Shared decision making

Abstract

Summary Shared decision making offers a path toward more patient-centred care, improved medication adherence and patient satisfaction. The impact of shared decision making includes decisions that are informed by evidence and match the patient's wishes. Implementation of shared decision making in clinical practice requires both patient activation (e.g. decision aids) and training in communication skills.

Full text

Home medicines reviews (HMRs)
aim to improve a patient’s
quality of life and health
outcomes, and optimise medication
management. While many accredited
pharmacists lament the lack of clinical
information from referring general
practitioners (GPs), the patient is often
an underutilised resource. The luxury
of spending an hour or more with
the patient in the privacy of their own
home allows accredited pharmacists to
explore the patient’s beliefs, attitudes
and preferences about their medicines,
and their health and wellness. The
combination of medical evidence and
patients’ preferences is more likely to
support treatment decisions that lead to
health outcomes that patients value.
I recently attended the Joint
International Shared Decision-Making
and International Society for Evidence-
Based Health Care Conference in
Sydney. The keynote presentation was
given by Dr Victor Montori, Professor
of Medicine at Mayo Clinic, who
shared his research and practice on
the concept of shared decision making.
His keynote address highlighted
the importance of ‘context and
circumstances’ in caring for patients,
who are often burdened by multiple
chronic conditions and have limited
capacity to understand and live with
those conditions. The powerful message
which resonated with the audience
throughout the entire conference was
to be ‘careful and kind’.
One of the purposes of a HMR is to
improve the patient’s knowledge and
understanding of their medicines,
which in turn impacts on adherence and
persistence. The values and preferences
of patients should be explored during
the HMR. This is an essential part of
shared decision making. Patients often
ask during a HMR whether they really
need all their prescribed medicines
or may have already decided to cease
medicines without understanding the
risks and benets. To be procient
at conducting medication reviews a
pharmacist needs to understand the
concept of patient-centred care with
shared decision making.
Evidence and text books alone never
tell you what to do. Evidence-based
guidelines are disease-specic and
context blind. The late Dave Sackett’s
1996 denition of evidence-based
medicine highlights that a health
professional’s clinical experience and
the patient’s values must be integrated
with the best available ev idence.1 In
fact, Sackett suggest s that all these
elements are necessary to create a
therapeutic alliance that will lead to
optimal health outcomes and improve
the patient’s quality of life.2
Shared decision making
▲ Debbie Rigby, consultant clinical pharmacist
To be proficient at conducting medication reviews a pharmacist
needs to understand the concept of patient-centred care with
shareddecision making.
One of the purposes of a HMR is to
improve the patient’s knowledge
and understanding of their
medicines, which in turn impacts on
adherence and persistence.
AFTER READING T HIS ARTICLE, THE
LEARNER SHOULD B E ABLE TO:
• define the process of shared
decision making;
• describe s teps for shared
decision making;
• identify skills and attitude
required to engage in sh ared
decision making;
• incorporate shared decision
making into HMR interviews.
The 2010 Co mpetency Standards
addressed by this activity include
(but may not be limited to):
2.1.1, 2.1.3, 6.1.1, 6.1.2, 6.2.1,
6.2.2, 6.2.3, 7.1.1, 7.1.2, 7.1.3, 7.1.4
Accre ditation nu mber: CX15003 8
This activity ha s been accredited for
0.5 hours of G roup On e CPD (or 0.5CPD
credits) suitable for in clusion in an
individ ual pharmacist ’s CPD pla n, which
may be conve rted to 1Group Two CPD
credit upo n successful comp letion of the
associated a ssessment activity.
What is shared decision making?
Shared decision making is the process
in which a health professional and
the patient collaborate in making
the best use of evidence to make
informed, values -based decisions
that they can both agree upon. It
involves the provision of evidence-
based information about options,
outcomes and uncertainties, together
with decision support counselling.3
By incorporating the process into
the patient interview it provides
an opportunity for patients to ask
questions, state concerns and share
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OCTOBER 2015
64

