Shared Decision Making Towards better outcomes

Paul Myres

Academy of Medical Royal Colleges Wales

Better Conversations

Better decisions

Better outcomes

Less waste, more value

Sub-optimal care for patients of low value results from :

Inappropriate clinical (and social) interventions

Culture of over-medicalisation

Poor application of evidence

Patients not involved enough in clinical (and other) decisions

More is not always better

Patients: unaware of treatment

or management options and outcomes

Clinicians: unaware of patients’

circumstances and preferences

The Unknowns

Mulley et al, King’s Fund, 2012

One in three patients feel uninformed about their treatment

About half want more involvement in decisions about their care

Patient Information Forum 2015

Clinicians and patients

working together to select

tests, treatments,

management or support

options based on clinical

evidence and the patient’s

informed preferences.

Suspicion – rationing by another name

Over confidence – I do it already

“Doctor know best”

Fear of being sued – I’ll get done, if it doesn’t work

Lack of time – it takes too long

Lack of good (accessible) information

Desire to reach targets

What are my options?

What are the benefits and harms?

Do I really need this?

What can I do to help myself?

INFO -Research evidence, Consensus Anecdote Clinician :

Examination. Clinical experience

Patient: History. Experience, Aspirations Wants

Patient

Health or social care organisation

Health practitioner

The Media, Friends, Family

Government requirements Profits & business interests

Journals, Pharma, Targets

Resources. Public Health Priorities

Clinician

Diagnosis

Disease aetiology

Prognosis

Treatment options

Outcome probabilities

Patient

Experience of illness Social circumstances Attitude to risk Goals, values,

preferences

There is always a choice

Describe the options

Consider options and what is important to patient

Choice Talk

Option Talk

Decision Talk

Decision support

Initial preferences

Revisedd preferences

Decision

Elwyn et al J Gen Int Med 2012;27(10):1361-7

DELIBERATION

Tools to help people participate in decision-making

Provide information on options

Help patients clarify and communicate their values and preferences

Clinical Guidelines Assumes doctor makes the

decisions

Primarily for doctor

Evidence-based

Describes likelihood of various outcomes

Outlines uncertainties

Recommendations based on values of clinical experts

Patient Decision Aids Assumes shared decision

making

Primarily for patient

Evidence-based

Describes likelihood of various outcomes

Outlines uncertainties

Does not make recommendations, describes options

Relevant

Evidence-based

Complete

Authoritative

Clear

Understandable by all

Up-to-date

18

1. Scans and X-rays aren’t usually needed for straightforward back pain.

2. In advanced incurable cancer, the risks and benefits of chemotherapy need to be considered carefully.

3. For most people with reflux and indigestion, long-term use of Proton Pump Inhibitor (PPI – stomach acid suppressants ) medicines (omeprazole & lansoprazole) is best avoided.

4. In the very frail and the terminally ill, there should be very careful consideration of whether long-term medicines need to be continued.

5. In iron-deficiency anaemia, blood transfusions are usually not needed unless the Haemoglobin level is below 70g/l.

6. Daily blood glucose monitoring is usually not needed for most cases of Type 2 Diabetes.

Discuss

•Potential benefits

•Potential risks

•Concepts of

palliation

Avoid

•Assuming all possible

treatment is wanted.

•Assuming comfort is

the most important

outcome

•Assuming the clinician

has all the answers

Consider

•Treatment aimed at

symptom control

•Actions patients can

take for themselves

•What can the

community provide

What can Clusters do to support better clinical conversations?

What can LHBs do to support shared decision making?

I am as involved in discussions and

decisions about my care, support and

treatment as I want to be

I have the information, and support to use it, that I need to make decisions

and choices about my care and support

I am supported to understand my

choices and to set and achieve my goals

I have help to make informed

choices if I need and want

it

BETTER CONVERSATIONS

National Voices/TLAP 2016: A Narrative for Person-Centred Care

I have used my experience and expertise to assess the problem

I have explained the options available and taken account of what is important to patient and what is possible

We have considered these options together and agreed what is the best course of action for this individual.

I have only ordered tests or undertaken procedures that have a likelihood of causing benefit with low risk of harm to the patient.

We are meeting the needs and preferences of individuals interacting with our services

Our clinicians are applying evidence in the light of individual problems

There is less waste in our system We are using community and personal assets

effectively and efficiently We are aiming to achieve outcomes relevant

to individuals. We are providing value based care