Shared Decision Making Michele O’Brien RN,MSN,ACNS-BC, BA Minnesota Oncology Thoracic Oncology Clinical Nurse Specialist

Potential Barriers to Timely Health Care  Financial  Health care system  Patient and family understanding of disease and goal of treatment  Social support  Fear  Transportation  Cultural

National Institutes of Health Analysis  Growth and aging of the U.S. population Medical expenditures for cancer in the year 2020 are projected to be $158 billion (in 2010 dollars)  27 % over 2010  Analysis is online, 1/12/2011, in the Journal of the National Cancer Institute Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, and Brown ML. Projections of the Cost of Cancer Care in the United States: Jan 19, 2011, JNCI, Vol. 103, No. 2.

National Institutes of Health Analysis Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, and Brown ML. Projections of the Cost of Cancer Care in the United States: Jan 19, 2011, JNCI, Vol. 103, No. 2.

Guided Care Reduces Cost  Multi-site, randomized controlled trial of Guided care  Involved 14 primary care teams of 49 physicians, 904 older patients with chronic conditions  8 locations in Baltimore, Washington  Guided care model is a proactive, evidence based health care provided by a physician-nurse team Am J Manag Care. 2009;15(8): )

Guided Care Reduces Cost  Using insurance claims-compared health care services  Guided care patients had 24% fewer hospitalizations 37% fewer skilled nursing facility stays 15% fewer ER visits 29% fewer home care episodes Representing an annual net saving of $75,000 per nurse or $1,364 per patient Am J Manag Care. 2009;15(8): )

How does SDM translate to oncology?

Complex Care Management  Quality of care and medical services for seriously ill patients are key elements in the ongoing debate over health care reform in the US

Pro-active Approach  Aimed to reduce physical and psychological distress includes: Interdisciplinary programs Patient navigation Survivorship/SDM QOL measurements

Quality of Life Predicts Lung Cancer Survival  ROTG 9801 QOL study included patients with locally advanced NSCLC Study of 239 patients found those with QOL score less than median 66.7 had 69% higher death rate Married patients and those with partner had the highest QOL scores Oncology Times: Volume 29 (24)25 December 2007

Early Palliative Care  Study performed at Massachusetts General Hospital, Boston  Eligible patient enrolled within 8 weeks after diagnosis  1:1 randomization  Early palliative care resulted in survival Prolonged by 2 months Clinical improvement QOL and mood N ENGL J MED 363;8 August 19, 2010

Shared Decision Making Model (SDM)  Ongoing process in oncology care  Important to create flow of communication between Physicians, patients and Advanced Practice Nurse  Patient’s need to be evaluated throughout their cancer journey

Minnesota Oncology Survivorship Program  Formalized SDM into survivorship program  Multidisciplinary approach  Goals of program to improve: Clinical outcomes Improve overall QOL Real time evaluation of patients QOL Early interventions Supportive Emotional Functional Patient participation in care Access to advocacy Decrease hospitalizations

Decision Support/Aids Shared Decision Making Collaborative Conversation Map Build Rapport Planning Tailor Intervention Reassess Copyright © 2010 ICSI All Rights Reserved 1 Makoul G, Clayman M, An integrative model of shared decision making in medical encounters, Patient Education and Counseling, 60 (2006)

Patient Presentation  69 year old female  History of smoking 1pack/day for 30 years quit 6 years ago  Married and works full time  Pre-operative chest x-ray for knee surgery revealed abnormality  Asymptomatic for any lung cancer symptoms

Planning Phase  Diagnostics tests revealed masses in left upper and lower lobe  Left upper lobe lung biopsy was positive for lung cancer  Discussion with surgeon about diagnosis and treatment options

Building Rapport  Surgeon provided information Diagnosis Prognosis Surgery  Clinical Nurse Specialist (CNS) met with patient and husband to offer education and support

Tailored Intervention  Formal visit with CNS formal Reviewed understanding of the diagnosis and treatment options Evaluated physical concerns  Recovery from knee surgery  What to expect from lung surgery Emotional concerns  Fear of death and unknown

Decision Support Aids  CNS Identified resources  Educational materials regarding lung cancer, surgery Patient and husband verbalized understanding  Risk and benefits of surgery Provided patient with community resources  Lung cancer support group Identified that if patient had a health care directive Identified who was her support system

Reassess  Patient’s post operative course was uncomplicated  Issues with pain management post operatively  Physician discussion if this represented two separate primary tumors (Stage IB) or a spread LUL and LLL tumors Overall stage determined to be Stage IIIB

Planning Phase  After patient recovered from surgery  Met with oncologist to discuss Prognosis Role of chemotherapy to decrease recurrence risk  Oncologist recommended chemotherapy

Building Rapport  Discussion with Surgeon and Oncologist to review recommendations  CNS met with patient and husband

Tailored Interventions  CNS formal visit Evaluated recovery from surgery Referred patient to respiratory therapy Reviewed  Understanding of pathology results and stage of cancer  Chemotherapy treatment plan Identified concerns about  Next phase of treatment  Discussed fears

Decision Support Aids  CNS Identified resources  Written educational materials regarding chemotherapy Educational resources in clinic  Chemotherapy class

Reassess  Patient followed during chemotherapy Symptom management Coping skills  Completed chemotherapy

Planning  Patient met with oncologist to discuss: Role of maintenance therapy Follow up plan  Patient will start Maintenance therapy couple months after chemotherapy

Tailored Interventions  CNS formal visit Evaluated recovery from chemotherapy Discussed patients concerns about maintenance therapy  Feeling stronger/ more energy  Side effects are resolving  Trying to understand her “new normal” Patient expressed  Wants to do everything she can to keep the cancer from coming back

Decision Support Aids  CNS Identified resources  Written materials regarding maintenance therapy

Reassess  Close observation and counseling regarding clinical management of therapy  Patient experienced Several side effects from maintenance therapy Palliative care  Patient continues on therapy  CNS formal visit Referred patient to Complementary Therapy Center  Guided imagery  Massage Offered counseling regarding the emotional impact the side effects have had

Evaluation of Patient Experience  Improved communication Patient-physicians Patient-nurse Patient-family  Early interventions  Saved hospital re-admission  Increased patient satisfaction

Patient’s Feedback  “The reality of today’s medical care is that physicians do not have the time to sit with a patient and deal with the emotional aspect of a horrible disease.”  “I felt like part of the decision making process.”  “The survivorship program helped me regain my mental health and that lead to my physical recovery.”

Questions? Thank You for your time!