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Shared Decision Making Towards better outcomes
Paul Myres
Academy of Medical Royal Colleges Wales
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Better Conversations
Better decisions
Better outcomes
Less waste, more value
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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
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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
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One in three patients feel uninformed about their treatment
About half want more involvement in decisions about their care
Patient Information Forum 2015
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Clinicians and patients
working together to select
tests, treatments,
management or support
options based on clinical
evidence and the patient’s
informed preferences.
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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
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What are my options?
What are the benefits and harms?
Do I really need this?
What can I do to help myself?
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INFO -Research evidence, Consensus Anecdote Clinician :
Examination. Clinical experience
Patient: History. Experience, Aspirations Wants
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Patient
Health or social care organisation
Health practitioner
The Media, Friends, Family
Government requirements Profits & business interests
Journals, Pharma, Targets
Resources. Public Health Priorities
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Clinician
Diagnosis
Disease aetiology
Prognosis
Treatment options
Outcome probabilities
Patient
Experience of illness Social circumstances Attitude to risk Goals, values,
preferences
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There is always a choice
Describe the options
Consider options and what is important to patient
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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
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Tools to help people participate in decision-making
Provide information on options
Help patients clarify and communicate their values and preferences
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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
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Relevant
Evidence-based
Complete
Authoritative
Clear
Understandable by all
Up-to-date
18
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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.
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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
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What can Clusters do to support better clinical conversations?
What can LHBs do to support shared decision making?
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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
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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.
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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