1. Decision Support as a Clinical Skill.
August 2008

2. Workshop Outline Module 1: Context Module 2: Decision support process
Shared decision making
Preference sensitive care
Difficult decisions
Decisional conflict
Module 2: Decision support process
Ottawa Decision Support Framework
Decision Support
Ottawa Personal Decision Guide
Module 3: Communicating risk information
Module 4: Decision support tools
Decision aids
Other resources

3. Key Concepts Shared Decision Making
Effective vs. Preference Sensitive Care
Decisional Conflict
Decision Quality

4. Module 1: Context. Shared decision making. Values-sensitive care
Module 1: Context Shared decision making Values-sensitive care Difficult decisions Decisional conflict
Module 1 is an introduction to the background, research, some of the science of decision making and the basic concepts that are useful as context for the decision support process.

5. Shared Decision Making
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)

6. Original Model of “Shared Decision Making”
Patient shares values and lifestyle preferences:
may be based on past experience with medical choices
may depend on current social situation
Clinician shares medical expertise:
diagnosis
treatment choices
probabilities of outcomes
This model works well, unless the patient is experiencing decisional conflict and is unable to make a decision during the clinical encounter. So, you can either send the patient home “to think about what she wants to do” and get back to you, or…you can use the new model of shared decision making developed by Dr. Annette O’Connor and her team in Ottawa
Together they arrive at an informed, shared decision

7. New model of shared decision making for values-sensitive decisions
Physician Role
Diagnose problem; discuss options, roles; screen for decisional conflict;
refer for decision support
Patient Role
Communicate informed values & preferences shaped by their social circumstances
Goal:
Informed,
values-based
decision making
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
In this new model, the added step for the clinician is to screen for and diagnose decisional conflict. What you do about it will depend on the flow of care and resources in each practice setting.
In addition, the decision-making dyad of clinician and patient has become a triad, with a decision coach as the third party. The clinician trained in decision support coaching can retain this role, but most will not have the time required.
The tool used to structure decision support, the Ottawa Personal Decision Guide (see slides ) is designed as a self-guided tool for patients or as a coaching tool with a trained coach walking the patient through the steps. Thus, a practice may ask a patient to use it on her own, or may train a staff member to administer it.
(Charles C et al., 1997; Coulter A 2002; O’Connor A, Legare F, & Stacey D 2003; O'Connor A et al., 1998)

8. Categories of Care Effective Values-sensitive
Benefits are large compared to harms
Goal is usually to increase uptake
e.g. taking an antibiotic for bacterial pneumonia; having a pap smear, flu vaccine
Values-sensitive
Benefit/harm ratios are either uncertain or depend on patient values
Patient participation
Improves decision quality;
Prevents overuse of options patients do not value
e.g. elective surgery, PSA screening; tamoxifen for higher risk women
The focus of decision support is on values-sensitive decisions
Decisional conflict can occur in any situation where the patient faces a health decision (more on this later), but this is less likely in situations where effective care supported by good evidence is at issue.
People (patients, clinicians) tend to generally be in agreement about effective care, and clinicians generally make a recommendation that is agreed to by the patient.
(Wennberg, BMJ, 2002;325:961-4; O’Connor, Legare, Stacey BMJ; in press)

9. Canadian Task Force on Preventive Health Care / US Task Force
The examples in white are of “effective and ineffective care”
Those is green are examples of values-sensitive decisions that are either close call or there is insufficient information to generate practice guidelines or recommendations. With these decisions, a person’s preference regarding which option to choose is based on personal values and life circumstances.
Decision support has until now focused on the close call or no recommendation decisions, those for which the benefit/harm ratios makes them values-sensitive decisions
(CMAJ 2003; 169: 207-8; Harris et al., Am J Prev Med, 2001; 20:21-35)

10. Decision Making is… A Process of Choosing between
courses of action (including inaction)
We generally want to choose options that achieve valued outcomes and avoid undesirable outcomes

