1. Values-based Practice An Interdisciplinary event
Bill Fulford and Ashok Handa
Ashok Handa
Collaborating Centre for Values-based Practice
St Catherine’s College, OxfordWednesday 25th November 2015

2. Outline INTRODUCTION Values and values-based practice
Values-based surgical care
Montgomery
2 CASE DISCUSSIONS
3 TAKE HOME TWEAKS
4 Summary

3. Outline INTRODUCTION Values and values-based practice
Values-based surgical care
Montgomery
2 CASE DISCUSSIONS
3 TAKE HOME TWEAKS
4 Summary

4. First Exercise - what are values?
Write down three words (or very short phrases) that mean ‘values’ to you …
Then compare with your neighbour …

5. What are Values? Principles Needs Wishes Preferences Hopes Ambitions
Concerns
Virtues
Etc!

6. What are Values?
Values are individually diverse

7. Resources for working with values
Ethics
Medical humanities
Decision analysis
Health economics
Etc

8. Values-Based Practice adds to these ….
……. a process that supports balanced decision making on diverse values within frameworks of shared values

9. Values-based practice
Together these support balanced dissensual decision making within frameworks of shared values
Ten Key Process Elements
4 Clinical Skills
2 Aspects of the model of service delivery
3 Strong links between VBP and EBP
Partnership in decision-making

10. Values-based practice
Together these support balanced dissensual decision making within frameworks of shared values
Ten Key Process Elements
Awareness Skills
2 Aspects of the model of service delivery
3 Strong links between VBP and EBP
Partnership in decision-making

11. Second Exercise - It’s your decision …
Imagine you have developed early symptoms of a potentially fatal disease …
NICE has approved two possible treatments
TREATMENT A - gives you a guaranteed period of remission but no cure
TREATMENT B - gives you a 50:50 chance of ‘kill or cure’
Your decision – how long a period of remission would you want from Treatment A to choose that treatment rather than go for the 50:50 ‘kill or cure’ from Treatment B?

12. It’s your decision …
“How long a period of remission would I want from Treatment A to choose that treatment rather than go for the 50:50 ‘kill or cure’ from Treatment B?”
Write down your own answer thinking about your decision from own point of view and in your own particular circumstances
Then compare your answer with your neighbours’ answers

13. Choosing treatment A over B …15 7 8 4 3 2 1
No!
>6m
>1y
>1<5
5-10
>10
>25
>80

14. Values-based Practice links science with people
Evidence Based Practice

16. David Sackett’s definition of evidence-based medicine …
… the integration of ~best evidence ~clinical experience ~patient values

17. ‘By patient values we mean the unique preferences, concerns and expectations each patient brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient.’

18. Values-based Practice links science with people
Evidence Based Practice

19. VBP and EBP are partners in the delivery of person-centred care
Values Based Practice
Evidence Based Practice

20. Collaborating Centre

21. valuesbasedpractice.org

22. Key Areas of Collaboration

23. Outline INTRODUCTION Values and values-based practice
Values-based surgical care
Montgomery
2 CASE DISCUSSIONS
3 TAKE HOME TWEAKS
4 Summary

24. Surgery of ‘Old’
School
Dress
Behaviour
Patronage
etc

25. Pitfalls

26. What surgery is about: ‘every man should know his limitations’

27. What surgery is NOT about: ‘feeling lucky today punk?’

28. Background Bill Fulford and meeting at St Catherine’s College
Reflection on surgical practice
3 categories of decisions in clinic/ward/emergency department
Plans for surgical seminar series

29. Surgical seminars 7 seminars to date
Content of 3 word and forced choice exercises
Case based discussions
Multi-disciplinary teams
Patients and patient groups actively involved

30. Surgical seminar outcomes
Feedback very positive
Teams keen to have follow up seminars
Other follow ups
Seminars for Trainees in School of Surgery
HETV Educators forum Dec 2015
Embedded in Oxford UG curriculum 2016
6 further speciality seminars in 2016
Online seminar learning materials
Specialist Nurse seminars eg Midwives

31. How VBP has changed my practice

32. How VBP has changed my practice
‘What would you do doctor?’
Pre-VBP: answer based on my values

33. How VBP has changed my practice
‘What would you do doctor?’
Pre-VBP: answer based on my values
‘What’s important to you?’
Post-VBP: answer based on patient’s values

34. Outline INTRODUCTION Values and values-based practice
Values-based surgical care
Montgomery
2 CASE DISCUSSIONS
3 TAKE HOME TWEAKS
4 Summary

35. The Montgomery Ruling Montgomery (Appellant) v Lanarkshire Health Board (Respondent), April 2015

36. How this will change everyone’s practice
The Montgomery Ruling Montgomery (Appellant) v Lanarkshire Health Board (Respondent), April 2015

37. Background Mrs Nadine Montgomery’s case: The facts:
High risk pregnancy (diabetes) under care of Dr McLellan
Baby born with shoulder dystocia
Child left with serious disabilities
The facts:
Mothers with diabetes are more likely to have a large baby
10% risk of shoulder dystocia
Mrs Montgomery had raised concerns about vaginal delivery, but Dr McLellan's policy was not routinely to advise diabetic women about shoulder dystocia

