A panel of experts has put together a guide to implementing shared decision-making that provides tips for integrating the model into busy oncology practices.
A panel of healthcare experts has put together a practical guide to implementing shared decision-making that summarizes its benefits and challenges and provides tips for integrating the model into busy oncology practices.
Shared decision-making is different than simply providing patients with evidence-based information, wrote the authors of a review article published in CA: A Cancer Journal for Clinicians. The goal is to create a plan of care that is both consistent with medical evidence and personalized to each patient by helping patients and families make decisions that take into account their specific needs, values, and preferences.
Surveys suggest that many oncologists are interested in engaging patients and families in treatment decisions but perceive practical barriers, the authors said. Some of the most commonly cited include time constraints, insufficient provider training, and inadequate clinical information systems. Physicians also express concerns related to patient anxiety, misinformation, and unwillingness to participate.
The authors acknowledged that while shared decision-making is likely to improve patient outcomes, the process is complex and puts significant demands on physicians’ time. Care often involves multiple specialists and decision points when patients need to understand how one decision affects another, such as the implications of undergoing neoadjuvant therapy on surgery treatment options, and vice versa. In addition, patients often need to revisit decisions as their goals and preferences evolve.
Cancer patients benefit most from shared decision-making when they must choose which of several reasonable treatment options is most compatible with their individual preferences and values, the authors said. For example, if lumpectomy and mastectomy are both viable options, a woman must prioritize the value she places on preserving her breast, avoiding radiation treatment, and achieving peace of mind regarding local recurrence.
“Patient involvement in decision-making is also important when considering treatment goals, such as choosing a less aggressive (and potentially less efficacious) treatment to provide increased quality of life,” the authors wrote. “Shared decision-making is also critical in cancer treatment decisions involving limited or conflicting evidence or with high degrees of uncertainty. In these situations, clinicians need to help patients understand the uncertainties and elicit patient preferences and emotional responses to uncertainties.”
Asking patients upfront about their preferences can help oncologists maximize the time spent on shared decision-making because not all patients want or require the same level of support, the authors said. They also recommended using a team approach, with nurses, patient navigators, and other staff playing key roles in providing information and tools and addressing questions.
As a guide to implementation, the authors included an adapted version of the Informed Medical Decisions Foundation’s six-step strategy, which includes the following:
1. Invite the patient to participate: Let the patient know that he or she has options and that their goals and concerns are a key part of the decision-making process.
2. Present the available treatment options.
3. Provide information on benefits and risks based on the best medical evidence and ensure patients correctly understand the information.
4. Assist patients in evaluating options based on their goals and concerns: Ask about patients’ priorities and concerns.
5. Facilitate deliberation and decision-making by letting patients know they have time to consider choices and asking what else they need to feel comfortable making decisions.
6. Implement shared decision-making: Identify and present the next steps, assess whether the patient understands, and discuss any possible challenges with implementation. For example, you might start a conversation with, “Sometimes things in medicine aren't as clear as most people think. Let's work together so we can come up with the decision that's right for you,” or “People have different goals and concerns. As you think about your options, what's important to you?”