11. Difficult Decisions What are difficult decisions?
The process and framework we are using is designed for ‘tough’ decisions for which no one choice is right for everyone
______________________________________________
What are examples of difficult decisions in your practice?
What make these decisions difficult?
not enough information?
emotions attached to these decisions?
trade-off of benefits and harms: none of the choices have clear benefits and minimal harm
People facing these decisions may experience
DECISIONAL CONFLICT

12. Diagnosing Decisional Conflict
Definition:
Uncertainty about which course of action to take, resulting from…
Simultaneous opposing tendencies to accept and reject a given course of action
Janis & Mann, Decision Making, 1977
Characterized by uncertainty about the best alternative or the most appropriate course of action
“Decisional conflict” comes from the nursing literature;
the North American Nursing Diagnosis Association definition is:
Decisional Conflict is the uncertainty about which course of action to take when choice among competing actions involves risk, loss, regret or challenge to personal life values (specify the focus of conflict, such as personal health, family relationships, career, finances, or other life events)

13. Signs and Symptoms unsure what to do
unclear about best choice for them
concern about bad results
waver between choices
delay decision
question what is important
distressed, anxious, tense
preoccupied with decision
You may not have had a name for it, but chances are you have both seen and experienced these signs and symptoms

14. Inherent (unchangeable) characteristics of difficult decisions:
multiple options
outcomes:
risky/uncertain
irrevocable
high stakes
values trade-offs: losses versus gains
anticipated regret
Inherent factors in a difficult decision cannot be changed -
Competing options
Uncertain or risky outcomes
High stakes (e.g. cancer treatment)
Tradeoffs between losses vs. gains: no one option contains all of the valued outcomes and none of the unwanted outcomes
Anticipated regret – worry that, in retrospect, you won’t be happy with the option you chose
(NANDA. Tenth conference for Classification of Nursing Diagnoses )

15. Modifiable Factors Contributing to Decisional Conflict
Lack knowledge
Unrealistic expectations
Unclear values
Unclear about others’ opinions
Social pressure
Lack of support or resources
Lack skill or self-confidence
There are a number of factors that will make a decision difficult but can be changed; it is these factors that are the focus when addressing decisional conflict. We can assess (diagnosis) and address (treatment) them, then evaluate how well the plan worked (follow up).

16. Consequences of unresolved decisional conflict & related factors
59 times more likely to change mind
23 times more likely to delay decision
5 times more likely to have regret
3 times more likely to fail knowledge test
19% more likely to blame practitioner for bad outcomes
Addressing the modifiable factors contributing to decisional conflict using a decision support process will help to resolve decisional conflict and reduce the likelihood of these potential consequences.
Sun, Q. [MSc thesis]. University of Ottawa, Gattelari & Ward J Med Screen 2004;11:

17. Treating Decisional Conflict
Framework
Ottawa Decision Support Framework (ODSF)
Process (based on framework)
Decision support using the Ottawa Personal Decision Guide© (OPDG)
Walks patients through the process of making a decision
Tools:
Decision Aids
Adjuncts to decision support counseling
Present content and implicit values clarification
Based on the Ottawa Decision Support Framework, decision support is structured to walk through the process of decision making using the Ottawa Personal Decision Guide©. Decision support is enhanced by the addition of a decision aid, if available for the decision being considered.
The OPDG© stands on its own as an effective tool for resolving decisional conflict, with or without a decision aid.