AJP CPD
continuing
professional
development
achieving positive health outcomes,
especially in relation to chronic
disease management and medication
adherence. In a patient-centred model,
decision making stems from the
exchange of:6
1. Balanced, evidence-based,
disease-specic information
2. Presentation of treatment options
and their inherent benets and
trade-offs
3. Assessment of patient values,
priorities and goals
4. Alignment of patient values with
treatment decisions
There is compelling evidence that
patients who are active participants
in managing their health have better
outcomes than patients who are
passive recipients of care.3 Shared
decision making brings many benets
across all levels of health care. Shared
decisionmaking:7, 8
• increases patient knowledge;
• helps ensure patients have realistic
expectations about treatment
choices;
• reduces decisional conict;
• stimulates patients to be more active
in decision making;
• helps patients clarif y their
preferences;
• increases overall patient engagement
and empowerment;
• creates a structured approach to
reviewing options and outcomes;
• increases agreement between
providers and patients; and
• increases patient satisfaction with
consultations.
Improving risk perception accuracy
is particularly relevant to the HMR
patient population. Patients and
prescribers ty pically overestimate
the benets of medicines and
underestimate the harms.9
Recommendations to the GP to
commence new medications, especially
those for primary prevention, can
be strengthened by adding the
patient preferences. Conversely,
recommendations to discontinue a
medication should be supported by the
patient’s lack of perceived benet or
unacceptable risk of harm.
Shared decision making steps
Shared decision making should not
be viewed as a separate component
of a consultation.7 Rather it should
be viewed as a framework for a
conversation with the patient during a
HMR about their medication choices
and outcomes.
Pharmacists conducting HMRs
can prepare for the patient interview
by gathering information on the
patient’s conditions, including
the options, benets and harms.
Communication of the probabilities,
in terms of number needed to treat
(NNT) and number needed to harm
(NNH) may be useful if conveyed in
an easy-to-understand manner, with
the help of patient decision aids.
This can lead to exploration of the
What is evidence-based medicine?
Evidence-based medicine is the conscientious, explicit,
and judicious use of current best evidence in making
decisions about the care of individual patients. The practice
of evidence-based medicine means integrating individual
clinical expertise with the best available external clinical
evidence from systematic research. By individual clinical
expertise we mean the proficiency and judgment that
individual clinicians acquire through clinical experience and
clinical practice. Increased expertise is reflected in many
ways, but especially in more effective and efficient diagnosis
and in the more thoughtful identification and compassionate
use of individual patients’ predicaments, rights, and
preferences in making clinical decisions about their care.
Source: Sa ckett DL, Rosenb erg WM, Gray JA, et al. Eviden ce-based med icine,
what it is an d what it isn’t. BMJ 1996;312:71-2.
Figure 1: Definition of evidence-based medicine
Research
evidence
Patient
values and
preferences
Context
Figure 2: Shared decision making continuum
100%
0%
Patient
responsibility
for decisions
100%
100%
Patient
responsibility
for decisions
Patient- or
agent-driven
Physician
recommendation
Equal
partners
Informed
nondissent
Physician-driven
information. Basically it is about
improving the safety and quality use
of medicine: doing things right versus
doing the right thing.
Patients should expect to be actively
involved in their own care and to be
informed of their condition, their
medicines and of alternate treatments.
However, patients are not universally
inclined towards shared decision
making. Shared decision making does
not mean the same thing in all cases
and therefore can best be understood
as a continuum.4
In the context of medicines, shared
decision making is particularly
appropriate for primary prevention
and end-of-life care. It is also
appropriate when several options are
available and the evidence does not
point to a clear best choice.5
Involving the patient in goal setting
and decision making is essential in
OCTOBER 2015 65

