Toward Optimal Decision Making among Vulnerable Patients Referred for Cardiac Surgery: A Qualitative Analysis of Patient and Provider Perspectives

2016 ◽  
Vol 37 (5) ◽  
pp. 600-610 ◽  
Author(s):  
Ryan A. Gainer ◽  
Janet Curran ◽  
Karen J. Buth ◽  
Jennie G. David ◽  
Jean-Francois Légaré ◽  
...  
Keyword(s):  
Decision Making ◽  
Cardiac Surgery ◽  
Focus Groups ◽  
Shared Decision Making ◽  
Consent Process ◽  
Decision Making Process ◽  
Shared Decision ◽  
Provider Perspectives ◽  
Increased Risk ◽  
The Impact

Objectives. Comprehension of risks, benefits, and alternative treatment options has been shown to be poor among patients referred for cardiac interventions. Patients’ values and preferences are rarely explicitly sought. An increasing proportion of frail and older patients are undergoing complex cardiac surgical procedures with increased risk of both mortality and prolonged institutional care. We sought input from patients and caregivers to determine the optimal approach to decision making in this vulnerable patient population. Methods. Focus groups were held with both providers and former patients. Three focus groups were convened for Coronary Artery Bypass Graft (CABG), Valve, or CABG +Valve patients ≥ 70 y old (2-y post-op, ≤ 8-wk post-op, complicated post-op course) (n = 15). Three focus groups were convened for Intermediate Medical Care Unit (IMCU) nurses, Intensive Care Unit (ICU) nurses, surgeons, anesthesiologists and cardiac intensivists (n = 20). We used a semi-structured interview format to ask questions surrounding the informed consent process. Transcribed audio data was analyzed to develop consistent and comprehensive themes. Results. We identified 5 main themes that influence the decision making process: educational barriers, educational facilitators, patient autonomy and perceived autonomy, patient and family expectations of care, and decision making advocates. All themes were influenced by time constraints experienced in the current consent process. Patient groups expressed a desire to receive information earlier in their care to allow time to identify personal values and preferences in developing plans for treatment. Both groups strongly supported a formal approach for shared decision making with a decisional coach to provide information and facilitate communication with the care team. Conclusions. Identifying the barriers and facilitators to patient and caretaker engagement in decision making is a key step in the development of a structured, patient-centered SDM approach. Intervention early in the decision process, the use of individualized decision aids that employ graphic risk presentations, and a dedicated decisional coach were identified by patients and providers as approaches with a high potential for success. The impact of such a formalized shared decision making process in cardiac surgery on decisional quality will need to be formally assessed. Given the trend toward older and frail patients referred for complex cardiac procedures, the need for an effective shared decision making process is compelling.

Abstract 276: A Qualitative Analysis of Shared Decision Making in Cardiac Surgery

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Ryan Gainer ◽  
Karen Buth ◽  
Jennie David ◽  
Rose Garson ◽  
Hani Mufti ◽  
...  
Keyword(s):  
Decision Making ◽  
Cardiac Surgery ◽  
Informed Consent ◽  
Focus Groups ◽  
Shared Decision Making ◽  
Institutional Care ◽  
Consent Process ◽  
Patient Specific ◽  
Shared Decision ◽  
Patient Groups