18. Module 2: Decision support process. Ottawa Decision Support Framework
Module 2: Decision support process Ottawa Decision Support Framework Decision Support Ottawa Personal Decision Guide

19. OTTAWA DECISION SUPPORT FRAMEWORK (ODSF)
British Medical Journal 327: , 2003
Decision Quality Informed, values-based
Actions
Delay, continuance
Impact
Values-based health
outcomes
Regret and blame
Appropriate use & cost
of health services
Decisional Needs
Decisional conflict
(uncertainty)
Decision: type, timing, stage,
leaning
Knowledge & Expectations
Values clarity
Support/resources
Personal/Clinical
Characteristics
Dr. Annette O’Connor and her team in Ottawa designed the ODSF,
a framework demonstrating that:
UNRESOLVED decisional needs → adversely affect → decision quality
and that:
DECISION SUPPORT → improves decision quality → by addressing unresolved needs
A good decision is not only informed, as in obtaining informed consent, but also takes into account a person’s values and preferences so that it is truly both informed and a choice.
Moving forward in the decision making process and in acting on the decision is an indicator that it is a quality decision.
Decision Support
Clarify decision and needs
Provide facts, probabilities
Clarify values
Support/Guide/Coach
Monitor/Facilitate progress

20. Health Decisions Best Suited to the ODSF
No clear “choice” that’s right for everyone
Stimulated by new circumstance, medical diagnosis, or developmental transition
Options have different benefit/harm profiles that clients value differently
Careful deliberation --- uncertain outcomes (scientific uncertainty)
More effort in deliberation than in implementation
No clear recommendation, therefore values - sensitive decisions
Situation that stimulates the need to make a decision such as a new circumstance, medical diagnosis or developmental transition (e.g. pregnancy – decisions re: work and child care arrangements, death of a partner –decisions re: changes in lifestyle or living arrangements)
Benefits or harms that clients value differently
e.g. if I have Stage IV lung cancer, I might value having chemotherapy in addition to supportive care if it gives me hope of seeing my daughter get married. However, if I value the quality of life I have remaining, I might prefer just have supportive care.
Some decisions require more effort during deliberation than during implementation:
For example, making a decision about whether or not to have surgery requires effort in deliberation. However, once the decision is made, it is easy to implement.
Whereas, when making a lifestyle decision such as quitting smoking or weight loss, it is much more difficult to implement. Decision support may be helpful in this circumstance, but additional support may be required to assist with long term behavioral change

21. Decision Support Process
Decision support is a process of:
assessing decisional needs: modifiable factors
intervening to address individual needs
evaluating the progress and quality of decision making
Quality decisions:
informed
congruent with personal values
acted upon
THE GOAL OF DECISION SUPPORT IS TO HELP CLIENTS MAKE HIGH QUALITY DECISIONS, WHICH MEANS THEY ARE
informed
based on values
acted upon (implemented)
satisfied with decision.
(O’Connor, Jacobsen, Stacey, JOGNN, 2002)

22. Ottawa Personal Decision Guide©: A tool for implementing decision support
The OPDG is a GENERIC decision support tool that can be used for any decision for which there are at least 2 options to consider.
It is designed to be used independently or with a coach.
It was designed for health and social decision making.
It is likely that you have used most or all of the steps in the Guide when facing a difficult decision (job change, house or car purchase, choice of college), but you may not have applied them systematically or in this order.

23. Step 1 Clarify the Decision
What decision do you face? What is your reason for making this decision? Clarify decision in patient’s own words, this sometimes differs from what the clinician has identified as the decision being made.
Timing: When do you need to make a choice? The plan needs to be tailored to the time pressures. Decisions that have a deadline of months or years may be too “hypothetical” to stimulate completion of the decision-making process; often people thinking about these decisions are either trying to plan ahead or “practicing” so they are better prepared if they ever actually face the choices being considered. Conversely, if the decision must be made within a few days, the plan must be designed so it can realistically be carried out quickly.
Stage: How far along are you with making a choice?
Not thinking about the options (pre-contemplation): medical information may be useful at this stage
Most clients who request decision support counseling are either considering the options or close to choosing an option.
Some have already made a choice (e.g. already scheduled their surgery) but find that DS can help to validate the decision, which may reduce future decisional regret.
Leaning: Are you leaning toward one option?
May already be leaning toward a specific option, even if they know little about the options, pros and cons. It is useful to identify biases (naïve preference) at the beginning. May be based on anecdotal experience of a loved one facing the same choice or on inaccurate public information.

