1. Concepts Decision Support as a Clinical Skill Module I: Key Concepts Last update: September 2008

2. Key Concepts I. Effective vs. Preference Sensitive Care II. Decisional Conflict III. Shared Decision Making

3. Key Concept I. Effective vs. Preference Sensitive Care Effective Care Benefits are large compared to harms Benefits are large compared to harms Goal is usually to increase uptake Goal is usually to increase uptake  e.g. taking an antibiotic for bacterial pneumonia; having a pap smear, flu vaccine Preference Sensitive Care Benefit/harm ratios are either uncertain or depend on patient values Benefit/harm ratios are either uncertain or depend on patient values Patient participation Patient participation Improves decision quality; Improves decision quality; Prevents overuse of options patients do not value Prevents overuse of options patients do not value  e.g. PSA screening; Tamoxifen for higher risk women; laser eye correction (Wennberg, BMJ, 2002;325:961-4; O’Connor, Legare, Stacey BMJ, 2003;327:736-740)

4. Canadian Task Force on Preventive Health Care / US Task Force (CMAJ 2003; 169: 207-8; Harris et al., Am J Prev Med, 2001; 20:21-35)

5. Decision Making is… A Process of Choosing between A Process of Choosing between courses of action (including inaction) We generally choose options that achieve valued outcomes and avoid undesirable outcomes (values-sensitive or preference sensitive decisions) We generally choose options that achieve valued outcomes and avoid undesirable outcomes (values-sensitive or preference sensitive decisions)

6. Difficult Decisions What are difficult decisions?

7. Have you ever seen a patient like this? unsure what to do unsure what to do unclear about best choice for them unclear about best choice for them concern about bad results concern about bad results waver between choices waver between choices delay decision question what is important distress, tense preoccupied with decision other

8. Key Concept II. Decisional Conflict Uncertainty about which course of action to take Choice dilemma: Simultaneous opposing tendencies to accept and reject a given course of action Janis & Mann, Decision Making, 1977

9. Inherent (Unchangeable) Characteristics of Difficult Decisions  multiple options  outcomes  risky/uncertain  irrevocable  high stakes  value trade-offs: losses versus gains  anticipated regret (NANDA. Tenth conference for Classification of Nursing Diagnoses. 1992.)

10. Modifiable Factors Contributing to Decisional Conflict Lack knowledge Lack knowledge Unrealistic expectations Unrealistic expectations Unclear values Unclear values Unclear about others’ opinions Unclear about others’ opinions Social pressure Lack of support or resources Lack skill or self- confidence

11. Consequences of unresolved decisional conflict 59 times more likely to change mind 59 times more likely to change mind 23 times more likely to delay decision 23 times more likely to delay decision 5 times more likely to have regret 5 times more likely to have regret 3 times more likely to fail knowledge test 3 times more likely to fail knowledge test 19% more likely to blame practitioner for bad outcomes 19% more likely to blame practitioner for bad outcomes Sun, Q. [MSc thesis]. University of Ottawa, 2005. Gattelari & Ward J Med Screen 2004;11:165-169

12. Key Concept III. Shared Decision Making An integrative process between patient and clinician that: An integrative process between patient and clinician that:  Engages the patient in decision making  Provides the patient with information about alternative treatments  Facilitates the incorporation of patient preferences and values into the medical plan (Charles C, Soc Sci Med 1997;44:681)

13. Original Model of Shared Decision Making Clinician shares medical expertise:  diagnosis  treatment choices  probabilities of outcomes Patient shares values and lifestyle preferences:  may be based on past experience with medical choices  may depend on current social situation Together they arrive at an informed, shared decision

14. Decisional Needs  Decisional conflict (uncertainty)  Decision: type, timing, stage, leaning  Knowledge & Expectations  Values clarity  Support/resources  Personal/Clinical Characteristics Quality Informed, values-based Actions Delay, continuance Impact Values-based health outcomes  Reduce regret and blame  Appropriate use & cost of health services Decision Support 1.Clarify decision and needs 2.Provide facts, probabilities 3.Clarify values 4.Support/Guide/Coach 5.Monitor/Facilitate progress British Medical Journal 327:736-740, 2003 OTTAWA DECISION SUPPORT FRAMEWORK

15. Prochaska’s Stages of Change

16. Clinician Role Diagnose problem; Discuss options, roles; Screen for decisional conflict; Refer for decision support Decision Support (Ottawa Decision Support Framework, 1998) Prepare patient to participate in decisions in ways they prefer 1. Assess decisional needs (decisional conflict, knowledge, values clarity, support) 2. Provide decision support tailored to needs (evidence-based patient decision aids, coaching) 3. Evaluate progress in resolving needs and decision quality Patient Role Communicate informed values & preferences shaped by their social circumstances New model of shared decision making for preference sensitive decisions ( Charles C et al., 1997; Coulter A 2002; O’Connor A, Legare F, & Stacey D 2003; O'Connor A et al., 1998) Goal: Informed, values-based decision making

17. Conclusions Decision support is a process of:  Assessing decisional need  Intervening to address individual needs  Evaluating the quality of decision making A Quality Decision is an “Informed Choice”  Informed, Values-based and Acted on Decision quality for preference sensitive decisions improves with shared decision making utilizing:  Patient decision aids  Personal health coaching using a structured decision guide (IPDAS 2005; Kennedy, JAMA, 2002; O’Connor, Cochrane Lib, 2003; O’Connor, 2002) Support Values Clarity Knowledge