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Skip to 0 minutes and 14 seconds ‘What is shared decision making?’Shared decision-making is a term that was first created by a presidential commission set up in the United States to look into improving ways of achieving consent for medical treatment. And that presidential commission consisted of a committee of lawyers, ethicists, and doctors. And it was actually a lawyer that came up with the term shared decision-making as a way of combining both the patient’s perspective on decision-making and the doctor’s perspective on decision-making I think shared decision-making should be used by all health care professionals in all interactions with patients.

Skip to 1 minute and 3 seconds Some of it can be a simple provision of information saying you are allowed choice, or information on the internet, or through paper, or through videos for patients.

Skip to 1 minute and 17 seconds What are the benefits of shared decision making? Certainly, the benefits are to both clinician, patient, family, health care organisation condition as a whole– they consist of reduced regret for both the patient, the family, and the clinicians in particular. What I mean by that is that whether the outcome is good or bad, according to the patient following the surgery, their regret tends to be less if they have had substantial involvement in a decision-making process. So, if they have an operation and they suffer as a consequence, they feel to a degree that at least they’ve had the opportunity to be involved in discussion.

Skip to 1 minute and 57 seconds They’ve understood what complications may arise and they feel unfortunate, and they wish, perhaps, that they had had a good outcome, but the degree of regret they feel is less than if they hadn’t been involved in shared decision-making Similarly as clinicians– both Mike and I have both been involved with patients who subsequently either dies or survived with significant permanent damage. And the change in the way that we’ve provided shared decision-making with patients over the last 10 years, and the increasing amount that we’ve used it, has resulted in fewer regrets on our part even when the patient has died or had a bad outcome.

Skip to 2 minutes and 47 seconds When patients are involved in shared decision-making for major, usually invasive, procedures there is a lower rate of operations than if patients are not involved, of approximately about 20%. So one in five patients who would have had an operation, if the clinicians remained largely in charge if you had surgery– one in five don’t have it if the patient’s are involved much more in understanding the pros and cons of having different treatments. So, from a health care point of view, it would allow us to spend money where it’s wanted by patients rather than spending it in one in five cases on patients who actually would not have wanted that procedure– that operation– if they had been involved in the decision-making process.

Skip to 3 minutes and 39 seconds What are the barriers to shared decision making? I think the barriers to shared decision-making are actually its name. And the problem is everybody understands, or has an understanding of the meaning of the two words. Shared and decision-making are in common parlance. Where the barrier lies is that people don’t have insight into their knowledge about those three word and, therefore, don’t do shared decision-making I’ll give you an example. If you go and ask a group of patients, did they feel they had a shared decision-making consultation, they will give you a much lower response of yes compared to going to the same group of doctors who saw those patients.

Skip to 4 minutes and 34 seconds So, people think they’re doing shared decision-making but they’re not and they don’t have insight into the fact that they’re not. Now, the real crux of shared decision-making is finding out what matters to the patient and how that influences their decision-making This does not come naturally to doctors. Doctors use consultation skills to make diagnoses. And this involves questions that close down. Whereas shared decision-making you have to use open questions, and you have to use questions that patients understand. You also need to gain the trust of the patient for them to share their decision-making with you. I think what John and I have a particular special interest in is shared decision-making for high risk surgery.

Skip to 5 minutes and 32 seconds And the barriers to that are learning how to do the consultations– obtaining the time within your job planning to see a patient for between 30 and 45 minutes. Now, if you go and ask for a consultation for 30 to 45 minutes most hospitals will tell you, we don’t have that resource. We think, if you target the right patients, devoting that time and resource will give you the benefit by reducing wrong patient surgery that has an expensive and poor outcome for patients.

Skip to 6 minutes and 17 seconds What role does risk assessment have in shared decision making? I think it’s a key component.

Skip to 6 minutes and 25 seconds And I think it’s not just risk. It’s really chance of harm or benefit from all the patient treatment options. John has more expertise– Well, I was just going to say, what we need to aim for are tools that will answer those desires of the patients. So the things that the patient wants in the future– we need to term how much that proposed operation will help them achieve those outcomes. So, they usually can include survival. So, it’s reasonable to have a risk assessment tool, but it needs to be survival into the future. So, not 30 days. It needs to be two years, three years, five years, 10 years. It needs to be quality of life during that period.

Skip to 7 minutes and 13 seconds So, what are the things the patient wants to do? And we’ll be having very personal conversations with patients about grandchildren who are getting married. So, we’re often looking at patients who are 80 years old. They may have a niece or grandchild getting married in two or three months time. They’ve got a cancer. Do they have an operation that has risk of killing them or certainly making them less mobile and maybe unable to attend that wedding? How much they want to do that? So, we have patients who decide they’re going to postpone surgery, other patients who want to go ahead with surgery. It’s a very personal thing. And that’s what Mike’s referring to and unlocking it.

Skip to 7 minutes and 48 seconds And the risk assessment tools need to be not just about survival, but hopefully with more patient reported outcome measures, we’re going to colour in the gaps in our knowledge about what these various choices that they have in front of them– how much they’re going to give the patient each of those desires. Well, I think, in terms of surgical risk, most focus is put on 30 day mortality, because that’s what the doctors measure. That is not what a patient measures. No patient goes into an operation with a desire to have a specific 30 day survival. And if we solely concentrate on that, then just about every patient would decide not to have a scheduled surgery.

Skip to 8 minutes and 32 seconds Because their chance of being alive in 30 day is almost always higher if they avoid surgery. For elective surgery. There is very little elective surgery where there is a higher chance of dying without surgery in 30 days.

Skip to 8 minutes and 47 seconds How can shared decision making be achieved? I think we need to develop videos that demonstrate the consultation. And I think they should be done with doctors like ourselves in high risk clinics. They should be done with nurses in preassessment clinics, physiotherapists assessing patients before and after surgery. And I think, actually, you get shared decision-making when you see it and you understand it wasn’t what you were thinking. And talking about it I don’t think gets it. But I think watching it, either by sitting in consultations, or watching videos is the way forward. Yeah, so drop us a line. Come and visit us. Yeah, come and visit Torbay Hospital, high risk shared decision-making clinic. [LAUGHTER] You’re always welcome.

Shared decision-making

Doctors John Carlisle and Michael Swart are consultant anaesthetists who run a high risk shared decision-making clinic at Torbay and Southern Devon Health and Care NHS Trust.

We caught them just after a conference and asked them to outline the importance of shared decision-making and the benefits it can have for patients, healthcare professionals and NHS trusts.

Share your experiences of shared decision making, and how it has benefited your patients. Are there any specific barriers to shared decision-making that you have come across?

In the following step we will investigate aids you can use to help with shared decision-making and also experience a case which demonstrates the benefits of shared decision making in practice.

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Perioperative Medicine in Action

UCL (University College London)