Shared Decision MakingShared Decision Making

&&Patient Empowerment in Family Medicinein Family Medicine

Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM

PO Box 27121 – Riyadh 11417Tel: 4912326 – Fax: 4970847 1

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Objectives

– Discuss the definition of patient empowerment– Discuss the status of patient empowerment in FP– Explain the need for patient empowerment– Discuss the reasons of powerless patients– Explain how to empower patients

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Contents

• Shared decision making• Patient Empowerment• The old model vs. the new• Common problems that can lead to poor

decisions• Model for Clinical Problem Solving & ISDMModel for Clinical Problem Solving & ISDM• What is a "good" health care decision?

What is Patient Empowerment?

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Patient Empowerment

• Empowerment is a concept that has recently emerged in the health scene. It embraces the idea that everyone has the right to make their own choices about their health care

• because patients are the ones who experience the consequences of both having and treating their illnesses, they have the right to be the primary decision makers regarding their medical conditions

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Patient Empowerment

• A key part of empowerment is that the patient, personally, must actively search out sufficient information to fully understand their health conditions and their treatment plans

• Although their physician should be involved in the decision-making process, the final determination of what is best for the patient is both the right and responsibility of the individual patient.

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• Evaluating both the disease and the illness experience

• Understanding the whole person

• Finding common ground with the patient about the problem and its management

• Incorporating prevention and health promotion

• Enhancing the doctor-patient relationship

• Being realistic

Why Patient Empowerment?Remember the “patient centered clinical method”

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• Only 9% of consultations with surgeons and primary care physicians meet full criteria for informed decision making. Braddock JAMA 1999

• Distinguishing elements of shared decision making occurred in 0-11% of audio taped patient interviews with general practitioners. Elwyn 2001

• “.. Checking of understanding, and the involving of patients in decision making .. are rarely demonstrated” [in video taped consultations submitted for MRCGP examination]. Campion BMJ 2002

Why Patient Empowerment?

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What is shared decision making?

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• Two definitions of shared decision making: • The process of interaction of patients with their

health care providers in making health care decisions

• Involvement of patients with their providers in making health care decisions that are informed by the best available evidence about treatment / screening / illness management options, potential benefits, and harms, and that consider patient preferences.

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What is it?

• an individual being an active member of his/her disease management team

Laura E. Santurri. Patient Empowerment: Improving the Outcomes of Chronic Diseases Through Self-Management Education. http://www.case.edu/med/epidbio/mphp439/Patient_Empowerment.htm

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Shared decision making

combines the measurement of patient preferences with evidence-based practice.

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Why is shared decision making important?

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• Interventions have different benefits/ risks that patients value differently

• There is no single right answer for everyone

• Ethical principle of patient autonomy and legal requirement of informed consent

• Evidence-based practice movement

• Increasing realization that an important piece of evidence is missing without the patient’s perspective

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• Patients cannot be forced to follow a lifestyle dictated by others.

• Preventive medicine requires patient empowerment for it to be effective.

• Patients as consumers have the right to make their own choices and the ability to act on them

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• Patient is sick, weak, vulnerable, not feeling fully oneself…

• Patient may be afraid

• Patient in a state of dependency

• Lack of medical knowledge

• Lack of knowledge on the “system” and how it works

• Unfamiliar environment

Why is the concentration of power in this relationship with physician?

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• Education• Professional status/authority• Knowledge• Skills• Expertise• Experience• On familiar territory• GATEKEEPER TO HEALTHCARE SYSTEM

Why is the concentration of power in this relationship with physician?

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“People whose lives are affected by a decision must be a part of the process of arriving at that decision.”

–John Naisbitt, Megatrends

Why Patient Empowerment?

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• Education

• supporting self care and self-management

• Offering a choice of providers

• Sharing treatment decisions

How to empower patients

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Benefits of Patient Empowerment

• Learning from our patients

• Taking a proactive role• Providing a support & information service

to our patients and staff• Complaint Resolution• Negotiation & Mediation• Building trust

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The old model vs. the new

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Patient says: Doctor responds

(Old model) (New model)

"I hate this exercise plan."

"Then try walking after dinner every night with your husband for 10 minutes

"What do you hate about it? What would help you do better at it?"

"I don't think I can quit smoking."

"Smoking is the leading cause of preventable death ..."

Why do you think that? What has happened in the past when you tried to quit? What concerns you most when you think about

trying to quit?

I haven't been able to test my blood sugar four times a day."

"It's hard at first, but just keep trying. You really need to keep track of it."

"What is preventing you from doing that? Do you know what the numbers mean?"

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Some useful hints

• The skilled family physician can spend 10 minute with a patient and the patient feels it was 20 minutes

• Even the busiest physician can accomplish wonders in a few minutes by indicating that their full attention is on the patient

• Please conclude every interview with the statement “is their anything else bothering you that we have not discussed?”

• Rather than assuming that the patient have understood the instructions, ask them to repeat as they understood

• Use the patients name or ask him what he prefer to be called as• Use “how can I help you? Rather than “what brings you here

today?”

24Follow-up

Management / treatment

Presenting concern“patient’s story”

History and physical exam

Hypothesis

Identified problem or diagnosis

Identify choices

Review pt’s preference for information

Present evidence

Respond to pt’s ideas, concerns and expectations

re: management

Assess partnership (review previous steps)

DOCTOR - PATIENT COMMUNICATION

Establish pt’s role in decision making

Agree on an action plan

Negotiate a decision

Model forModel forClinical Problem Solving & ISDMClinical Problem Solving & ISDM

Step 1 Step 2

Step 3

Step 4

Step 5

Step 6

Step 7

Step 8

**ISDMISDM: Informed Shared Decision Making: Informed Shared Decision Making

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Common problems that can lead to poor decisions:

• Relationships and roles are unclear

• Objective data are inadequate

• Values, interests and assumptions are unexplored

• Too few options have been considered

• Alternatives are unclear

• Communication is poor

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What is a "good" health care decision?

o Well informed, supported by the best available evidence, weighs pros and cons, compatible with patient's values and practical (Dow, 1999).

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Feeling vulnerable

Not involved No dialogue

Disempowered

No Partnership

No Voice in the System

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Empowerment allows our relationships to grow in strength

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“Coming together is a beginning; keeping together is progress; working together is success.”

Henry Ford