What does a person need in order to make a decision about their healthcare?
The SHARE Approach—Essential Steps of Shared Decisionmaking: Expanded Reference Guide with Sample Conversation Starters
Workshop Curriculum: Tool 2 Show
Cover Note: The SHARE Approach is a 1-day training program developed by the Agency for Healthcare Research and Quality (AHRQ) to help health care professionals work with patients to make the best possible health care decisions. It supports shared decisionmaking through the use of patient-centered outcomes research (PCOR). BackgroundThe concept of engaging patients in their health care decisionmaking to improve the quality of health care in the United States was firmly grounded in the Institute of Medicine (IOM) report: Crossing the Quality Chasm.The IOM defined patient-centered care as "care that is respectful of and responsive to individual patient preferences, needs, and values" and that ensures "that patient values guide all clinical decisions."
The SHARE Approach: Essential Steps of Shared Decisionmaking outlines five steps health care professionals can take to ensure that they are effectively implementing shared decisionaking with patients during clinical encounters. The steps were designed to incorporate the essential elements that have been defined for shared decisionmaking. Essential Steps of Shared Decisionmaking
About This ToolThis tool was designed to help you incorporate the SHARE Approach from the Agency for Healthcare Research and Quality (AHRQ) into your practice. It describes each step in the SHARE Approach, and offers sample conversation starters for you to consider as you engage in meaningful discussions with your patients about their health care options. As you begin implementing the SHARE Approach in practice, you will find that shared decisionmaking is an individualized process with your patient. The SHARE Approach usually begins with inviting your patient to be a part of the decisionmaking process. As you implement the SHARE Approach, you may find that some of the steps overlap with one another. That is okay. The steps are intended to serve as prompts to help ensure you are engaging your patients in their health care decisions through meaningful dialogue about the benefits, harms, and risks of their health care options, and what matters most to them. Use the checklist offered at the end of this document to check off the steps that you used with your patient. Intended Audience for This ToolThis tool is designed for health care professionals who engage in shared decisionmaking discussions with patients. The SHARE ApproachStep 1: Seek your patient's participationStudies suggest that many health care professionals believe that patients are not interested in participating in their health care decisionmaking. While patients may not want to play a prominent role in problem-solving, evidence suggests that most patients want more information than they are routinely given by health care professionals, and many would like to be involved in decisionaking about their health care., Many patients are not aware that they can and should participate in their health care decisionmaking. Additionally, many patients are not aware of the uncertainty in medicine, and that the outcomes of various treatments can be unpredictable at an individual level. Communicate that a choice exists and invite your patient to participate in the process. Tips
Note: Some patients may not want, or be ready, to participate. The active decision not to participate in the decisionmaking process, or to delegate the decision to the provider or a caregiver, should be respected. Step 2: Help your patient explore and compare treatment optionsMany health care decisions have multiple treatment options, including the option of no care. Often no single option is clearly superior. Use evidence-based decisionmaking resources to compare the treatment options. Discussing options with your patient can help you build a trusting relationship. Letting your patients know that there are options available (including watchful waiting), and guiding them through both benefits and risks of each option, can help your patients feel their views are valued and needed. Assess what your patient already knows about his or her options Some of your patients may gather their own information from the Internet, word of mouth, or other sources. It is important to explore what your patient may already know or understand about his or her condition and options.
Write down a list of the options and describe them in plain language Before making an informed decision, your patients need to know all the options available to them. Tips
Clearly communicate the risks and benefits of each option Explain the limitations of what is known and unknown about the treatment options, and what would happen with no treatment. A balanced discussion allows patients to make more informed decisions. It is critical to present both the benefits and risks of each option. These can be presented in the form of trade-offs. For example, "Medicine [xxx] is more expensive than the one you are currently taking, but you will only have to take it once a day." Try These Conversation Starters To Explore Pros and Cons"Let me tell you what the research says about the benefits and risks of the medicines you are considering.""These options may have different effects for you compared with other people, so I want to describe them.""The treatments I just described are not always effective for everyone, and the chances of having side effects can vary from one person to another."
Communicate numbers in a way that your patient can understand Numbers can be a big part of discussing risk and communicating information about the potential benefits and harms of treatments. Communicating numbers can be challenging because even people with high health literacy can have low health numeracy. Refer to Communicating Numbers to Your Patients: A Reference Guide for Health Care Providers (Tool 5) for more information. Tips
Offer evidence-based decision aid tools whenever possible Research has demonstrated that using decision aids in shared decisionmaking with patients has several benefits:
Use evidence-based decision aids and other decision resources to facilitate patient decisionmaking. Decision resources can be presented to your patient in advance of the visit, during the visit, or sent home with your patient to review and consider after his or her visit. Roles for Other Members of the Interdisciplinary Health Care Team Along with prescribing clinicians, other members of the interdisciplinary health care team may be tasked with helping patients and their caregivers in a shared decisionmaking process. They may provide decision tools and resources to help facilitate patient decisionmaking. Try These Conversation Starters When Introducing Decision Aids"These tools have been designed to help you understand your options in more detail.""I have some booklets I want to give you that have information about your condition and the treatment options. They will be able to help you in your decisionmaking process.""This online tool offers a handout as well as a video. The video highlights the pros and cons of each treatment option. Let's discuss your options and go over the benefits and risks at our next visit.""These online resources provide information to patients about the importance of exploring your treatment options. They compare the benefits and risks of each and offer information on options that you may want to discuss at your next visit."