24. Step 2 Identify Decision Making Needs
This is the decisional conflict scale
-Support includes not only emotional support but resources, both financial and practical. See slide 25.
-Knowledge Knowledge gaps are the key. Patients who have not yet thought about the options are not ready to engage in decision support counseling. Similarly, if they have not met with the clinician(s) who have the information on options, pros and cons and likelihood of each pro or con occurring, they are not ready to move forward with decision making. Determine what their knowledge needs are, who they should talk to, and ask them to return for counseling if the DC persists once the knowledge gaps have been addressed.
Values:
Even those who say yes to this benefit from the values clarification exercise in Slide 26.

25. Step 3 Explore Decision Needs: Support
Who else is involved?
Others’ opinions - Help client focus on getting advice from people whose opinions matter to them.
Which option does the person prefer?
Is it different from what the patient is leaning toward?
Is this person pressuring you? Often a family member, sometimes a clinician.
Explore the nature of the pressure:
Source
How important is this person’s opinion?
Points of agreement/disagreement
Is the other person well informed, what are that person’s values? Do they match or conflict with your patient’s values?
How can this person support you?
Handling pressure: plan your communication with the person/people your client needs support from
Communicate patient’s knowledge & values
Consider having a mediator
Role play
Ask the important other person to fill out the guide so you can both see where you match and where you disagree. Your negotiation for that person’s support can focus on the areas of disagreement.
What role do you prefer in making your choice?
Important to recognize and respect desired role in decision making – however some who initially want to delegate decision making to others, feel more empowered to be involved in making the decision once they go through this process.
For example:
we often think that younger people are more likely to want to participate in the decision making, while older individuals are more accustomed to leaving the decision making to their practitioners. This is definitely changing.
In a national survey of Canadians, women were more likely to be the decision makers. This is seen in many cultures where women make most of the health care decisions for themselves and their families. (example – couple where husband needed to make decision but together they explained that the wife is the information gatherer and decision maker and they were both comfortable with these roles)
In some cultures, men are the decision makers..(Middle Eastern, other??)
The Inuits practice group decision making – decisions are made based on what is best for the group rather than for the individual
Women approach decision making differently than men and have higher levels of decisional conflict.
Health status is an important determinant when older individuals are considering options
Desired role may vary for the same person in different circumstances.

26. Step 3 Clarify Values
This is the section of the guide where much of the hard work is done and patients often have an “aha” moment.
It allows them to see, in black and white, what matters most, and how much it matters.
Benefits and risks are put in the context of reasons to choose or avoid an option.
During this discussion knowledge gaps may be revealed and specific questions are identified that need to be answered, and by whom. These questions become part of the PLAN.
Person providing support can help to clear up misconceptions, find information, or refer to other providers
FIRST: list pros and cons as the client identifies them. You may suggest some that they have not considered, and include them if the client views them as important.
SECOND: underline “the benefits and risks that you think are most likely to happen”; this helps realign unrealistic expectations about suffering harm or achieving a desired goal. For clinicians this is one of the most valued outcomes of decision support.
THIRD: Indicate how much each pro and con matters by assigning 1-5 stars
FOURTH: Circle the option that has the benefits that matter most AND are most likely to happen.

27. Step 3 Example
Lets look at an example of a person considering knee replacement for osteoarthritis.
FIRST: list the options (as the patient views them)
SECOND: List pros and cons of each option
You can see this person has some questions about whether repeat surgery would be required and whether he would experience more side effects if he increased the pain medication – this information could be clarified for the patient, or he could be referred back to his clinician to help answer these questions
THIRD: underline the benefits and risks the client thinks are most likely to happen

28. Assess Importance: How Much Each Pro and Con Matters
FOURTH: Indicate how much each pro and con matters by assigning 1-5 stars
Having to quantify how much each potential risk or benefit matters is perhaps the most important step in the decision support process. Attributes that seem important when they are bouncing around in the distressed person’s head may take on a different degree of importance when viewed in the context of the entire list of pros and cons.
FIFTH: Circle the option that has the benefits that matter most AND are most likely to happen (based on percentages derived from evidence-based information).

