Contextualizing decisions: Stepping out of the SDM track

Medical Care as Flea Market Bargaining? An International Interdisciplinary Study of Varieties of Shared Decision Making in Physician-Patient Interactions

Phenomenon: Shared decision making (SDM) is a core ideal in the interaction between healthcare providers and patients, but the implementation of the SDM ideal in clinical routines has been a relatively slow process. Approach: In a sociological study, 71 interactions between physicians and simulated patients enacting chronic heart failure were video-recorded in China, Germany, the Netherlands, and Turkey as part of a quasi-experimental research design. Participating physicians varied in specialty and level of experience. The secondary analysis presented in this article used content analysis to study core components of SDM in all of the 71 interactions and a grounded theory approach to observe how physicians responded actively to patients even though they did not actively employ the SDM ideal. Findings: Full realization of the SDM ideal remains an exception, but various aspects of SDM in physician-patient interaction were observed in all four locations. Analyses of longer interactions show dynamic processes of interaction that sometimes surprised both patient and physician. We observed varieties of SDM that differ from the SDM ideal but arguably achieve what the SDM ideal is intended to achieve. Our analysis suggests a need to revisit the SDM ideal-to consider whether varieties of SDM may be acceptable, even valuable, in their own right. Insights: The gap between the SDM ideal and SDM as implemented in clinical practice may in part be explained by the tendency of medicine to define and teach SDM through a narrow lens of checklist evaluations. The authors support the argument that SDM defies a checklist approach. SDM is not uniform, but nuanced, dependent on circumstances and setting. As SDM is co-produced by patients and physicians in a dynamic process of interaction, medical researchers should consider and medical learners should be exposed to varieties of SDM-related practice rather than a single idealized model. Observing and discussing worked examples contributes to the physician's development of realistic expectations and personal professional growth.

Navigating choices: understanding the decision-making journey of patients with localised kidney cancer

OBJECTIVE

To explore patients' experience of decision making regarding treatment of localised kidney cancer.

METHODS

A total of 21 patients with localised kidney cancer, across three countries, participated in either four focus groups or seven semi-structured interviews that lasted on average 2 h. Focus groups and interviews were all conducted in the participants' native language, recorded, transcribed and (if applicable) translated into English. Thematic analysis was used to develop a codebook and identify themes.

RESULTS

All participants expressed a desire to be actively involved in the treatment decision-making process. However, due to the emotional toll of the cancer journey, which often necessitates quick decisions, actively engaging in the decision-making process was described as challenging. The study revealed 12 key themes. These themes included the impact of diagnostic paths, patient characteristics, patient empowerment, health literacy, source of support, fear of recurrence, trust in treatment and healthcare providers, shared decision making (SDM), professional interaction, personal belief system, and organisational and administrative issues.

CONCLUSIONS

The findings highlight the complexity of decision making, underscoring the desire for patient involvement, SDM, and clear communication. We reveal a significant gap between research recommendations and clinical practice, emphasising the need to translate research findings to clinical application to enhance patient-centred care.

"The challenge is the complexity" - A qualitative study about decision-making in advanced lung cancer treatment

INTRODUCTION

The value of shared decision-making and decision aids (DA) has been well documented yet remain difficult to integrate into clinical practice. We wanted to investigate needs and challenges regarding decision-making about advanced lung cancer treatment after first-line therapy, focusing on DA applicability.

METHODS

Qualitative data from separate, semi-structured focus groups with patients/relatives and healthcare professionals were analysed using systematic text condensation. 12 patients with incurable lung cancer, seven relatives, 12 nurses and 18 doctors were recruited from four different hospitals in Norway.

