adrian edwards shared decision making in cardiology: training workshop
TRANSCRIPT
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Adrian Edwards
Shared Decision Making in Cardiology: Training Workshop
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Workshop outline
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Part One
Introduction & Workshop Overview
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Aim & Learning Outcomes
Aim
In-depth skills training in shared decision making
Learning Outcomes
Have understood and practiced a number of core skills in SDM in Preventive Cardiology context
Have worked on the ‘next steps’ for you and your training
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Housekeeping
• Use of the workbook
• Microskills & clinical scenarios
• Role of feedback
• One caveat…
• Responsibilities as learners
• Workshop evaluation
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Exercise
What makes a good decision?
5 minutes
Page 7 in workbook
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Definition of SDM
“Shared decision making is an approach where clinicians and
patients communicate together using the best available
evidence when faced with the task of making decisions, where
patients are supported to deliberate about the possible attributes
and consequences of options, to arrive at informed preferences
in making a determination about the best action and which
respects patient autonomy, where this is desired, ethical and
legal”
Wikipedia, 2010
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Models of Clinical Decision Making in the Consultation
Paternalistic Informed ChoiceShared Decision Making
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I’m fairly sure we made this decision for you last week?
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SDM – Why do we do it ?
Evidence:• Cochrane Review of decision support (O’Connor, 2009; Stacey
2011):
– Improves knowledge and more accurate risk perception
– Increases participation and comfort with decision
– Fewer undecided
– Reduces uptake of elective surgery
• Improves adherence to medication (Joosten, 2008)
• 48 % inpatients & 30 % outpatients want more involvement in decisions about their care (CQC Patient surveys)
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Are patients involved?
Wanted more involvement
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Shared decision making
‘Involving the patient in the decision making, to the extent
that they desire’
Key skills or ‘competences’
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Case Study 1 – cardiovascular risk
• Mr Jones consults his GP for check up on blood pressure and cholesterol levels, motivated by the fact that his father suffered a heart attack at age 52. No other first degree relative has coronary heart disease. Mr Jones is 55 years old and has no history of any disease. He quit smoking ten years ago, and he is renowned for his skills in orienteering. He has no symptoms and does not take any medication.
• At the first consultation his blood pressure is 160/90 mmHg, total-cholesterol 7.9 mmol/l and non-fasting glucose is 5.3 mmol/l. Mr Jones gets a medical workup including physical examinations, repeated blood pressure measurements and fasting blood tests, and he receives dietary advice.
• After three months there has not been much of a change. Blood pressure is still 158/96 mmHg, total cholesterol 7.5 mmol/l, HDL cholesterol 1.1 mmol/l, LDL cholesterol 6.1 mmol/l, triglycerides 2.0 mmol/l, glucose 4.3 mmol/l, body mass index 24.5, and hip waist ratio 1.1. His electrocardiogram is normal.
• .
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Case Study 2 – cardiovascular risk
• Mrs Jones consults her GP for check up on blood pressure and cholesterol levels, motivated by the fact that her father suffered a heart attack at age 52. No other first degree relative has coronary heart disease. Mrs Jones is 55 years old and has no history of any disease. She smokes 10/day, although used to be fit as a swimming teacher. She has no symptoms and does not take any medication.
• At the first consultation her blood pressure is 160/90 mmHg, total-cholesterol 6.4 mmol/l ; ratio chol/HDL = 8 (high); and non-fasting glucose is 5.3 mmol/l. Mrs Jones gets a medical workup including physical examinations, ECG, repeated blood pressure measurements and fasting blood tests;
• QRISK score = 15% over 10 yrs; QD score = 1% for DM over 10 yrs.
• She returns for discussion about the risk factors and what to do next .
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Part Two
Core Skills in SDM
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Key assumptions in SDM
1. An informed patient is desirable and important to you as a health care professional
2. Engaging patients in treatment decisions where there are real options is a desired goal and health care professionals need to support individuals to achieve this
3. A patient who is not informed of the possible consequences of the options is not able to determine what is important to them
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Three Key stages in SDM
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ChoiceTalk
OptionTalk
Preference Talk
Decision Support Brief & Extensive
Good Decision
D E L I B E R A T I O N
Prior Preferences
Informed Preferences
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Part Three
Choice Talk Practice Session
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Choice talk 35 minutes
Core skills
• Step back
• Choice exists
• Justify choice & signpost ‘what’s important to
you’
• Check reaction
• Defer closure
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Part Four
Option Talk Practice Session
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Option Talk 35 minutes
Core Skills
• Check existing knowledge
• List options
• Describe options
• Describe benefits and harms
• Provide decision support
• Summarise and check next step
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Part FivePreference Talk Practice Session
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Preference talk 15 minutes
Core Skills
• Focus on preferences “what is important to you?”
• Moving to a decision
• Review
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Part SixPractice Session – practicing all the skills
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Part SevenWorkshop Summary
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Where does this lead?