EVERYTHING YOU NEED TO KNOW ABOUT SHARED DECISION MAKING YOU LEARNED IN KINDERGARTEN By: Donna Dubuc This Kindergarten Lesson is Conflict Free I have no Conflict of Interest to disclose or report. Basic principles Values and beliefs of shared decision making A seesaw has more than two positions Shared decision making is used for preference sensitive situations, where there is no clear cut answer about which treatment option is best (equipoise). Look both ways before you cross the street Shared decision making is a two-way street. You must look at both sides before moving forward. The provider identifies the medical problem and lays out reasonable options. Patients identify and convey goals and concerns relevant to the decision. You are not the boss of me Shared decision making is based on the belief that individual selfdetermination should be encouraged. Clinicians support autonomy by building good relationships and respecting patients’ competence and independence. Sharing is caring The responsibility for preference-sensitive decisions is shared through the creation of a partnership. With their provider’s support, patients won’t feel abandoned or like they have to decide on their own. Using an Options Grid Using a decision support tool in an exam room encounter Take your turn but don’t go first Before offering information to patients, ask what they already know, ask “Have you read or heard anything about lung cancer screening?” Check for understanding. Is the pre-existing knowledge accurate? Don’t stare In the exam room, when you offer a patient a decision aid allow for review time. Busy yourself with another task such as clinical note taking or email while the patient reads and considers the options. Share your crayons When asking a patient to review a list of options or a decision support tool, give them a pen to make notes or circle the options they want to talk more about. Do your homework Know the options available to a patient and the risks and benefits of each. Have decision support tools ready. Write Neatly When no existing decision tool exists, compile a list of options yourself. Buddy up and “hold hands” Sticking together as patient and provider has psychological, social, and emotional factors that will influence deliberation dialogue. Glyn Elwyn breaks down this dialogue into choice talk, option talk, and decision talk. Routines are good A three step model for routine SDM by Glyn Elywn Choice talk: Patients learn a choice exists, and that their personal preferences matter in making that choice Option talk: Patients learn about treatment options in more detail to understand the different harms/benefits and consider the outcomes. Providers check for understanding . Decision talk: Providers support patients in the exploration of what matters most to them. Providers elicit a preference. Check for certainty. Review decision. Ask Permission Before moving from choice or option talk into decision talk, ask permission. “Shall we go on?” “Do you think you know how you feel about your options?” “Do you feel ready to make a decision?” Tell them what you know, not what you believe Offer an objective, unbiased presentation of options to consider. Review the pros and cons of these options. Describe options in practical terms. (+) and (-) = solution Be clear about the pros and cons of different treatment options. Offer a neutral presentation of benefits and harms. Use easy-to-understand examples of risk. (Absolute instead of relative risk) Don’t use your words, use theirs Use plain language. Low literacy and numeracy are obstacles to shared decision making. There are also cultural barriers. Make sure you meet people where they are at to form a partnership for shared decision making. Listen when someone is talking It is essential to understand what matters most to patients and support the process of deliberation. Decisions should be influenced by an exploration of preferences. Ask questions. Encourage a dialogue. Allow for pauses and silence. Listen carefully. Reflect back what is said. Confirm what you hear. Be patient Know that informed patients have to spend time to consider their goals and concerns. It might not happen in one visit. You will not always be “right” Patients are different from each other and their provider. Patients’ decisions may surprise you and be based on priorities you do not share. Respect every decision. When there is no right or wrong, every answer is correct The basic application of shared decision making is for situations when there is no “best” solution. The right answer is what best reflects the patient’s priorities and values. It is also OK to decide not to decide. Make it a habit Integrate shared decision making into routine care as part of existing workflow. Check for and resolve operational conflicts with existing systems, priorities, targets and incentives. BE HAPPY It is important to develop a positive attitude about involving patients in decisions. Say Thank You Based on Glyn Elwyn, PhD et al. “Shared Decision Making: A Model for Clinical Practice. Journal” J Gen Intern Med 27(10):1361-7, 2012. ONE MORE THING YOU LEARNED IN KINDERGARTEN Don’t forget to wash your hands!