RESULTS

The participants described the following needs and challenges affecting treatment decisions: 1) Continuity of clinician-patient-relationships as a basic framework for decision-making; 2) barriers to information exchange; 3) negotiation of autonomy; and 4) assessment of uncertainty and how to deal with it. Some clinicians feared DA would steal valuable time and disrupt consultations, arguing that such tools could not incorporate the complexity and uncertainty of decision-making. Patients and relatives reported a need for more information and the possibility both to decline or continue burdensome therapy. Participants welcomed interventions supporting information exchange, like communicative techniques and organizational changes ensuring continuity and more time for dialogue. Doctors called for tools decreasing uncertainty about treatment tolerance and futile therapy.

CONCLUSION

Our study suggests it is difficult to develop an applicable DA for advanced lung cancer after first-line therapy that meets the composite requirements of stakeholders. Comprehensive decision support interventions are needed to address organizational structures, communication training including scientific and existential uncertainty, and assessment of frailty and treatment toxicity.

Identifying Patterns in Preoperative Communication about High-Risk Surgical Intervention: A Secondary Analysis of a Randomized Clinical Trial

INTRODUCTION

Surgeons are entrusted with providing patients with information necessary for deliberation about surgical intervention. Ideally, surgical consultations generate a shared understanding of the treatment experience and determine whether surgery aligns with a patient's overall health goals. In-depth assessment of communication patterns might reveal opportunities to better achieve these objectives.

METHODS

We performed a secondary analysis of audio-recorded consultations between surgeons and patients considering high-risk surgery. For 43 surgeons, we randomly selected 4 transcripts each of consultations with patients aged ≥60 y with at least 1 comorbidity. We developed a coding taxonomy, based on principles of informed consent and shared decision making, to categorize surgeon speech. We grouped transcripts by treatment plan and recorded the treatment goal. We used box plots, Sankey diagrams, and flow diagrams to characterize communication patterns.

RESULTS

We included 169 transcripts, of which 136 discussed an oncologic problem and 33 considered a vascular (including cardiac and neurovascular) problem. At the median, surgeons devoted an estimated 8 min (interquartile range 5-13 min) to content specifically about intervention including surgery. In 85.5% of conversations, more than 40% of surgeon speech was consumed by technical descriptions of the disease or treatment. "Fix-it" language was used in 91.7% of conversations. In 79.9% of conversations, no overall goal of treatment was established or only a desire to cure or control cancer was expressed. Most conversations (68.6%) began with an explanation of the disease, followed by explanation of the treatment in 53.3%, and then options in 16.6%.

CONCLUSIONS

Explanation of disease and treatment dominate surgical consultations, with limited time spent on patient goals. Changing the focus of these conversations may better support patients' deliberation about the value of surgery.Trial registration: ClinicalTrials.gov Identifier: NCT02623335.

HIGHLIGHTS

In decision-making conversations about high-risk surgical intervention, surgeons emphasize description of the patient's disease and potential treatment, and the use of "fix-it" language is common.Surgeons dedicated limited time to eliciting patient preferences and goals, and 79.9% of conversations resulted in no explicit goal of treatment.Current communication practices may be inadequate to support deliberation about the value of surgery for individual patients and their families.

Development of a scale to measure shared problem-solving and decision-making in mental healthcare

OBJECTIVES

The aim of this study was to create a measure of collaborative processes between healthcare team members, patients, and carers.

METHODS

A shared decision-making scale was developed using a qualitative research derived model and refined using Rasch and factor analysis. The scale was used by staff in the hospital for four consecutive years (n = 152, 121, 119 and 121) and by two independent patients' and carers' samples (n = 223 and 236).

RESULTS

Respondents had difficulty determining what constituted a decision and the scale was redeveloped after first use in patients and carers. The initial focus on shared decision-making was changed to shared problem-solving. Two factors were found in the first staff sample: shared problem-solving and shared decision-making. The structure was confirmed on the second patients' and carers' sample and an independent staff sample consisting of the first data-points for the last three years. The shared problem-solving and decision-making scale (SPSDM) demonstrated evidence of convergent and divergent validity, internal consistency, measurement invariance on longitudinal data and sensitivity to change.