29. Step 4 Plan Next Steps based on identified needs
The last step is to review decision making status, progress during counseling session, next steps.

30. Using the Ottawa Personal Decision Guide©
1. Form groups of two
‘Client’ making a difficult decision
‘Practitioner’ coaching
‘Client’ choose a real decision
(health, career, education, move, buy a car)
‘Practitioner’ interviews patient & documents on the Ottawa Guide
Discussion
Keep in mind the auto-tutorial content that addressed the attributes of high quality decision coaching:
Listening skills: encouraging, paraphrasing, reflecting feelings, summarizing, validating
Questioning skills: high proportion of open-ended vs. closed questions
Sending messages skills: providing feedback, providing information

31. What happened? What helped?
Ask participants to share their perspectives on using the tool

32. Module 3: Communicating risk information
For clinicians, the focus of their role is on helping patients understand their options and the magnitude of risks and benefits of each option, in ways that are meaningful to the patient. If available, decision aids present this information in a balanced way, and clinicians can then tailor the information so it is specific to the patient and reinforce the information in the decision aid.

33. Presenting Risk Information
Similar profile: Probability of outcome in people ‘like me’ who experience the problem
Format: Use quantitative, qualitative and graphic formats (100 faces) to enhance understanding
Framing: Risk message + ‘Positive’ message improves message framing
This slide shows a woman’s risk of hip fracture for women at low risk (low risk based on how many risk factors were checked earlier in the decision aid.)
The graphic uses several strategies to present risk:
visual presentation of the risk (with 100 faces),
numbers and words
gain and loss framing
The 100 faces graphic has been shown to be more meaningful in terms of communicating percentages than things such as pie charts and bar graphs. This graphic also frames the numbers as both positive (gain) and negative (loss), another good technique to help patients put the chances of a good or bad thing happening in perspective.

34. Helping patients interpret risk information1
Risk of what?
Getting a disease?
Dying from it?
Getting a symptom?
How big is the risk?
Chance that your patient will experience the outcome
“Out of how many?”
Over what timeframe?
An important aspect of decision support is helping patient weigh the pros and cons of the options. This often requires an understanding of the likelihood that a bad thing will happen or a good thing will be achieved. As part of the realignment of unrealistic expectations and the understanding of personal values, it is essential that your patients accurately understand risk information.
Does the risk information reasonably apply to your patient?
Understand whether the information is based on people like your patient (similar age, sex, health status?).
Does the risk information reasonably apply to your patient?
1 From: Schwartz LM, Woloshin, S and Welch HG, “Know Your Chances: Understanding Health Statistics.”

35. How big is the risk?1 A person’s risk of getting colon cancer is:
0.048
4.8%
The average person’s chance of getting colon cancer is…
Less than 1 out of 1000 in the next year
5 out of 1000 in the next 10 years
20 out of 1000 in the next 20 years
48 out of 1000 OVER A LIFETIME*
It is not enough to define the chance of getting colon cancer, as this does not place the information in any context.
Aspects of context:
chance in what timeframe?
chance for the “average person” or for someone with a specific history or set of co-morbidities?
And remember, what the patient may most need to know is not the chance of getting colon cancer, but the chance of dying from it…or the reverse.
And the chance of dying of colon cancer is 17 out of 1000
*In this case, a lifetime is defined as 85 years…

36. Helping patients interpret risk information1
How big is the change in risk?
“Lower than what?”
Explain your patient’s degree change in risk if she does something (e.g., take a drug, changes lifestyle)
vs. if she does not
Does the change in risk information
reasonably apply to your patient?
Are the people this change in risk information is based on similar to your patient? Sex, age, health status?
How big is the change in risk?
When explaining change in risk (e.g., “42% lower”), be sure to explain “Lower than what?” Explain what the risks are if your patient does something (e.g., take a drug, change your lifestyle) versus if she doesn’t.
Does the change in risk information reasonably apply to your patient?
e.g. if a drug decreases risk of death from heart attack in those who have both high cholesterol AND heart disease, does this apply to your patient?
How does this risk compare to other risks?
Provide some context so your patient can develop a sense of just how big (or small) the risk really is.
How does this risk compare to other risks?
Provide some context
From: Schwartz LM, Woloshin, S and Welch HG, “Know Your Chances: Understanding Health Statistics.”