OBJECTIVES Comprehension of risks, benefits, and alternative treatment options is poor among patients referred for cardiac interventions. We have previously demonstrated that frail, elderly patients undergoing cardiac surgery require complex procedures and are at markedly increased risk of postoperative death and prolonged institutional care. An effective informed consent process is critical in this population. We suggest this vulnerable patient population may benefit from the institution of a formalized shared decision making (SDM) process. METHODS Three focus groups were convened for CABG, Valve, or CABG +Valve patients over 70 who were either within two years post-op, within 4-8 weeks post-op or had had a complicated post-operative course. Two focus groups were convened for the caretaker group: IMCU nurses & ICU nurses and surgeons, anesthesiologists & cardiac intensivists. In a semi-structured interview format, groups were asked questions regarding personal experience with informed consent, comprehension of discussions prior to surgery, potential improvements to the consent process, and SDM in cardiac surgery. Transcribed audio data was analyzed to develop consistent and comprehensive themes. RESULTS Patient groups were supportive of changing standard consent by including patient-specific risk factors through graphics, reduced language complexity and increased font size as means to improve comprehension and discussion. Patient groups felt access to this information earlier on in their care would allow time to identify personal values and desires for treatment. Both care provider groups supported a consent process that would provide patients with information earlier through decisional aids presented in a structured SDM process. All groups were supportive of a dedicated RN employed as a decisional coach to meet with patients and families prior to surgery to discuss their values, concerns, and questions to facilitate SDM with the care team. CONCLUSIONS Data from these groups will aid in the development of decision aids that serve to educate patients about their disease, the procedure proposed, and its risks and alternatives. Utilizing validated risk prediction models from our own experience allows us to provide patient specific risks for in-hospital mortality, major morbidity, and prolonged institutional care as well as long term outcomes freedom from mortality and re-hospitalization for cardiac cause.

Decision aids to prepare patients for shared decision making: Two randomized controlled experiments on the impact of awareness of preference-sensitivity and personal motives

2020 ◽  
Author(s):  
Marie Eggeling ◽  
Simone Korger ◽  
Ulrike Cress ◽  
Joachim Kimmerle ◽  
Martina Bientzle
Keyword(s):  
Decision Making ◽  
Shared Decision Making ◽  
Cruciate Ligament ◽  
Decision Aids ◽  
Future Research ◽  
Control Group ◽  
Decision Making Process ◽  
Shared Decision ◽  
Decision Strategies ◽  
The Impact

Objective: To participate in shared decision-making (SDM), patients need to understand their options and develop trust in their own decision-making abilities. Two experiments investigated the potential of decision aids (DAs) in preparing patients for SDM by raising awareness of preference-sensitivity (Study 1) and showing possible personal motives for decision-making (Study 2) in addition to providing information about the treatment options.Methods: Participants (Study 1: N=117; Study 2: N=217) were put into two scenarios (Study 1: cruciate ligament rupture; Study 2: contraception), watched a consultation video, and were randomized into one of three groups where they received additional information in the form of 1) narrative patient testimonials; 2) non-narrative decision strategies; 3) an unrelated text (control group). Results: Participants who viewed the patient testimonials or decision strategies felt better prepared for a decision (Study 1: P<.001, η²p=0.43; Study 2: P<.001, η²p=0.57) and evaluated the decision-making process more positively (Study 2: P<.001, η²p=0.13) than participants in the control condition. Decision certainty (Study 1: P<.001, η2p=0.05) and satisfaction (Study 1: P<.001, η2p=0.11; Study 2: P=.003, d=0.29) were higher across all conditions after watching the consultation video, and certainty and satisfaction were lower in the control condition (Study 2: P<.001, η²p=0.05).Discussion: DAs that explain preference-sensitivity and personal motives can be beneficial for improving people’s feelings of being prepared and their perception of the decision-making process. To reach decision certainty and satisfaction, being well informed of one’s options is particularly relevant. We discuss the implications of our findings for future research and the design of DAs.

scholarly journals Patient-reported outcomes in RA care improve patient communication, decision-making, satisfaction and confidence: qualitative results

Rheumatology ◽  
2019 ◽  
Vol 59 (7) ◽  
pp. 1662-1670 ◽  
Author(s):  
Susan J Bartlett ◽  
Elaine De Leon ◽  
Ana-Maria Orbai ◽  
Uzma J Haque ◽  
Rebecca L Manno ◽  
...  
Keyword(s):  
Decision Making ◽  
Focus Groups ◽  
Shared Decision Making ◽  
Patient Reported Outcomes ◽  
Medical Decision ◽  
Measurement Information ◽  
Shared Decision ◽  
Clinic Staff ◽  
Patient Reported ◽  
The Impact

