Adrian Edwards Shared Decision Making in Cardiology: Training Workshop

Workshop outline

Part One Introduction & Workshop Overview

Aim & Learning Outcomes Aim In-depth skills training in shared decision making Learning Outcomes Have understood and practiced a number of core skills in SDM in Preventive Cardiology context Have worked on the ‘next steps’ for you and your training Page 5

Housekeeping Use of the workbook Microskills & clinical scenarios Role of feedback One caveat… Responsibilities as learners Workshop evaluation Page 5 - 6

Exercise What makes a good decision? 5 minutes Page 7 in workbook

Definition of SDM “Shared decision making is an approach where clinicians and patients communicate together using the best available evidence when faced with the task of making decisions, where patients are supported to deliberate about the possible attributes and consequences of options, to arrive at informed preferences in making a determination about the best action and which respects patient autonomy, where this is desired, ethical and legal” Wikipedia, 2010 Page 7

Models of Clinical Decision Making in the Consultation Paternalistic Informed Choice Shared Decision Making Page 8

I’m fairly sure we made this decision for you last week?

SDM – Why do we do it ? Evidence : Cochrane Review of decision support (O’Connor, 2009; Stacey 2011): – Improves knowledge and more accurate risk perception – Increases participation and comfort with decision – Fewer undecided – Reduces uptake of elective surgery Improves adherence to medication (Joosten, 2008) 48 % inpatients & 30 % outpatients want more involvement in decisions about their care (CQC Patient surveys)

Are patients involved? Wanted more involvement

Shared decision making ‘Involving the patient in the decision making, to the extent that they desire’ Key skills or ‘competences’

Case Study 1 – cardiovascular risk Mr Jones consults his GP for check up on blood pressure and cholesterol levels, motivated by the fact that his father suffered a heart attack at age 52. No other first degree relative has coronary heart disease. Mr Jones is 55 years old and has no history of any disease. He quit smoking ten years ago, and he is renowned for his skills in orienteering. He has no symptoms and does not take any medication. At the first consultation his blood pressure is 160/90 mmHg, total- cholesterol 7.9 mmol/l and non-fasting glucose is 5.3 mmol/l. Mr Jones gets a medical workup including physical examinations, repeated blood pressure measurements and fasting blood tests, and he receives dietary advice. After three months there has not been much of a change. Blood pressure is still 158/96 mmHg, total cholesterol 7.5 mmol/l, HDL cholesterol 1.1 mmol/l, LDL cholesterol 6.1 mmol/l, triglycerides 2.0 mmol/l, glucose 4.3 mmol/l, body mass index 24.5, and hip waist ratio 1.1. His electrocardiogram is normal.. Page 9

Case Study 2 – cardiovascular risk Mrs Jones consults her GP for check up on blood pressure and cholesterol levels, motivated by the fact that her father suffered a heart attack at age 52. No other first degree relative has coronary heart disease. Mrs Jones is 55 years old and has no history of any disease. She smokes 10/day, although used to be fit as a swimming teacher. She has no symptoms and does not take any medication. At the first consultation her blood pressure is 160/90 mmHg, total- cholesterol 6.4 mmol/l ; ratio chol/HDL = 8 (high); and non-fasting glucose is 5.3 mmol/l. Mrs Jones gets a medical workup including physical examinations, ECG, repeated blood pressure measurements and fasting blood tests; QRISK score = 15% over 10 yrs; QD score = 1% for DM over 10 yrs. She returns for discussion about the risk factors and what to do next. Page 9

Part Two Core Skills in SDM Page 10

Key assumptions in SDM 1.An informed patient is desirable and important to you as a health care professional 2.Engaging patients in treatment decisions where there are real options is a desired goal and health care professionals need to support individuals to achieve this 3.A patient who is not informed of the possible consequences of the options is not able to determine what is important to them Page 10

Three Key stages in SDM Page Choice Talk Option Talk Preference Talk Decision Support Brief & Extensive Good Decision D E L I B E R A T I O N Prior Preferences Informed Preferences

Part Three Choice Talk Practice Session Page

Choice talk 35 minutes Core skills Step back Choice exists Justify choice & signpost ‘what’s important to you’ Check reaction Defer closure Page

Part Four Option Talk Practice Session Page

Option Talk 35 minutes Core Skills Check existing knowledge List options Describe options Describe benefits and harms Provide decision support Summarise and check next step Page

Part Five Preference Talk Practice Session Page

Preference talk 15 minutes Core Skills Focus on preferences “what is important to you?” Moving to a decision Review Page

Part Six Practice Session – practicing all the skills Page 21

Part Seven Workshop Summary Page 22

Where does this lead?