37. NUMBER TRANSLATOR1
1 in ____
____ out of 1000
Percent
1 in 1
1000
100%
1 in 2
500
50%
1 in 3
333
33%
1 in 4
250
25%
1 in 5
200
20%
1 in 6
167
17%
1 in 7
143
14%
1 in 8
125
13%
1 in 9
111
11%
1 in 10
100
10%
1 in 20 50
5.0%
1 in 25 40
4.0%
1 in 50 20
2.0%
1 in 100 10
1.0%
1 in 200 5
0.50%
1 in 250 4
0.40%
1 in 300
3.3
0.33%
1 in 400
2.5
0.25%
1 in 500
2.0
0.20%
1 in 600
1.7
0.17%
1 in 700
1.4
0.14%
1 in 800
1.3
0.13%
Numeracy is challenging even for those who love math; for the rest of us it can be a mystery. Your patient may be a person who prefers to understand chances as a percent, or may do better with 1 in __ or __ out of This table, also available as a handout, is a quick translator for use during conversations about degrees of risk and benefit.
1 From: Schwartz LM, Woloshin, S and Welch HG, “Know Your Chances: Understanding Health Statistics.”

38. This diagram is another way to help patients think about comparing benefits and risks side-by-side in a systematic way.
Like the OPDG, this algorithm puts criteria in order and prioritizes them.
From: Schwartz LM, Woloshin, S
and Welch HG, “Know Your Chances: Understanding Health Statistics.”

39. Module 4: Decision Support Tools

40. Decision Aids
While the OPDG is generic and useful for any health or personal decision, decision aids are designed to address specific decisions.
Decision aids are defined by the International Patient Decision Aid Standards (IPDAS) Collaboration as tools that, “at a minimum,…provide information about the options and their associated relevant outcomes. They also help patients to personalize this information, to understand that they can be involved in choosing among the various options, to appreciate the scientific uncertainties inherent in that choice, to clarify the personal value or desirability of potential benefits relative to potential harms, to communicate their values to their practitioners, and to gain skills in the steps of collaborative decision making.”
Elwyn, et. al. Developing a quality criteria framework for patient decision aids: online international Delphi consensus process. BMJ August 26; 333(7565): 417.

41. Decision Aids adjunct to counseling inform re options, benefits, risks
specify probabilities of outcomes
clarify personal values & norms
guide in deliberating & communicating
DAs may be used with or without decision support counseling
are an adjunct to the decision support process
can enhance but do not replace the clinician-patient decision-making dyad.

42. Improve realistic expectations Lower decisional conflict
Cochrane Review
Decision Aids:
Improve knowledge
Improve realistic expectations
Lower decisional conflict
Increase patient involvement in decision making
Decrease number undecided
Increase agreement between values & choice
Cochrane Systematic Review of Decision Aids has repeatedly demonstrated the value of decision aids.
See:
Decision aids exist in many formats: videos, paper (booklet, booklet with audiotape), web, story board.
See slides for web-based decision aids.
Contact the Foundation for Informed Medical Decision Making at for access to video (DVD, VHS) decision aids.

43. ***** *** **** ** * Benefits and Risks Importance of benefits (pros)
Importance of risks (cons)
Ritalin for ADHD
Pros
Importance
Cons
More focus in school
*****
Don’t like medication
***
Less stressful for family
****
Slowed growth **
Get along better with classmates
Sleep problems *
Many decision aids show side-by-side comparisons of risks and benefits of the available options.