Abstract Objective To evaluate the impact of integrating patient-reported outcomes (PROs) into routine clinics, from the perspective of patients with RA, clinicians and other staff. Methods We conducted a prospective cohort study using a mixed methods sequential explanatory design at an academic arthritis clinic. RA patients completed selected Patient-Reported Outcomes Measurement Information System measures on tablets in the waiting room. Results were immediately available to discuss during the visit. Post-visit surveys with patients and physicians evaluated topics discussed and their impact on decision making; patients rated confidence in treatment. Focus groups or interviews with patients, treating rheumatologists and clinic staff were conducted to understand perspectives and experiences. Results Some 196 patients and 20 rheumatologists completed post-visit surveys at 816 and 806 visits, respectively. Focus groups were conducted with 24 patients, 10 rheumatologists and 4 research/clinic staff. PROs influenced medical decision-making and RA treatment changes (38 and 18% of visits, respectively). Patients reported very high satisfaction and treatment confidence. Impact on clinical workflow was minimal after a period of initial adjustment. PROs were valued by patients and physicians, and provided new insight into how patients felt and functioned over time. Reviewing results together improved communication, and facilitated patient-centred care, shared decision making, and the identification of new symptoms and contributing psychosocial/behavioural factors. Conclusion PRO use at RA visits was feasible, increased understanding of how disease affects how patients feel and function, facilitated shared decision-making, and was associated with high patient satisfaction and treatment confidence.

scholarly journals Head to head randomized trial of two decision aids for prostate cancer

2019 ◽  
Author(s):  
Angela Fagerlin ◽  
Margaret Holmes-Rovner ◽  
Timothy P. Hofer ◽  
David Rovner ◽  
Stewart C. Alexander ◽  
...  
Keyword(s):  
Decision Making ◽  
Shared Decision Making ◽  
Decision Aid ◽  
Physician Visit ◽  
Treatment Preference ◽  
Decision Making Process ◽  
Shared Decision ◽  
Patient Centered ◽  
Standard Language ◽  
The Impact

Purpose: While many studies have tested the impact of a decision aid (DA) compared to not receiving any DA, far fewer have tested how different types of DA affect key outcomes such as treatment choice, patient-provider communication, or decision process/satisfaction. This study tested the impact of a typical medical oriented DA compared to a patient centered decision aid designed to encourage shared decision making and the decision making process in men with clinically localized prostate cancer.Patients and Methods: 1028 men at 4 VA hospitals were recruited after a scheduled prostate biopsy. Participants completed baseline measures and were randomized to receive either a patient centered or standard language DA. Participants were men with clinically localized cancer (N = 285) by biopsy and whom completed pre-clinic surveys. Survey measures: baseline (Time 1); immediately prior to seeing the physician for biopsy results (Time 2); one week following the physician visit (Time 3). Outcome measures included treatment preference and treatment received, knowledge, preference for shared decision making, decision making process, and patients’ use and satisfaction with the DA.Results: Participants who received the patient centered DA had greater interest in shared decision making after reading the DA (p=0.03), found the DA more helpful (p’s<0.01) and were more likely to be considering surveillance (p=0.03) compared to those receiving the standard language DA at Time 2. While these differences were present before patients saw their urologists, there was no difference between groups in the treatment patients received.Conclusions: The patient centered DA led to increased desire for shared decision making and for less aggressive treatment. However, these differences disappeared following the physician visit, which appeared to change patients’ treatment preferences.

Abstract 397: Shared Decision Making In Cardiology: Measures Of Shared Decision Making In Patients With Severe Aortic Stenosis Considering Valve Replacement

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
KD Valentine ◽  
Felisha Marques ◽  
Alexandra Selberg ◽  
Laura Flannery ◽  
Nathaniel Langer ◽  
...  
Keyword(s):  
Decision Making ◽  
Cardiac Surgery ◽  
Aortic Stenosis ◽  
Shared Decision Making ◽  
Valve Replacement ◽  
Severe Aortic Stenosis ◽  
Interventional Cardiology ◽  
Decision Making Process ◽  
Concomitant Disease ◽  
Shared Decision