AHRQ Resources for Patients
Use the teach-back technique to check for understanding After presenting the information, it is important to make sure that your patient understands the information you have shared. Ask your patient to explain in his or her own words what the options are. Refer to Using the Teach-Back Technique: A Reference Guide for Health Care Providers (Tool 6) for more information on teach-back technique. If your patient appears apprehensive or actively disagrees, offer additional information or try presenting the information in a different way. Being able to use different approaches, such as Web-based decision aids, printed handouts, or handwritten drawings, will help you adapt to the different ways in which people learn and process information. Look for signs of decisional conflict., Your patient may:
Step 3: Assess your patient's values and preferencesStudies have shown that most health care providers are not aware of the outcomes that matter most to patients., Moreover, a number of studies have shown that patient treatment decisions change after patients become well informed about their options and the associated risks.,, Use effective communication and listening skills to help your patients assess their values and preferences.,, Tips
Assessing preferences matters, especially when patients defer decisions to clinicians Clinicians should ensure that the dialogue reflects important information about the options (e.g., specific procedures, risks, and benefits) and that a patient's preferences are acknowledged. This may impact greatly on achieving satisfactory health outcomes and patient satisfaction. Step 4: Reach a decision with your patientMaking a decision, particularly for complex and potentially life-altering health care conditions, may take time. This is especially true when treatment decisions are irreversible, such as surgery. Patients may not identify their preferred option until they have had time to think it over or speak with others. Patients may also want to talk with family members, friends, or their caregivers before making a decision. This additional time provides a good opportunity to share with patients decision support materials, such as AHRQ consumer summaries and interactive decision aids, or other evidence-based resources, that they can take home and discuss with others. Tips
Step 5: Evaluate your patient's decisionOnce a decision has been made, it will be important to follow up with your patient on how he or she is doing. For patients facing life-threatening conditions, some of the decisions will be irreversible, so careful consideration prior to making a decision is critical (e.g., a decision for mastectomy versus lumpectomy in early stage breast cancer). For many decisions, however, particularly those centered on the management of a chronic illness, decisions can and should be revisited after a trial period. Tips:
Patient buy-in is essential to adherence The patient, not the health care provider, is generally responsible for implementing many of the decisions made during a clinical encounter, particularly decisions made in a primary care setting (e.g., making necessary lifestyle changes or taking medications as prescribed). Patient adherence to treatment plans is enhanced by shared decisionmaking.,, This tool is to be used in conjunction with the Agency for Healthcare Research and Quality's SHARE Approach workshop. To learn more about the workshop, visit http://www.ahrq.gov/shareddecisionmaking. References1. National Research Council. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press, 2001. 2. Makoul G., Clayman M.L. An integrative model of shared decision making in medical encounters. Patient Educ Couns 2006 Mar;60(3):301-12. PMID: 16051459. 3. Légaré F., Ratté S., Gravel K., et al. Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals' perceptions. Patient Educ Couns 2008. Dec;73(3):526-35. PMID: 18752915. 4. Guadagnoli E., Ward P. Patient participation in decision-making. Soc Sci Med 1998 Aug;47(3):329-39. PMID: 9681902. 5.Levinson W., Kao A., Kuby A., et al. Not all patients want to participate in decision making. A national study of public preferences. J Gen Intern Med 2005 Jun;20(6):531-5. PMID: 15987329. 6. Little P., Everitt H., Williamson I., et al. Preferences of patients for patient centred approach to consultation in primary care: observational study. BMJ 2001. 322(7284):468-72. PMID: 11222423. 7. Coulter A., Parsons S., Askham A. Where are the patients in decision-making about their own care? Health Systems and Policy Analysis 2008: p. 1-26. 8. Stacey D., Légaré F., Col N.F., et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2014 Jan 28;1:CD001431. PMID: 24470076. 9. O'Connor A., Jacobsen M. Decisional conflict: Supporting people experiencing uncertainty about options affecting their health. Monograph; 2006. Retrieved from: http://careinaging.duke.edu/longtermcare/dynamic/resources/1027/Decisional_Conflict.pdf (PDF File, 718.58 KB). 