44. Should I have a TURP if I am still bothered by BPH Symptoms?
Should I have a TURP if I am still bothered by BPH Symptoms?
CONS
May die from surgery
(1 man in 100)
May not have normal ejaculations
(75 men in 100)
May not have normal sexual erections
(12 more men in 100)
Importance
*** *
PROS
Better reduction in symptoms
(lowered by 80% compared to 32-48% with other options)
Importance
*****
May be useful to add specific risk data to this –
Having enough information about the probabilities of an outcome can help patients better ‘value’ or determine how important an outcome is to them.
Can improve realistic expectations.

45. Providers’ Perspectives
“It is helpful to have my patients arrive at the consultation with familiarity of the options and knowledge of the risks and benefits”
Richard Barth, MD, surgical oncologist
"With this process, I can focus on helping each individual patient decide the best treatment for her.”
Kari Rosenkranz, MD, surgical oncologist
Providers tell us that when a patient comes to an appointment prepared with a decision aid, the quality and content of the conversation changes. The focus is now on tailoring the options, risks and benefits to that particular patient, and discussing values and preferences. It is no longer necessary to cover background information on what each option is and what the risks and benefits are. Because the patient is so well prepared, shared decision making can often occur during the appointment.

46. Patient Perspective
“At first I wondered what this was all for? It didn't take long for me to understand. The videos were the most helpful tools! I felt peace for the first time in a while. The whole shared decision making concept is wonderful and empowering. Thank you!”
Breast cancer patient

47. Patients’ Perspectives: Herniated Disc
“Before watching the video I was prepared for surgery. Now after watching it I am going to try non-surgical treatments to see if it works.”
“I found the video very informative and helpful and because of it I am more inclined to consider surgery, which is a new position.”
“This video made me realize I need to be more in charge of myself. And that surgery should be a last resort and that other options should be explored.”
“Nothing can replace a question & answer visit with the doctor. The video made it very clear about how undependable the statistics were.”
“The video helps in that “real people” that actually have back issues talked about their own experiences and the choices they made. It helps you understand that you are not alone in your pain, decisions or hardships.”

48. Decision Support Resources

49. The Ottawa Health Research Institute has:
Ottawa Decision Aids: a number of decision aids that they have developed
A decision aid library that links to a large resource of decision aids
The OPDG, their generic decision support tool for any health or social decision

50. Healthwise Decision Points
>100 Decision Points in Healthwise Knowledgebase
Provide Info re:
Summary of ‘Key Points’
Health condition
Options
Who it is appropriate or not appropriate for
Reasons to choose & Reasons not to choose (Pros & Cons) Wise Health Decision
What issues apply to you?
What choice are you leaning toward?
References
Healthwise decision aids are web-based and can be found on WebMd and Healthwise Preferred Care.
The OHRI web site also has links to the Healthwise Decision Points.
See Handouts for printed version
(O’Connor et al., Cochrane Library, 2004; Issue 1: A Decision Aid: provides, at minimum, information on options and outcomes)

51. Shared Decision Making Resources
DHMC Center for Shared Decision Making
Ottawa Health Research Institute
Healthwise Preferred Care
WebMD
Foundation for Informed Medical Decision Making
Health News Review
Healthwise Decision Points are imbedded on several web sites; Preferred Care and Peace Health have no ads, WebMd has many.

52. Conclusions Decision support is a process of:
assessing decisional needs
intervening to address individual needs
evaluating the quality of decision making
A high quality decision is informed, values-based, and acted upon
Decision quality improves with:
Patient decision aids
Personal health coaching using a structured decision guide …

53. Acknowledgements and Thanks
The Foundation for Informed Medical Decision Making
Health Dialog, Inc.
Annette O’Connor, MScN, PhD, FCAHS and the Ottawa Health Research Institute team
John Wennberg, MD, MPH
James N. Weinstein, DO, MS