38. Supreme Court Ruling
Patient should have been told about risk of shoulder dystocia
Judgment as a whole marks shift from ‘prudent clinician’ to ‘prudent patient’ test of consent in health and social care

39. Supreme Court Ruling
Patient should have been told about risk of shoulder dystocia
Judgment as a whole marks shift from ‘prudent clinician’ to ‘prudent patient’ test of consent in health and social care
This is NOT about:
~ ‘bombard(ing) patients with technical detail’
~ offering ‘futile’ treatments

40. Supreme Court Ruling
Patient should have been told about risk of shoulder dystocia
Judgment as a whole marks shift from ‘prudent clinician’ to ‘prudent patient’ test of consent in health and social care
This is NOT about:
~ ‘bombard(ing) patients with technical detail’
~ offering ‘futile’ treatments
What it IS about:
Clinicians engaging in ‘dialogue’ with their patient to the point that
they have sufficient understanding of the risks and benefits of the options available to make a choice that
takes into account ‘her own values’

41. Supreme Court Ruling What it IS about:
Clinicians engaging in ‘dialogue’ with their patient to the point that
they have sufficient understanding of the risks and benefits of the options available to make a choice that
takes into account ‘her own values’

42. Montgomery mandates shift to VBP+EBP

43. Montgomery mandates shift to VBP+EBP
Montgomery decision-making is
Values-based – diversity of individual patient’s values

44. Montgomery mandates shift to VBP+EBP
Montgomery decision-making is
Values-based – diversity of individual patient’s values
Evidence-based – choosing within evidence-based options

45. Montgomery mandates shift to VBP+EBP
Montgomery decision-making is
Values-based – diversity of individual patient’s values
Evidence-based – choosing within evidence-based options
ALSO
3. Feasible - ‘What matters to you?’

46. Montgomery mandates shift to VBP+EBP
Montgomery decision-making is
Values-based – diversity of individual patient’s values
Evidence-based – choosing within evidence-based options
ALSO
Feasible - ‘What matters to you?’
Good value for money!

47. Montgomery and Me: Implementing the New Standard for Consent to Treatment in Medicine and Healthcare
Where? St. Catherine’s College, Oxford
When? Friday October 28th 2016
Confirmed speakers include
Baroness Hale, Deputy President of the Supreme Court and one of the Montgomery judges
Professor Sir John Bell, Regius Professor of Medicine, University of Oxford
Professor Jonathan Herring, Professor of Law, University of Oxford

48. Outline INTRODUCTION Values and values-based practice
Values-based surgical care
Montgomery
2 CASE DISCUSSIONS
3 TAKE HOME TWEAKS
4 Summary

49.  Case 1
28 year old female presents with lactational breast abscess. Baby is 2 months old.
Treatment options are:
Admit for oral antibiotics + incision and drainage
Home on oral antibiotics only
No intervention with explanation of risks
Patient wants to have “strong pain killers” and go home
Things to consider:
Breast feeding and antibiotics
Analgesia to give if discharged
Separation from baby if admitted
Risks and benefits of incision and drainage v no intervention

50. Case 2
19 year old male presents with a 24 hour history of central abdominal pain, now migrated into the right iliac with associated anorexia, nausea and no diarrhoea.
WCC 14.6
Temp. 37.8
CRP <1
Likely diagnosis = acute appendicitis
His parents are present and want him admitted for an appendicectomy but he is very reluctant - sporting commitments
Your options are:
Admit for antibiotics, analgesia and laparoscopic appendicectomy
Admit for observation , analgesia, repeat bloods +/- imaging tomorrow
Discharge and ask to return for further investigations tomorrow
Things to consider:
Is he clinically stable enough for discharge?
Does he need further investigations before proceeding to surgery?
Are there other reasons (e.g. fear) that make him want to go home?

51. Case 3
63 year old obese female presents with 36 hours anorexia, severe RUQ pain after eating and ongoing nausea
Mildly elevated LFTs: bilirubin 24, ALT 57, ALP 144, amylase 32. WCC 14.1, CRP 15
USS multiple gallstones in gallbladder, acute cholecystitis, normal CBD
Options:
Give oral antibiotics and elective laparoscopic cholecystectomy
Admit for antibiotics + emergency laparoscopic cholecystectomy
Discharge home with oral antibiotics, lifestyle advice + outpatients review
Pain subsides with adequate analgesia and patient wants to be discharged today but her husband is reluctant to have her at home
Things to consider:
Why does she not want admission?
Pain may recur
Eating and drinking – often a problem with GB disease, will she need IV fluids?
Emergency v. Elective surgery
Why is the husband nervous about her being discharged?