10. O'Connor A., Stacey D., Jacobsen M. Improving practitioners’ decision support skills. Decision Support Tutorial. Ottawa Hospital Research Institute. 2011. Retrieved from: https://decisionaid.ohri.ca/ODST/pdfs/ODST.pdf (PDF File, 403.45 KB) 11. Mulley A., Trimble C., Elwyn G. PATIENTS' PREFERENCES MATTER Stop the silent misdiagnosis. Published by The King's Fund 11–13 Cavendish Square London www.kingsfund.org.uk © The King's Fund. 2012. 12. Ubel P.A., Angott A.M., Zikmund-Fisher B.J. Physicians recommend different treatments for patients than they would choose for themselves. Arch Intern Med 2011 Apr 11;171(7):630-4. PMID: 21482835. 13. Murray E., Charles C., Gafni A. Shared decision-making in primary care: tailoring the Charles et al. model to fit the context of general practice. Patient Educ Couns 2006 Aug;62(2):205-11. PMID: 16139467. 14. BeLue R., Butler J., Kuder J. Implications of patient and physician decision making: an illustration in treatment options for coronary artery disease. J Ambul Care Manage 2004 Oct-Dec;27(4):305-13. PMID: 15495743. 15. Thompson L., McCabe R. The effect of clinician-patient alliance and communication on treatment adherence in mental health care: a systematic review. BMC Psychiatry 2012 Jul 24;12:87. PMID: 22828119. 16. Duncan E., Best C., Hagen S. Shared decision making interventions for people with mental health conditions. Cochrane Database Syst Rev 2010 Jan 20;(1):CD007297. PMID: 20091628. Additional References for Sample DialogueEdwards A., Elwyn G., Mulley A., Explaining risks: turning numerical data into meaningful pictures. BMJ 2002 Apr 6;324(7341):827-30. PMID: 11934777. Elwyn G., Frosch D., Thomson R., et al. Shared decision making: a model for clinical practice. J Gen Intern Med 2012 Oct;27(10):1361-7. PMID: 22618581. Epstein R.M., Alper B.S., Quill T.E. Communicating evidence for participatory decision making. JAMA 2004 May 19;291(19):2359-66. PMID: 15150208. Frankel R.M., Stein T. Getting the most out of the clinical encounter: the four habits model. J Med Pract Manage 2001 Jan-Feb;16(4):184-91. PMID: 11317576. ICSI Shared Decision-Making Model. The Collaborative Conversation™. Institute for Clinical Systems Improvement (ICSI). 2012. Retrieved from: https://www.icsi.org/health_initiatives/shared_decisionmaking/collaborative_conversation_model/. O'Connor A., Stacey D., Jacobsen M. Improving practitioners’ decision support skills. Decision Support Tutorial. Ottawa Hospital Research Institute. 2011. Retrieved from: https://decisionaid.ohri.ca/ODST/pdfs/ODST.pdf (PDF File, 95.66 KB). Peters E., Hibbard J., Slovic P., et al. Numeracy skill and the communication, comprehension, and use of risk-benefit information. Health Aff (Millwood) 2007 May-Jun;26(3):741-8. PMID: 17485752. Paling J. Strategies to help patients understand risks. BMJ 2003 Sep 27;327(7417):745-8. PMID: 14512489. Sheridan S.L., Harris R.P., Woolf S.H. Shared decisionmaking about screening and chemoprevention. A suggested approach from the U.S. Preventive Services Task Force. Am J Prev Med 2004 Jan;26(1):56-66. PMID: 14700714. Stacey D., Murray M.A., Légaré F., et al. Decision coaching to support shared decision making: a framework, evidence, and implications for nursing practice, education, and policy. Worldviews Evid Based Nurs 2008;5(1):25-35. PMID: 18266768. Wexler R. Six steps of shared decision making. Informed Medical Decisions Foundation. 2012. Retrieved from: http://informedmedicaldecisions.org/wp-content/uploads/2012/02/Six_Steps_SDM_Language.pdf (PDF File, 172.41 KB). ChecklistUse this checklist to make sure you are incorporating elements of the SHARE Approach with your patients. What should we consider most in making a healthcare decision?The cost, timing and regularity of treatment will affect your healthcare decisions, as will the potential impact on your family, friends and working life. Decisions about your healthcare may be affected by your culture, religion or beliefs.
What is the decision making process in healthcare?Step 1: Seek your patient's participation. Step 2: Help your patient explore and compare treatment options. Step 3: Assess your patient's values and preferences. Step 4: Reach a decision with your patient.
What are the factors that influence decision making in healthcare?Factors such as availability of data, timely access to data and organised information greatly influences the quality of decision-making as illustrated in a causal loop diagram.
What are 5 steps needed for making good health decisions?5 Steps to Good Decision Making. Step 1: Identify Your Goal. One of the most effective decision making strategies is to keep an eye on your goal. ... . Step 2: Gather Information for Weighing Your Options. ... . Step 3: Consider the Consequences. ... . Step 4: Make Your Decision. ... . Step 5: Evaluate Your Decision.. |