Adrian Edwards

Shared Decision Making in Cardiology: Training Workshop

Workshop outline

Part One

Introduction & Workshop Overview

Aim & Learning Outcomes

Aim

In-depth skills training in shared decision making

Learning Outcomes

Have understood and practiced a number of core skills in SDM in Preventive Cardiology context

Have worked on the ‘next steps’ for you and your training

Page 5

Housekeeping

• Use of the workbook

• Microskills & clinical scenarios

• Role of feedback

• One caveat…

• Responsibilities as learners

• Workshop evaluation

Page 5 - 6

Exercise

What makes a good decision?

5 minutes

Page 7 in workbook

Definition of SDM

“Shared decision making is an approach where clinicians and

patients communicate together using the best available

evidence when faced with the task of making decisions, where

patients are supported to deliberate about the possible attributes

and consequences of options, to arrive at informed preferences

in making a determination about the best action and which

respects patient autonomy, where this is desired, ethical and

legal”

Wikipedia, 2010

Page 7

Models of Clinical Decision Making in the Consultation

Paternalistic Informed ChoiceShared Decision Making

Page 8

I’m fairly sure we made this decision for you last week?

SDM – Why do we do it ?

Evidence:• Cochrane Review of decision support (O’Connor, 2009; Stacey

2011):

– Improves knowledge and more accurate risk perception

– Increases participation and comfort with decision

– Fewer undecided

– Reduces uptake of elective surgery

• Improves adherence to medication (Joosten, 2008)

• 48 % inpatients & 30 % outpatients want more involvement in decisions about their care (CQC Patient surveys)

Are patients involved?

Wanted more involvement

Shared decision making

‘Involving the patient in the decision making, to the extent

that they desire’

Key skills or ‘competences’

Case Study 1 – cardiovascular risk

• Mr Jones consults his GP for check up on blood pressure and cholesterol levels, motivated by the fact that his father suffered a heart attack at age 52. No other first degree relative has coronary heart disease. Mr Jones is 55 years old and has no history of any disease. He quit smoking ten years ago, and he is renowned for his skills in orienteering. He has no symptoms and does not take any medication.

• At the first consultation his blood pressure is 160/90 mmHg, total-cholesterol 7.9 mmol/l and non-fasting glucose is 5.3 mmol/l. Mr Jones gets a medical workup including physical examinations, repeated blood pressure measurements and fasting blood tests, and he receives dietary advice.

• After three months there has not been much of a change. Blood pressure is still 158/96 mmHg, total cholesterol 7.5 mmol/l, HDL cholesterol 1.1 mmol/l, LDL cholesterol 6.1 mmol/l, triglycerides 2.0 mmol/l, glucose 4.3 mmol/l, body mass index 24.5, and hip waist ratio 1.1. His electrocardiogram is normal.

• .

Page 9

Case Study 2 – cardiovascular risk

• Mrs Jones consults her GP for check up on blood pressure and cholesterol levels, motivated by the fact that her father suffered a heart attack at age 52. No other first degree relative has coronary heart disease. Mrs Jones is 55 years old and has no history of any disease. She smokes 10/day, although used to be fit as a swimming teacher. She has no symptoms and does not take any medication.

• At the first consultation her blood pressure is 160/90 mmHg, total-cholesterol 6.4 mmol/l ; ratio chol/HDL = 8 (high); and non-fasting glucose is 5.3 mmol/l. Mrs Jones gets a medical workup including physical examinations, ECG, repeated blood pressure measurements and fasting blood tests;

• QRISK score = 15% over 10 yrs; QD score = 1% for DM over 10 yrs.

• She returns for discussion about the risk factors and what to do next .

Page 9

Part Two

Core Skills in SDM

Page 10

Key assumptions in SDM

1. An informed patient is desirable and important to you as a health care professional

2. Engaging patients in treatment decisions where there are real options is a desired goal and health care professionals need to support individuals to achieve this

3. A patient who is not informed of the possible consequences of the options is not able to determine what is important to them

Page 10

Three Key stages in SDM

Page 10 - 11

ChoiceTalk

OptionTalk

Preference Talk

Decision Support Brief & Extensive

Good Decision

D E L I B E R A T I O N

Prior Preferences

Informed Preferences

Part Three

Choice Talk Practice Session

Page 12 - 14

Choice talk 35 minutes

Core skills

• Step back

• Choice exists

• Justify choice & signpost ‘what’s important to

you’

• Check reaction

• Defer closure

Page 12 - 14

Part Four

Option Talk Practice Session

Page 15 - 18

Option Talk 35 minutes

Core Skills

• Check existing knowledge

• List options

• Describe options

• Describe benefits and harms

• Provide decision support

• Summarise and check next step

Page 15 - 18

Part FivePreference Talk Practice Session

Page 19 - 20

Preference talk 15 minutes

Core Skills

• Focus on preferences “what is important to you?”

• Moving to a decision

• Review

Page 18 - 19

Part SixPractice Session – practicing all the skills

Page 21

Part SevenWorkshop Summary

Page 22

Where does this lead?