Shared Decision Making

Abstract

Shared decision making is a bridge from evidence to action. Acquiring and appraising the evidence impacting a patient is only the beginning of the process. It is critically important that clinicians present information in a way that patients understand and incorporate patients’ values and preferences in making final clinical decisions. In this chapter we present the core principles of shared decision making as well as suggestions for applying shared decision making to each of the core content areas of this curriculum.

Appendix

Shared Decision Making Worksheets

Worksheet Template

Shared decision making step	Case analysis	Example of language to be used
Triage the individual issue under discussion to deem if it is appropriate for shared decision making	What is the clinical decision?
Develop your script for a particular topic	Frame the goal of decision making:
Assessing your patient’s personal context regarding the clinical topic	Their concerns: Barriers: Social Context:
Assess benefits and harms	Best estimate of baseline risk: Evidence supporting risk reduction: What are the harms?
Integrating patient context with your own recommendations	Decision Aid: Option 1: Option 2: Your recommendation: Address patient concerns:
Reach a decision	What’s the decision?

Worksheet Example: Searching the Literature

Case: A 54-year-old woman who had chronic right knee osteoarthritis and interested in getting a steroid knee injection.

SDM step	Case analysis	Example of language to be used
Triaging the individual issue under discussion to deem if it is appropriate for SDM	What is the clinical decision?	What is the effectiveness of steroid injection in the treatment of knee pain from osteoarthritis? (Search for a decision aid, or, if one is lacking, a guideline or useful evidence-based resource to assist.)
Developing your SDM script for a particular topic	What is your goal: What is the evidence: What is your preference:
Assessing your patient’s personal context regarding the clinical topic	What is their preference: Their concerns: Barriers: Social Context:	They would like relief of pain. They are worried about side effects but are not opposed to injection. No significant barriers. She is able to make it to an appointment for an injection and could afford it.
Assess Benefits and Harms	Best estimate of baseline risk: N/A Evidence supporting risk reduction: N/A Evidence supporting benefit: What are the harms?
Integrating patient context with your own recommendations	Decision Aid/EBM resources: Option 1: Option 2: Your recommendation: Address patient concerns:
Reach a decision	What’s the decision?

Worksheet Example: Causation/Harm

A 59-year-old man with chronic GERD comes to you wondering if he should stay on his current proton pump inhibitor that he has taken for 5 years given the reports he has read in the media about potential harms.

SDM step	Case analysis	Example of language to be used
Triaging the individual issue under discussion to deem if it is appropriate for SDM	What is the clinical decision?	Should a proton pump be continued, and how, given the evidence of potential adverse effects? (Find a decision aid, evidence-based resource, or evidence-based guideline addressing the strength of causation and how to balance harms and benefits.)
Developing your SDM script for a particular topic	What is your goal: What is the evidence: What is your preference:
Assessing your patient’s personal context regarding the clinical topic	What is their preference: Their concerns: Barriers: Social Context:	They would like relief of reflux symptoms but are worried about harms about being on a chronic medication. They are wondering whether they can take the medication on a less-than-daily basis. Social context: patient has significant anxiety about taking medications and potential harms.
Assess Benefits and Harms	Best estimate of baseline risk: Evidence supporting causation of harm: Evidence supporting benefit:
Integrating patient context with your own recommendations	Decision Aid/EBM resources: Option 1: Option 2: Your recommendation: Address patient concerns:
Reach a decision	What’s the decision?

Worksheet Example: Diagnosis

Your patient, 35 years old with a history of migraines, comes in requesting an MRI because of a headache which “feels different from my normal migraine.” She has no focal neurological abnormalities on physical exam.

SDM step	Case analysis	Example of language to be used
Triaging the individual issue under discussion to deem if it is appropriate for SDM	What is the clinical decision?	Should MRI be pursued in a patient with a history of migraines and changed headache without neurological findings?
Developing your SDM script for a particular topic	What is your goal: What is the evidence: What is your preference:
Assessing your patient’s personal context regarding the clinical topic	What is their preference: Their concerns: Barriers: Social Context:	They would like to make sure they do not have cancer. Cost is a barrier. An aunt was diagnosed three months ago with brain cancer after headaches.
Assess Benefits and Harms	Best estimate of prevalence: Best estimate of likelihood ratios/predictive values/NNT: What are the harms?
Integrating patient context with your own recommendations	Decision Aid/EBM resources: Option 1: Option 2: Your recommendation: Address patient concerns:
Reach a decision	What’s the decision?