questioning, and non-directive
guiding. Training in motivational
interv iewing technique is benecial.
Patient decision aids
Patient decision aids are commonly
used to facilitate shared decision
making. Decision aids help to support
difcult decisions in which patients
need to consider the benets versus
risks of treatment, as well as no
treatment at all. These tools support
patients in making evidence-informed
choices especially in ‘grey zone’
treatments that rely upon the patient’s
judgement of associated benets versus
harms.12 Decision aids prepare patients
for decision making by increasing their
knowledge about expected outcomes,
and improved risk perception accuracy
while incorporating personal values.
The key elements of patient decision
aids include:9
• facts on the condition, options, and
outcomes relevant to the patient’s
health status;
• risk communication on the chances
of outcomes and the level of
scientic uncertainty;
• values clarication to ascertain
which benets, harms and scientic
uncertainties matters most to
thepatient;
• structured guidance in the steps of
deliberating and communicating
with the personal health
practitioner; and
• balanced display of positive and
negative features of options.
There are now a large number of
patient decision aids available that are
specic to medications, such as aspirin
and statins in primary prevention,
and medication choice for depression,
diabetes and osteoporosis.
High-quality evidence suggests that
decision aids, compared to usual care,
improve people’s knowledge regarding
options, and reduce their decisional
conict related to feeling uninformed
and unclear about their personal
values. A Cochrane review found that
use of patient decision aids leads to:13
• greater knowledge;
• more accurate risk perceptions;
• informed values-based choice;
patient’s experiences and discussion
around which benets and harms
matter most. The Necessity- Concerns
Framework is a good model for
accredited pharmacists to elicit and
address key beliefs underpinning
patients’ attitudes and decisions about
treatment.10 The model suggests that
when faced with a decision regarding
taking treatment, patients weigh up
their perceived personal need for
treatment against their concerns about
potential adverse effects of treatment.
It is important for accredited
pharmacists not to undermine the
doctor–patient relationship. So
starting with a question like “Have
you discussed treatment options
with your GP?” will conrm whether
or not a dialog about the treatment
options has occurred and then allow
the pharmacist to assess the patient’s
understanding of those options.
While every encounter with a patient
will vary, the basic steps of shared
decision making involve:11
1. Dene problem/identif y decision
to be made
2. Present options
3. Discuss potential benets/risks
4. Identify patient values/
preferences
5. Explore patient ability
6. Present recommendations
7. Check understanding
8. Make/defer decision and arrange
for follow-up
Shared decision making has three
interrelated components, all of which
must be used in order for the approach
to succeed: decision support, decision
aids, and education and training.
Decision support
Decision support and health coaching
can help patients to develop the
knowledge, skills and condence
to manage their own health and
medication management, and to
make treatment decisions and/or
lifestyle changes accordingly. The NPS
MedicineWise website has a wealth
of patient information, resources
and tools.
Health coaching is a skilled task
involving listening, open and closed
1. Which three concepts are integral to the practice
of evidence-based medicine?
A Current best evidence, patient context, prescriber
values and preferences.
B Best available evidence, patient values and
preferences, clinical experience.
C Prescriber values and preferences, randomised-
controlled trials, GP judgment.
D Systematic reviews, clinical expertise,
patient choice.
2. In a patient-centred model, decision making stems
from all of the following aspects except one:
A Evidence-based, disease specific information.
B Consideration of harms only.
C Assessment of patient values and goals.
D Alignment of patient values with treatment
decisions.
3. One of the many benefits of shared decision
making includes:
A Realistic patient expectations.
B Increased decisional conflict.
C Disagreement between patients and prescribers.
D Reduced patient empowerment.
4. What is considered the most appropriate first
step in a HMR consultation incorporating shared
decision making?
A Check patient understanding of their medicines.
B Discuss chance of benefit and risk of harm from
medicines.
C Identify patient values and preferences.
D Elicit the patient’s concerns or problem.
5. Patient decision aids are designed to incorporate
all of the following elements, except:
A Clinical guidelines and evidence.
B Balanced representation of potential risks and
benefits.
C Outcome probabilities.
D Most appropriate treatment for all patients.
MEDICATION IN REVIEW
Shared decision making
This uni t attracts up to 1 Group Two CPD
credit. Accreditation number: CX150038
Each que stion has only one CORRECT answer.
1
CPD CREDIT
GROUP TWO
Decision aids help to support
difficult decisions…
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continuing
professional
development
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based m edicine, wh at it is and what i t isn’t. BMJ 1996 ;
312:71-2.
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based m edicine: how t o practice and te ach EBM. 2nd e d.
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clarif ying patie nts’ desired rol e in shared dec ision making
to match th eir level of eng agement wit h their preferen ces.
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path toward improved patient-centred outcomes. Circ
Cardiovasc Qual Outcomes 2012;5:e75-7.
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the syste m and patients m ake qualit y health care d ecisions.
Saskatoon: Health Quality Council, September 2009.
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decisi on making: wh at do clinici ans need to know a nd why
should they bother? Med J Aust 2014;201(1):35-9.
9. Hoffma n T, Del Ma r C. Patients’ ex pectations of t he
benefi ts and harms of t reatments, sc reening, a nd tests: a
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Art. No .: CD001431 .
• greater comfort w ith decisions;
• greater participation in decision
making;
• no increase in anxiety; and
• improved patient–practitioner
communication.
Education and training
To successfully implement shared
decision making into a consultation,
advanced communication skills are
required. These skills draw on the
principles of motivational interviewing.
Communication skills essential for the
patient inter view include:
1. Developing empathy and trust
2. Questioning
3. Listening
4. Explaining
5. Reecting
6. Using silence appropriately
Summary
Shared decision making offers a path
toward more patient-centred care,
improved medication adherence
and patient satisfaction. The impact
of shared decision making includes
decisions that are informed by ev idence
and match the patient’s wishes.
Implementation of shared decision
making in clinical practice requires both
patient activation (e.g. decision aids) and
training in communication skills.
Further information
• http://shareddecisions.mayoclinic.org/
• www.safet yandquality.gov.au/
our-work/shared- decision-making/•
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