Getting to the decision point

I am interested in shared medical decision making, and its value to patients. In an excellent paper on the subject, Charles et al. (Soc Sci Med 1997 Mar;44(5):681-692) identified the critical features of shared decision making in a healthcare context as follows:

That at least two participants, (physician and patient), are involved,
That both parties share information,
That both parties take steps to build a consensus about the preferred treatment,
That an agreement is reached on the treatment to implement.

I think this is a really useful framework for those who think about this issue.

I like to characterise the agreement of both parties as concordance, (a phrase originally applied in a medical context by the Royal Pharmaceutical Society of Great Britain), by which I mean, mutual agreement. If there is mutual agreement to proceed along a specific course, based on full participation by both parties, and an exchange between them, then I think there is concordance.

The agreement, however, leads to another element, and that is an expectation. Because the critical patient is interested in patient informatics, I think that it is important to be clear that the patient has an expectation of the outcome of the agreed course of action.

I think that many health care professionals overlook this aspect, and proceed on the basis of their expectation, rather than the patient's. So what can a patient do?

The key is for both parties to be upfront about their expectations.

Here are some ideas as to how to make that happen:

Inform the doctor about the patient’s problem, including the effect on them personally,
Specify how involved the patient wants to be in making the decision,
Facilitate the inclusion of the patient and doctor's personal values, fears and aspirations,
Inform the patient about their diagnosis, and treatment options,
Identify the specific decision that needs to be made, (including the option of no treatment),
Clarify and illustrate the risk associated with each treatment option,
Identify the patient’s lack of specific knowledge about this condition,
Identify other decisional conflicts [1] [2] that the patient may have,
Identify high quality evidence based information resources,
Identify a set of decision aids [3] [4] to improve knowledge and recall,
Outline a plan and timeframe for the process.

With this list, both parties can look at the process, and make a rational and shared decision as to whether the treatment is appropriate, and in line with good medical practice and the what the patient expects to happen.

Try it out next time you have a medical decision to make. I think it will give you a greater sense of participation and ultimately satisfaction with the outcome, even if the outcome did not meet original expectations due to complications that were considered in the decision making process.

Stay healthy,

Foster

[1] O’Connor A, Rostom A, Fiset V, Tetroe J, Entwhistle V, Llewellyn_Thomas H, Holmes_Rovner M, Barry M, Jones J Decision aids for patients facing health treatment or screening decisions:systematic review 1999 BMJ 319:731-734
[2] Murray E, Davis h, Tai SS, Coulter A, Gray A, Haines A Ransomised controlled trial of an interactive multimedia decision aid on hormone repleacement therapy in primary care 2001 BMJ 323:490
[3] O’Connor a, Rostrom A, Tetroe J, Fiset V, Entwhistle V, Llewellyn-Thomas H, Holmes-Rovner M, Barry M, Jones J Effectiveness of decision aids for people facing health treatment of screening decisions 1999 Best Evid. Health Care Cochrane Colloq. http://www.cochrane.org/reviews/en/ab001431.html
[4] http://decisionaid.ohri.ca/docs/Cochrane_Summary.pdf accessed September 12,2006