HealthPsyc6 Flashcards
Case study, Lucy:
Diagnosed 2 days ago with breast cancer
Aged 37; married with one child (3 years old); would like another child
Decisions to make
• Surgery
• ‘Mastectomy’ versus ‘Lumpectomy + Radiotherapy’?
• Breast reconstruction?
• Immediate or delayed or not at all?
• More (adjuvant) “insurance” treatment?
• Chemotherapy?
• Hormone therapy?
• Fertility options?
• Fertility treatment prior to chemotherapy?
• Other decisions: Complementary therapy; Clinical trial
• Weighing up medical and personal concerns
My health /the benefits in terms of survival
& My ability to keep the family functioning/quality of life
- Effects of treatment on ability to have children, sexuality or body image
- Weighing up uncertain risks against uncertain side-effects (additional chemotherapy / hormone therapy)
20% risk/chance of relapse
(Likely) loss of fertility / onset of menopausal symptoms
Paternalism
(Professional-centred approach) • Doctor is the Expert • Protects patient from disturbing information • Takes away the burden of decision-making • Projects confidence and care • Dr makes the decision in patient’s best interests
Patient-directed/Autonomous:
Patient as “the consumer”
Doctor
• Tells patient all the relevant information
• Is available to answer patient’s questions
• Does not make a recommendation
• Allows patient to reach his/her own decision
Shared decision-making (SDM)
• The SDM approach is positioned in
between the paternalistic and patientdirected
approaches
• A process in which the health professional
and the patient collaborate in making the
best use of evidence to make informed,
value-based decisions that they can both
agree upon
• Central tenet of SDM is that patients and
health professionals have different but
equally valuable perspectives and roles
within the medical encounter
Legislation and policy
• “Health programs should facilitate collaborative processes between patients, caregivers, and clinicians that engage the patient and caregiver in decision-making”. (US; 2010)
•“No decisions about me, without me” (UK, 2012)
• “Patients have a right to be included in decisions and choices about [their] care” (Australian Healthcare Charter of Healthcare Rights;
Australian Commission on Safety and Quality in Healthcare, 2008)
SDM Clinicians Expertise
Diagnosis Disease aetiology Prognosis Treatment options Outcome probabilities
SDM Patients Expertise
Experience of illness Social circumstances Attitude to risk Values Preferences
SDM Approaches
- Many different approaches/models of SDM
- Charles et al (1997; 1999)
- Legare et al. (2011)
- Elwyn et al. (2012)
- No one accepted “gold standard” definition of SDM
- Approaches often similar in their essence, but have different names, stages, focus.
SDM Approach: Charles et al. (1997; 1999)
SDM Framework by Charles, Gafni & Whelan (1997, 1999)
• Pioneering model of SDM
• Most widely cited model of SDM (2040 citations)
• An encounter in which BOTH health professional and patient:
- Share information (Information exchange): physician informs the patient of all relevant information about available treatment options (e.g. risks/benefits); patient provides information about their preferences, values, beliefs, social context, and knowledge about the illness/treatment.
- Mutually deliberate on treatment options (Deliberation): process of expressing and discussing treatment preferences in an interactive process.
- Choose a treatment to implement (Decision): both parties work towards reaching an agreement and action plan to follow.
See slides for some good diagrams
SDM Approach: Legare et al. (2011)
Legare et al. (2011) Interprofessional Model of SDM
• Extends upon the pioneering models of SDM
• Adds additional health professionals to SDM model
• Acknowledges the significant roles of family and decision coaches
• Includes additional stages of DM
• Decision to be made
• Feasibility
• Implementation
• Outcomes
See slides again
SDM Approach: Elwyn et al. (2012)
Shared decision making: a model for clinical practice.
• Extends upon the “pioneering” SDM models
• Provides guidance about how to accomplish approach in routine clinical practice
- 3-step model: practical, easy to remember
- Based on
- Choice Talk (introducing choice)
- Option Talk (describing options, decision-support tools)
- Decision Talk (helping patients explore preferences and make decisions)
- Underpinned by process of deliberation
Shared decision making: a model for clinical practice.
• Acknowledges that DM may be an ongoing and progressive process and may be repeated over time
• Acknowledges that the SDM process begins early, well before the patient has informed preferences
• Choice talk: does not necessarily have to occur during a face-to-face consultation (email, letter, telephone call)
• Option talk: May include use of decision support (e.g. decision aids, option grids) and discussions with others
When should SDM be used
- One size does not fit all
- Patient preferences vary
- BUT… Particularly appropriate in preference-sensitive scenarios:
- Treatment outcomes are uncertain
- Quality of life may be affected
- Patient values determine the best outcome
- For example:
- Mastectomy vs lumpectomy + radiotherapy
- Adjuvant chemotherapy where benefit is small
- Cancer prevention interventions (e.g. tamoxifen)
Do patients want SDM?
- Australian survey (Davey et al, 2002): >90% of women preferred SDM re screening and diagnostic tests
- European survey (Coulter & Jenkinson, 2005; n>8,000): >70% of patients wanted SDM
- Should not be forced on patients- DM style should align with patient’s preferences
- Discrepancies between preferred and actual decision-making roles may lead to:
- Decreased patient satisfaction with care
- Decreased quality of life (Singh et al., 2010)
Is SDM Effective?
- Patients involved in SDM report increased:
- Overall satisfaction with their care
- Satisfaction with the doctor-patient relationship
- Satisfaction with the decision-making process
- Knowledge
- Quality of life
- Treatment adherence
SDM Patient Barriers
Conforming to social expectations of doctor/patient
roles
• Emotionally vulnerable and emotional, possibly feeling
powerless
• Lack a medical vocabulary
There is great variability in the degree to which patients prefer to be involved in decision-making
Empowerment vs. Abandonment