CONCLUSIONS

Shared problem-solving was easier to measure than shared decision-making in this context.

PRACTICE IMPLICATIONS

Shared problem-solving is an important component of collaboration, as well as shared decision-making.

"I'm not the doctor; I'm just the patient": Patient agency and shared decision-making in naturally occurring primary care consultations

OBJECTIVES

To explore interactional processes in which clinical decisions are made in situ during medical consultations, particularly the ways in which patients show agency in decision-making processes by proposing and opposing actions, and which normative dimensions and role-expectations their engagement entail.

METHODS

Narrative analysis of verbatim transcripts of 22 naturally occurring consultations, sourced from a corpus of 212 consultations between general practitioners and patients in England. After thematically coding the whole dataset, we selected 22 consultations with particularly engaged patients for in-depth analysis.

RESULTS

Patients oppose further actions more often than they propose actions, and they oppose more directly than they propose. When they explain why they propose and oppose something, they reveal their values. Patients' role-performance changes throughout the consultations.

CONCLUSION

Assertive patients claim - and probably also achieve - most influence when they oppose actions directly and elaborate why. Patients display ambiguous role-expectations. In final concluding stages of decision-making processes, patients usually defer to GPs' authority.

PRACTICE IMPLICATIONS

Clinicians should be attentive to the ways in which patients want to engage in decision-making throughout the whole consultation, with awareness of normative dimensions of both process and content, and the ways in which patient's actions are constrained by their institutional position.

Communication Skills Training: A Means to Promote Time-Efficient Patient-Centered Communication in Clinical Practice

Purpose

We hypothesized that health care providers would behave in a more patient-centered manner after the implementation of communication skills training, without causing the consultation to last longer.

Methods

This study was part of the large-scale implementation of a communication skills training program called "Clear-Cut Communication With Patients" at Lillebaelt Hospital in Denmark. Audio recordings from real-life consultations were collected in a pre-post design, with health care providers' participation in communication skills training as the intervention. The training was based on the Calgary-Cambridge Guide, and audio recordings were rated using the Observation Scheme-12.

Results

Health care providers improved their communication behavior in favor of being more patient-centered. Results were tested using a mixed-effect model and showed significant differences between pre- and postintervention assessments, with a coefficient of 1.3 (95% Cl: 0.35-2.3; P=0.01) for the overall score. The consultations did not last longer after the training.

Conclusions

Health care providers improved their communication in patient consultations after the implementation of a large-scale patient-centered communication skills training program based on the Calgary-Cambridge Guide. This did not affect the length of the consultations.

Patient Involvement in Anesthesia Decision-making: A Qualitative Study of Knee Arthroplasty

BACKGROUND

Calls to better involve patients in decisions about anesthesia-e.g., through shared decision-making-are intensifying. However, several features of anesthesia consultation make it unclear how patients should participate in decisions. Evaluating the feasibility and desirability of carrying out shared decision-making in anesthesia requires better understanding of preoperative conversations. The objective of this qualitative study was to characterize how preoperative consultations for primary knee arthroplasty arrived at decisions about primary anesthesia.

METHODS

This focused ethnography was performed at a U.S. academic medical center. The authors audio-recorded consultations of 36 primary knee arthroplasty patients with eight anesthesiologists. Patients and anesthesiologists also participated in semi-structured interviews. Consultation and interview transcripts were coded in an iterative process to develop an explanation of how anesthesiologists and patients made decisions about primary anesthesia.

RESULTS

The authors found variation across accounts of anesthesiologists and patients as to whether the consultation was a collaborative decision-making scenario or simply meant to inform patients. Consultations displayed a number of decision-making patterns, from the anesthesiologist not disclosing options to the anesthesiologist strictly adhering to a position of equipoise; however, most consultations fell between these poles, with the anesthesiologist presenting options, recommending one, and persuading hesitant patients to accept it. Anesthesiologists made patients feel more comfortable with their proposed approach through extensive comparisons to more familiar experiences.