Worksheet Example: Screening

A 60-year-old Spanish-speaking man with a 30-pack-year smoking history, who quit smoking 5 years ago, asks you whether he should get the “lung cancer test.” He is asymptomatic.

SDM step	Case analysis	Example of language to be used
Triaging the individual issue under discussion to deem if it is appropriate for SDM	What is the clinical decision?	Is this patient eligible for lung cancer screening per evidence-based guidelines? If he is eligible, what is the benefit to him of screening, and should he be screened?
Developing your SDM script for a particular topic	What is your goal: What is the evidence: What is your preference:
Assessing your patient’s personal context regarding the clinical topic	What is their preference: Their concerns: Barriers: Social Context:	“I would like to do whatever you recommend, doctor.” He is concerned about cancer. Cost is a barrier. You have seen him before. His health literacy is poor in Spanish and English.
Assess Benefits and Harms	Best estimate of baseline risk: Evidence supporting risk reduction: Evidence supporting benefit: Evidence regarding test characteristics: What are the harms?
Integrating patient context with your own recommendations	Decision Aid/EBM resources: Option 1: Option 2: Your recommendation: Address patient concerns:
Reach a decision	What’s the decision?

Worksheet Example: Therapy

A 45-year-old woman with chronic back pain, fatigue, decreased energy, and anhedonia has been recently diagnosed by you with depression and returns to discuss treatment options. Her PHQ-9 is 15. She is able to work and be active in home life but finds her symptoms very disruptive; they keep her from playing with her kids as she would like to. She often feels overwhelmed. She has no suicidal ideation.

SDM step	Case analysis	Example of language to be used
Triaging the individual issue under discussion to deem if it is appropriate for SDM	What is the clinical decision?	Is psychotherapy, pharmacotherapy, or both the most appropriate option? If medication is indicated, which would you and she choose? (Find a guideline and/or evidence-based resource comparing pharmacotherapy and psychotherapy.)
Developing your SDM script for a particular topic	What is your goal: What is the evidence: What is your preference:
Assessing your patient’s personal context regarding the clinical topic	What is their preference: Their concerns: Barriers: Social Context:	She is wary of the side effects of medications and has never tried psychotherapy before. She is worried that she will have to be a on a habit-forming medication for the rest of her life. Barriers: There are only a few psychotherapists taking new patients who accept her insurance. Time commitment for weekly visits is also difficult given childcare and work.
Assess Benefits and Harms	Evidence supporting benefit of pharma Evidence supporting benefit of psychotherapy What are the harms?
Integrating patient context with your own recommendations	Decision Aid/EBM resources: Option 1: Option 2: Your recommendation: Address patient concerns:
Reach a decision	What’s the decision?

Worksheet Example: Prognosis

A 65-year-old grandmother comes to you to discuss her worsening shortness of breath. She has severe COPD (GOLD stage D) without significant comorbidities; she quit tobacco 15 years ago. She would like to know what she can expect for the future. She is on home oxygen and has been hospitalized three times in the past year. She is on a long acting beta agonist, inhaled corticosteroid, anticholinergic, and daily prednisone 10 mg. She likes to chat with her grandchildren and can walk to the kitchen and bathroom on the first floor of her house.

SDM step	Case analysis	Example of language to be used
Triaging the individual issue under discussion to deem if it is appropriate for SDM	What is the clinical decision?	What is the prognosis, both regarding life expectancy and quality of life, associated with this patient’s severe COPD? What should be the approach to her care on that basis? (Search for an evidence-based guideline regarding the prognosis of patients with severe COPD, including medical and surgical options.)
Developing your SDM script for a particular topic	What is your goal: What is the evidence: What is your preference:
Assessing your patient’s personal context regarding the clinical topic	What is their preference: Their concerns: Barriers: Social Context:	She would like to remain as active as possible and maximize her time with her grandchildren. She wonders whether there is any possibility of lung transplant but worries about risk of surgery. Cost is not a barrier. She has good social support.
Assess Benefits and Harms	Evidence supporting benefit of transplant compared to continue medical therapy Evidence regarding prognosis of severe COPD (life expectancy, quality of life) What are the harms?
Integrating patient context with your own recommendations	Decision Aid/EBM resources: Option 1: Option 2: Your recommendation: Address patient concerns:
Reach a decision	What’s the decision?

