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What is Shared Decision Making? Why is it important?

Larry MorrisseyPediatrician (who happens to work with Prostate Cancer)

Medical Director for Quality Improvement Stillwater Medical Group

Chair, Minnesota Shared Decision Making Collaborative (MSDMC)

Why Bother With SDM?

Patient Centered CareProviding care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.

-The Institute of Medicine: Crossing the Quality Chasm

The Patient as the Source of ControlGive the necessary informationGive the opportunity to exercise the degree

of control they choose over health care decisions that affect them

Accommodate differences in patient preferences

Encourage shared decision making

Institute of Medicine Crossing the Quality Chasm

What is shared decision making?

Attitude

ProcessTools

Key Components of SDMKnowledgeKnow that there are options including doing

nothingDiscuss RisksDiscuss BenefitsUnderstand patient preferences and values

and include them in the discussion

What is informed consent?It is a process of communication between a

patient and physician that results in the patient's authorization or agreement to undergo a specific medical intervention.

Has similar elements to SDMKnowledge, alternatives, risks, benefits

Both an ethical obligation and a legal requirement spelled out in statutes and case law in all 50 states.

Source: AMA website

Think of when you bought one of these.

How SDM goes beyond Informed ConsentCollaborative decision making—decide together

vs. accept or reject recommendationGiving the patient the best chance to be

adequately informedExplicit clarification of preferences and valuesAvoidable decision conflict surfaced and resolvedTaking the time to make a good decisionInformed consent is the legal “closing” of the

deal

Why is SDM important?Decisions are often complexPatients want to make a good choiceDecisional conflict often existsNature of the decision will affect our goalsVariation exists in motives for supporting it

EthicalEfficiencyEffectiveness

Ethical ImperativeThe strongest caseRespect the autonomy of the patientAddress the balance between helping and not

doing harmAvoid the danger of undeclared uncertaintyA person cannot express their preferences if

they do not know the choices they have

What is the nature of the intervention?

Effective CareLarge benefitMinimal harmsGood evidence

Preference Sensitive CareAlternatives exist with no clear best choiceDepends on personal valuesHow important are the benefits versus the

harms?

What is a “Quality” Decision?The goal is an informed decision that is based

on patient values and evidence.However:

Knowledge cannot be assumedBenefits and risks are not presented equallyWe can make unwarranted assumptions about

patient preferences and actions

An Important Challenge for Shared-decision MakingWhat outcomes do we expect? Should we expect?

Lower costs (i.e. Commonwealth report)Reduce non-adherenceKnowledge transfer Decrease liability (i.e. an enhanced informed

consent)Should we take a more simple approach? “It’s the

right thing to do.”How do you actually do this well in everyday

practice?

Barriers that Clinicians FearTimeCostAnother thing to doI already know/do thisResistance to the

resultsDifficulty with change

of our roleBeing afraid to take riskHow fast can this go

from a good idea to a proven way of improving the lives of our patients?

How do we make informed decisions based on medical evidence and patient values something people experience all the time?

“ Each one of us matters, has a role to play and makes a difference.”- Jane Goodall

Step one: You can inspire change!

Help them with the ride