52. Group work on cases Please read through your case and then
Write down the values you think are in play and from whose perspectives
Reflect on your own values: what would matter to you?
Then discuss as a group
You have 30 mins for this
Please agree one of you to give feedback in the plenary that will follow

53. Outline INTRODUCTION Values and values-based practice
Values-based surgical care
Montgomery
2 CASE DISCUSSIONS
3 TAKE HOME TWEAKS
4 Summary

54. Group work on take home tweaks
For this final session
Think about your own practice
Write down one small change you could make to improve your own values-based practice
You have 15 mins for this
Please be prepared to describe your ‘tweak’ briefly in the plenary that will follow

55. Outline INTRODUCTION Values and values-based practice
Values-based surgical care
Montgomery
2 CASE DISCUSSIONS
3 TAKE HOME TWEAKS
4 Summary

56. SUMMARY INTRODUCTION Diverse values drive diverse decisions
Values-based practice - working with diverse values
Values-based practice in surgical care
Montgomery consent is VB consent
2 CASE DISCUSSIONS
Diversity of values in everyday care
3 TAKE HOME TWEAKS
Values-based practice in everyday care

57. SUMMARY INTRODUCTION Diverse values drive diverse decisions
Values-based practice - working with diverse values
Values-based practice in surgical care
Montgomery consent is VB consent
2 CASE DISCUSSIONS
Diversity of values in everyday care
3 TAKE HOME TWEAKS
Values-based practice in everyday care

58. SUMMARY INTRODUCTION Diverse values drive diverse decisions
Values-based practice - working with diverse values
Values-based practice in surgical care
Montgomery consent is VB consent
2 CASE DISCUSSIONS
Diversity of values in everyday care
3 TAKE HOME TWEAKS
Values-based practice in everyday care

59. What are Values? Principles Needs Wishes Preferences Hopes Ambitions
Concerns
Virtues
Etc!

60. Choosing treatment A over B …15 7 8 4 3 2 1
No!
>6m
>1y
>1<5
5-10
>10
>25
>80

61. SUMMARY INTRODUCTION Diverse values drive diverse decisions
Values-based practice - working with diverse values
Values-based practice in surgical care
Montgomery consent is VB consent
2 CASE DISCUSSIONS
Diversity of values in everyday care
3 TAKE HOME TWEAKS
Values-based practice in everyday care

62. Values-based practice
Together these support balanced dissensual decision making within frameworks of shared values
Ten Key Process Elements
4 Clinical Skills
2 Aspects of the model of service delivery
3 Strong links between VBP and EBP
Partnership in decision-making

63. Values-based practice
Together these support balanced dissensual decision making within frameworks of shared values
Ten Key Process Elements
Awareness Skills
2 Aspects of the model of service delivery
3 Strong links between VBP and EBP
Partnership in decision-making

64. Values-based Practice links science with people
Evidence Based Practice

65. SUMMARY INTRODUCTION Diverse values drive diverse decisions
Values-based practice - working with diverse values
Values-based practice in surgical care
Montgomery consent is VB consentt
2 CASE DISCUSSIONS
Diversity of values in everyday care
3 TAKE HOME TWEAKS
Values-based practice in everyday care

66. What surgery is about: ‘every man should know his limitations’

67. How VBP has changed my practice
‘What would you do doctor?’
Pre-VBP: answer based on my values
‘What’s important to you?’
Post-VBP: answer based on patient’s values

68. SUMMARY INTRODUCTION Diverse values drive diverse decisions
Values-based practice - working with diverse values
Values-based practice in surgical care
Montgomery consent is VB consent
2 CASE DISCUSSIONS
Diversity of values in everyday care
3 TAKE HOME TWEAKS
Values-based practice in everyday care

69. Supreme Court Ruling What it IS about:
Clinicians engaging in ‘dialogue’ with their patient to the point that
they have sufficient understanding of the risks and benefits of the options available to make a choice that
takes into account ‘her own values’

70. Montgomery and Me: Implementing the New Standard for Consent to Treatment in Medicine and Healthcare
Where? St. Catherine’s College, Oxford
When? Friday October 28th 2016
Confirmed speakers include
Baroness Hale, Deputy President of the Supreme Court and one of the Montgomery judges
Professor Sir John Bell, Regius Professor of Medicine, University of Oxford
Professor Jonathan Herring, Professor of Law, University of Oxford

71. SUMMARY INTRODUCTION Diverse values drive diverse decisions
Values-based practice - working with diverse values
Values-based practice in surgical care
Montgomery consent is VB consent
2 CASE DISCUSSIONS
Diversity of values in everyday care
3 TAKE HOME TWEAKS
Values-based practice in everyday care

72. SUMMARY INTRODUCTION Diverse values drive diverse decisions
Values-based practice - working with diverse values
Values-based practice in surgical care
Montgomery consent is VB consent
2 CASE DISCUSSIONS
Diversity of values in everyday care
3 TAKE HOME TWEAKS
Values-based Practice in everyday care

73. LEARN MORE The Collaborating Centre valuesbasedpractice.org
Ashok Handa
Collaborating Centre for Values-based Practice
St Catherine’s College, OxfordWednesday 25th November 2015