Worksheet Example: Systematic Reviews

A 45-year-old working mother of three is healthy and without symptoms. She recently heard about two friends diagnosed with cancer and would like to know how best to prevent cancer. She wonders if there are foods she should include or avoid in her diet. She knows there have been a number of scientific studies—she has read about them in the lay press—but finds their results contradictory and confusing.

SDM step	Case analysis	Example of language to be used
Triaging the individual issue under discussion to deem if it is appropriate for SDM	What is the clinical decision?	What cancer-preventing diet, if any, should be recommended to this healthy patient? (Seek evidence-based resources regarding diet and cancer.)
Developing your SDM script for a particular topic	What is your goal: What is the evidence: What is your preference:
Assessing your patient’s personal context regarding the clinical topic	What is their preference: Their concerns: Barriers: Social Context:	She would like to reduce her risk of cancer. She enjoys a variety of foods but cost is a barrier. Her health literacy is high.
Assess Benefits and Harms	Evidence regarding absolute and relative risk reduction of diet in cancer What are the harms of pursuing specific diets?
Integrating patient context with your own recommendations	Decision Aid/EBM resources: Option 1: Option 2: Your recommendation: Address patient concerns:
Reach a decision	What’s the decision?

Worksheet Example: Non-inferiority

Your 66-year-old patient has atrial fibrillation and hypertension without other comorbidities. He enjoys building useful objects out of wood. He has been taking warfarin for years without noticeable adverse effects and has read about “new blood thinners.” He wonders if he should switch.

SDM step	Case analysis	Example of language to be used
Triaging the individual issue under discussion to deem if it is appropriate for SDM	What is the clinical decision?	Should this patient change from warfarin to a direct oral anticoagulant (DOAC)? Is a DOAC noninferior to warfarin for this patient? (Ascertain an evidence-based source to answer this question.)
Developing your SDM script for a particular topic	What is your goal: What is the evidence: What is your preference:
Assessing your patient’s personal context regarding the clinical topic	What is their preference: Their concerns: Barriers: Social Context:	Cost is a barrier but he finds it inconvenient to go to the anticoagulation clinic sometimes multiple times a week. He is concerned about avoiding bleeding.
Assess Benefits and Harms	Evidence regarding noninferiority of DOACs compared to warfarin. Evidence comparing the harms.
Integrating patient context with your own recommendations	Decision Aid/EBM resources: Option 1: Option 2: Your recommendation: Address patient concerns:
Reach a decision	What’s the decision?

Worksheet Example: Learner Assessment

This format can also be valuable in assessing your learners’ performance within evidence-based practice. What to look for from learners for each topic:

SDM step	Case analysis	What to look for in your learners
Triaging the individual issue under discussion to deem if it is appropriate for SDM	What is the clinical decision?	Can they develop a PICO question to search the literature
Developing your SDM script for a particular topic	What is your goal: What is the evidence: What is your preference:	Are they able to interpret the evidence to commit to what their own recommendation/preference would be?
Assessing your patient’s personal context regarding the clinical topic	What is their preference: Their concerns: Barriers: Social Context:	Are they able to integrate social context and barriers into the script they develop to speak with the patient while practicing role plays at the end?
Assess Benefits and Harms	Evidence supporting benefit of transplant compared to continue medical therapy Evidence regarding prognosis of severe COPD (life expectancy, quality of life) What are the harms?
Integrating patient context with your own recommendations	Decision Aid/EBM resources: Option 1: Option 2: Your recommendation: Address patient concerns:	How actively does the learner include the patient in the discussion and use of a decision aid. Are they able to troubleshoot the patient’s concerns using the evidence. Do they avoid jargon. Do they explain the statistics in patient friendly language?
Reach a decision	What’s the decision?