them • Invite the patient and caregiver to actively participate in the process of decision making • Provide all possible options and the known benefits and risks and utilize existing materials to support DM • Incorporate patient/caregiver values and concerns into the decision

10. Making SDM the Norm HEALTH CARE ORGANIZATIONS CAN: • Identify critical conditions and decisions that warrant shared decision making procedures and build them into the work flow (use patients/caregivers to help!) • Ensure there is adequate time and incentives for clinicians to engage their patients in decision making • Provide decision support tools that can assist the shared decision making process • Employ decision coaches and navigators to assist the process

11. Making SDM the Norm THE COMMUNITY CAN: • Engage in conversations about critical health care decisions and the issues they raise • Support organizations and clinicians who incorporate shared decision making into practice • Encourage community members to actively participate in the decisions about their health and care • Educate the community about how to make decisions with clinicians, how to consider trade offs, and how to ask questions

12. www.pateintfamilyengagement.org

13. Decision Aid Resources • Informed Medical Decisions Foundation. http://www.informedmedicaldecisions.org/shared-decision-making-in-practice/decision-aids/ • Effective Health Care Program, Agency for Healthcare Research and Quality www.effectivehealthcare.ahrq.gov • Mayo Clinic http://shareddecisions.mayoclinic.org/ • Ottawa Health Research Institute. www.ohri.ca/programs/clinical_epidemiology/OHDEC/default.asp.

14. Policy Resources O’Malley, AS, Carrier, ER, Docteur, E, Shmerling, AC, and Rich, EU. Policy Options to Encourage Patient-Physician Shared Decision Making. National Institute for Health Care Reform Policy Analysis Brief No. 5 (2011, September. Available at http://www.nihcr.org/Shared-Decision-Making

15. Bibliography • Braddock, Clarence H., “The Emerging Importance and Relevance of Shared Decision Making in Clinical Practice,” Medical Decision Making, Vo. 30, No. 5 (Supplement) (September/October 2010). • Bryant GD, Norman GR. Expressions of probability: words and numbers. N Engl J Med 1980;302:411. • Charles C, Gafni A, Whelan T. Shared decisionmaking in the medical encounter: what does it mean? (or it takes at least two to tango). SocSci Med 1997;44:681-92. • Charles C, Gafni A, Whelan T. Decisionmaking in the physician-patient encounter: revisiting the shared treatment decisionmaking model. SocSci Med1999;49:651-61 • Coulter A, Entwistle V, Gilbert D. Sharing decisions with patients: is the information good enough? BMJ 1999;318:318-22. • DeberRB, Kraetschmer N, Irvine J. What role do patients wish to play in treatment decision making? Arch Intern Med 1996;156:1414-20. • ElwynG, Edwards A, Kinnersley P, Grol R. Shared decision making and the concept of equipoise: the competences of involving patients in healthcare choices. Br J Gen Pract2000;50:892-9. • EntwistleVA, Sheldon TA, Sowden A, Watt IS. Evidence-informed patient choice. Practical issues of involving patients in decisions about health care technologies. Int J Technol Assess Health Care 1998;14:212-25. • Feldman-Stewart D, Kocovski N, McConnell BA, Brundage MD, Mackillop WJ. Perception of quantitative information for treatment decisions. Med Decis Making 2000;20(2):228-38 • Grimes DA, Snively GR. Patients' understanding of medical risks: implications for genetic counseling. ObstetGynecol 1999;93:910-4. • Sheridan SL, Harris RP, Woolf SH, for the Shared Decisionmaking Workgroup, Third U.S. Preventive Services Task Force. Current methods of the U.S. Preventive Services Task Force: a review of the process. Am J Prev Med 2004;26(1):56-66. • Teno, Joan M., et al., “Medical Care Inconsistent with Patients’ Treatment Goals: Association with 1-Year Medicare Resource Use and Survival,” Journal of the American Geriatrics Society, Vol. 50, No. 3 (March 2002). • Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA 2001;285:2750-6.