CONCLUSIONS

Anesthesia consultations are multifaceted encounters that serve several functions. In some cases, the involvement of patients in determining the anesthetic approach might not be the most important of these functions. Broad consideration should be given to both the applicability and feasibility of shared decision-making in anesthesia consultation. The potential benefits of interventions designed to enhance patient involvement in decision-making should be weighed against their potential to pull anesthesiologists' attention away from important humanistic aspects of communication such as decreasing patients' anxiety.

EDITOR’S PERSPECTIVE

Shared decision making: What is the work?

Cooperation has emerged as a fundamental characteristic of human society, and many argue that this ability is the basis for the phenomenal development in our capability as a species. When we focus our attention to the interactions that occur in healthcare, we inevitably notice power asymmetry due to unequal knowledge, experience, and status. However, as many have argued since the 1970s, there is an ethical imperative to respect the agency of individuals, offer information, collaborate, and support deliberation when difficult decisions arise. This process is particularly important when reasonable alternative courses of action exist and where the priorities and preferences of individuals would be expected to sway such decisions. This position article argues that this process, commonly described as shared decision making, involves work that is cognitive, emotional, and relational, and, particularly if people are ill, should have the underpinning goal of restoring autonomy. It covers the origin of the term and describes the core components; it describes how to do the cognitive, emotional, and relational work that is required, and offers a model to guide the process.

Observer Ratings of Shared Decision Making Do Not Match Patient Reports: An Observational Study in 5 Family Medicine Practices

BACKGROUND

Measuring shared decision making (SDM) in clinical practice is important to improve the quality of health care. Measurement can be done by trained observers and by people participating in the clinical encounter, namely, patients. This study aimed to describe the correlations between patients' and observers' ratings of SDM using 2 validated and 2 nonvalidated SDM measures in clinical consultations.

METHODS

In this cross-sectional study, we recruited 238 complete dyads of health professionals and patients in 5 university-affiliated family medicine clinics in Canada. Participants completed self-administered questionnaires before and after audio-recorded medical consultations. Observers rated the occurrence of SDM during medical consultations using both the validated OPTION-5 (the 5-item "observing patient involvement" score) and binary questions on risk communication and values clarification (RCVC-observer). Patients rated SDM using both the 9-item Shared Decision-Making Questionnaire (SDM-Q9) and binary questions on risk communication and values clarification (RCVC-patient).

RESULTS

Agreement was low between observers' and patients' ratings of SDM using validated OPTION-5 and SDM-Q9, respectively (ρ = 0.07; P = 0.38). Observers' ratings using RCVC-observer were correlated to patients' ratings using either SDM-Q9 (rpb = -0.16; P = 0.01) or RCVC-patients (rpb = 0.24; P = 0.03). Observers' OPTION-5 scores and patients' ratings using RCVC-questions were moderately correlated (rφ = 0.33; P = 0.04).

CONCLUSION

There was moderate to no alignment between observers' and patients' ratings of SDM using both validated and nonvalidated measures. This lack of strong correlation emphasizes that observer and patient perspectives are not interchangeable. When assessing the presence, absence, or extent of SDM, it is important to clearly state whose perspectives are reflected.

Patient involvement in micro-decisions in intensive care

OBJECTIVE

The objective of this study was to explore how bedside micro-decisions were made between conscious patients on mechanical ventilation in intensive care and their healthcare providers.

METHODS

Using video recordings to collect data, we explored micro-decisions between 10 mechanically ventilated patients and 60 providers in interactions at the bedside. We first identified the types of micro-decisions before using an interpretative approach to analyze the decision-making processes and create prominent themes.

RESULTS

We identified six types of bedside micro-decisions; non-invited, substituted, guided, invited, shared and self-determined decisions. Three themes were identified in the decision-making processes: 1) being an observer versus a participant in treatment and care, 2) negotiating decisions about individualized care (such as tracheal suctioning or medication),and 3) balancing empowering activities with the need for energy restoration.

