COMMUNICATING SHARED DECISION MAKING Choosing Wisely Putting Theory

COMMUNICATING SHARED DECISION MAKING Choosing Wisely – Putting Theory into Practice 2018 Wellington 2 March 2018 Dr John Marwick

EDUCATION AND RISK MANAGEMENT Patient preferences – clinical decision making process 30% of patients want to be more involved in decisions about their care Health Quality and Safety Commission NZ 2017, Degner et al 1997, Stewart et al 2004 Most wanted to be involved in choices involving surgery Picker Institute 2008 96% want to be offered choices and asked their opinions Chung et al 2011, Levinson et al 2005 Patients tend to place more value on the process of involvement in decision making rather than who actually makes the decision Longo et al 2006 Edwards et al 2006

EDUCATION AND RISK MANAGEMENT Preferences – patients and doctors Informative “PATIENT’S CHOICE” DOCTOR “DOCTOR’S ORDERS” Prescriptive Passive PATIENT Active

EDUCATION AND RISK MANAGEMENT ? Simply matching doctor and patient preferences will not consistently fulfil the legal, ethical and risk management requirements of modern practice

EDUCATION AND RISK MANAGEMENT Ethics Work in partnership with patients by: § listening to them and responding to their concerns and preferences § giving them the information they want or need in a way they can understand ensuring they understand it § respecting their right to reach decisions with you about their treatment and care § supporting them in caring for themselves to improve and maintain their health. Good Medical Practice: A guide for doctors 2016, MCNZ

EDUCATION AND RISK MANAGEMENT The “voices” in a consultation Clinician’s expertise Patient’s expertise Diagnosis Experience of illness Disease aetiology Social circumstances Prognosis Attitude to risk Treatment options Values Outcome probabilities Preferences Coulter et al, King’s Fund 2011

EDUCATION AND RISK MANAGEMENT Patients are encouraged to ask: ASK What are my options? (One option will always be wait and watch) SHARE KNOW What are the possible benefits and harms of those options? How likely are each of those benefits and harms to happen to me? Ask more and share more in order to know more http: //askshareknow. com. au/

EDUCATION AND RISK MANAGEMENT The 6 D Framework© for Shared Decision Making D EVELOP trust D ISCOVER patient’s views & values D ISCUSS options, benefits and risks D OUBLE-CHECK understanding D ECIDE D OCUMENT

EDUCATION AND RISK MANAGEMENT D EVELOP § use effective communication skills to underpin the whole process Develop trust § encourage patient involvement § acknowledge complexity of decision if appropriate § establish patient preferences for information – amount and how it is presented.

EDUCATION AND RISK MANAGEMENT D ISCOVER Discover patient’s views and values Knowledge: Tell me what you already know about all this. Ideas: Do you have any thoughts about your condition and its treatment? Concerns: Many patients have concerns about this procedure – what worries you? Expectations: What were you hoping for from treatment? What would be a good result for you? Preferences: What preferences do you have about how we should manage your condition? Values: What else do we need to consider before we make this decision. What is most important to you? What about time off work?

EDUCATION AND RISK MANAGEMENT D ISCUSS § list options including the “no action” option § outline risks/benefits and likely Discuss options, benefits and risks outcomes for each option: § risks that apply to any reasonable patient § risks that apply particularly to THIS patient. § make recommendations having regard to the patient’s values.

EDUCATION AND RISK MANAGEMENT “Double” 1 in 20 “Uncommon” THE RISK IS 5% 15/100 V 2/10 Crowson et al 2007, Gigerenzer 2008, 2014, Paling 2003 Outcomes No problems Infection Scar Disappointed

EDUCATION AND RISK MANAGEMENT D ISCUSS They can take a variety of forms including: § printed materials Decision aids § photos and graphics § hand-written notes or drawings § videos § option grids.

EDUCATION AND RISK MANAGEMENT D OUBLE-CHECK I’ve given you a lot of information. Is there anything you don’t understand? (Yes-No) Double-check understanding It’s important that you do this exactly the way I explained. Could you tell me what I’ve told you? (Tell Back Directive) I’ve given you a lot of information. It would be helpful to me to hear your understanding about your condition and its treatment (Tell Back Collaborative) Kemp et al 2008

EDUCATION AND RISK MANAGEMENT D ECIDE § choose to defer the decision – consider what will help: Decide § more time to consider § talk to family § use decision aid § more information § second opinion § agree next step and timing. § make a decision § reflect on and review the decision agreed.

EDUCATION AND RISK MANAGEMENT D OCUMENT Document In general, records that are adequate for continuity of care also sufficiently comprehensive for legal use. MPS factsheet UK ‘Medical Records’ (2015) Remember that patients, their family or, sometimes, their legal advisors may read your records.

EDUCATION AND RISK MANAGEMENT The 6 D Framework© for Shared Decision Making D EVELOP trust D ISCOVER patient’s views & values D ISCUSS options, benefits and risks D OUBLE-CHECK understanding D ECIDE D OCUMENT

EDUCATION AND RISK MANAGEMENT ? Questions and comments