Objective: To identify the degree to which shared decision making (SDM) is occurring for patients with severe aortic stenosis (AS) considering aortic valve replacement (AVR) as measured by the Shared Decision Making Process (SDMP) measure. Methods: Patient eligibility was ascertained via the electronic medical record. Eligible patients were between 18-85, spoke English, were diagnosed with severe AS, either had no prior AVR or had AVR more than 6 months prior, and were at low to intermediate risk for surgical AVR (SAVR). Patients were ineligible if they had a concomitant disease of the aorta or another heart valve that required intervention. Eligible patients were approached in either the Interventional Cardiology or Cardiac Surgery clinic after the respective visit and asked to complete the Shared Decision Making Process (SDMP) Measure, which includes 6 questions with a total score ranging from 0-4. The questions focus on if options were presented (yes/no), preferences elicited (yes/no), and if the pros and cons of transcatheter AVR (TAVR) and SAVR were discussed (“a lot”, “some”, “a little”, or “not at all”). A higher score indicates greater shared decision making occurred. Results: Of 60 enrolled patients, 59 (98%) returned their survey. Most patients were recruited after the visit with an interventional cardiologist (68%, 40 of 59). The average age was 72 years (SD=7 years), all patients were white, 67.8% (40 of 59) were men, and 82.1% (46 of 56) had more than a high school education. There was a trend toward patients reporting higher SDMP scores if patients were recruited in the cardiac surgery clinic (M=3.0, SD=0.7) when compared to those recruited in the interventional cardiology clinic (M=2.6, SD=1.1; t(57)=1.4, p=.164, d=.39). Nearly all (96.6%, 57 of 59) patients stated they were presented with different options to treat their AS and 88.1% (52 of 59) reported discussing the pros of TAVR while 78.0% (46 of 59) discussed SAVR “some” or “a lot.” Conversely, fewer patients stated they discussed the cons of TAVR (57.6%, 34 of 59) or SAVR (49.2%, 29 of 59) “some” or “a lot.” Most patients stated they were asked what they wanted to do to treat their AS (64.4%, 38 of 59). Conclusions: One third of patients did not recall being asked for their preference—a key component of shared decision making conversations. Given the importance of patients being well informed in this preference sensitive decision context, future work should seek to understand both how this multidisciplinary approach may benefit patients, and how to ensure the downsides of options and patient preferences are discussed during the visit.

The impact of patient narratives on medical students’ perceptions of shared decision making: A randomized controlled trial

2020 ◽  
Author(s):  
Martina Bientzle ◽  
Marie Eggeling ◽  
Simone Korger ◽  
Joachim Kimmerle
Keyword(s):  
Decision Making ◽  
Medical Students ◽  
Shared Decision Making ◽  
Medical Training ◽  
Controlled Trial ◽  
Future Research ◽  
Shared Decision ◽  
Randomized Controlled ◽  
Information Text ◽  
The Impact

BACKGROUND: Successful shared decision making (SDM) in clinical practice requires that future clinicians learn to appreciate the value of patient participation as early as in their medical training. Narratives, such as patient testimonials, have been successfully used to support patients’ decision-making process. Previous research suggests that narratives may also be used for increasing clinicians’ empathy and responsiveness in medical consultations. However, so far, no studies have investigated the benefits of narratives for conveying the relevance of SDM to medical students.METHODS: In this randomized controlled experiment, N = 167 medical students were put into a scenario where they prepared for medical consultation with a patient having Parkinson disease. After receiving general information, participants read either a narrative patient testimonial or a fact-based information text. We measured their perceptions of SDM, their control preferences (i.e., their priorities as to who should make the decision), and the time they intended to spend for the consultation.RESULTS: Participants in the narrative patient testimonial condition referred more strongly to the patient as the one who should make decisions than participants who read the information text. Participants who read the patient narrative also considered SDM in situations with more than one treatment option to be more important than participants in the information text condition. There were no group differences regarding their control preferences. Participants who read the patient testimonial indicated that they would schedule more time for the consultation.CONCLUSIONS: These findings show that narratives can potentially be useful for imparting the relevance of SDM and patient-centered values to medical students. We discuss possible causes of this effect and implications for training and future research.

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