CONCLUSION

This study revealed that bedside decision-making processes in intensive care were characterized by a high degree of variability between and within patients. Communication barriers influenced patients' ability to express their preferences. An increased understanding of how micro-decisions occur with non-vocal patients is needed to strengthen patient participation.

PRACTICE IMPLICATIONS

We advise providers to make an effort to solicit patients' preferences when caring for critically ill patients.

Generalized shared decision making approaches and patient problems. Adapting AHRQ's SHARE Approach for Purposeful SDM

OBJECTIVE

Generalized shared decision making (SDM) describes the involvement of patients in choosing options. However, there are many situations in which patients and clinicians make decisions together that don't focus on choosing between options, e.g. problem-solving dialysis and insulin use while traveling. Poor uptake associated with clinicians' perception that SDM doesn't apply to clinical situations they face may reflect the lack of adaptation of generalized SDM approaches to patients' problems. The Purposeful SDM schema published in 2019 identifies problems for which different kinds of SDM are appropriate.

METHODS

The U.S. Agency for Healthcare Research and Quality developed SHARE as a generalized SDM approach. We sought to adapt SHARE to the different problems that patients face using a matrix to relate SHARE steps and Purposeful SDM modes and describe changes in generalized concepts and practices of SDM across these modes.

RESULTS

Many SHARE communicative behaviors applied across modes, although the meaning of SDM terms and practices, e.g. patients involved as problem solvers versus experts, varied substantially.

CONCLUSION

Aspects of SHARE require adaptation to different patient problems.

PRACTICE IMPLICATIONS

SDM in education, practice, and tools may be supported by adapting generalized SDM approaches to patients' problems.

What does 'quality' add? Towards an ethics of healthcare improvement

In this paper, we argue that there are important ethical questions about healthcare improvement which are underexplored. We start by drawing on two existing literatures: first, the prevailing, primarily governance-oriented, application of ethics to healthcare 'quality improvement' (QI), and second, the application of QI to healthcare ethics. We show that these are insufficient for ethical analysis of healthcare improvement. In pursuit of a broader agenda for an ethics of healthcare improvement, we note that QI and ethics can, in some respects, be treated as closely related concerns and not simply as externally related agendas. To support our argument, we explore the gap between 'quality' and 'ethics' discourses and ask about the possible differences between 'good quality healthcare' and 'good healthcare'. We suggest that the word 'quality' both adds to and subtracts from the idea of 'good healthcare', and in particular that the technicist inflection of quality discourses needs to be set in the context of broader conceptualisations of healthcare improvement. We introduce the distinction between quality as a measurable property and quality as an evaluative judgement, suggesting that a core, but neglected, question for an ethics of healthcare improvement is striking the balance between these two conceptions of quality.

Purposeful SDM: A problem-based approach to caring for patients with shared decision making

OBJECTIVE

Patient involvement focused the growth of Shared Decision Making (SDM) in contemporary healthcare practice, research, and education. Whilst important, securing appropriate patient involvement or equipping patients to choose is not necessarily the principal purpose of SDM. The purpose of SDM like all medical decision making is to act well in response to a patient's problem, broadly conceived. In which situations and how SDM addresses patient problems is unclear. We seek to develop a purposeful approach to SDM that is oriented to the kinds of problems that SDM might help resolve.

METHODS

Through vignettes of the experience of a patient, Rachel we demonstrate different kinds of situations in which Rachel, her family, and clinicians need to make decisions together.

RESULTS

Different methods of SDM are needed in situations of: CONCLUSION: SDM may be understood as a range of methods that vary substantially with patients' situations and the purpose that they pursue.

PRACTICE IMPLICATIONS

Clinicians struggle to adopt SDM when they do not see it as relevant to clinical work. Orienting SDM to the problems that patients and clinicians routinely face may further SDM adoption, education, and research.