Shared decision-making presents opportunity for APPs

October 3, 2018

"Advanced practice providers are uniquely positioned to advocate for an individualized approach to patient care through shared decision-making," writes Adele M. Caruso, DNP, CRNP.

Dr. Caruso is a nurse practitioner at the University of Pennsylvania Health System, Philadelphia.

Advanced practice providers (APPs) are uniquely positioned to advocate for an individualized approach to patient care through shared decision-making. Is shared decision-making something we simply talk about? How well are we doing in incorporating this process into our everyday clinical practice? In this blog post, I will give an overview of the shared decision-making process and share strategies for implementing it in your practice.

 

What is shared decision-making?

There is a fine line between paternalism and acting as a facilitator and educator. The earliest mention of shared decision-making dates back to 1982 with the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research’s report, “Making Health Care Decisions” as the President’s Commission summarized the common elements of shared-decision-making as theyrelated to the implications of informed consent in the patient-provider relationship. Since that time, implementation of a shared decision-making process has beenrecommended as part of patient-centered care and is associated with increased patient knowledge,better patient experience, more engagement with care, and possible reduction of medical costs.

Shared decision-making is a “collaborative process between patients and their health care providers relevant to medical decisions where medical options are considered clinically acceptable” (Urol Pract 2016; 5:355-63). Although the principles of shared decision-making are well documented in the form of white papers, guidance about how to best incorporate this process into clinical practice is lacking.

 

Implementing a shared decision-making model

The decision-making process often occurs in the absence of any framework to guide patients. Studies suggest that although providers identify shared decision-making as their preferred style of decision-making over paternalism (BMC Fam Pract 2007; 8:10), fewer than 10% utilize shared decision-making effectively (Cochrane Database Syst Rev 2003; CD001431). Elwyn et al propose a three-step process for incorporating a shared decision-making model into clinical practice (J Gen Intern Med 2012; 27:1361-7). This includes: choice talk, option talk, and decision talk, where the provider supports deliberation throughout the process.

Choice talk refers to making sure that patients know that reasonable options are available. Option talk refers to providing a structured conversation with detailed information about the treatment options with the risks and benefits of treatment outcomes, and decision talk refers to the process of considering preferences-being respectful and responsive based on their risk-benefit profile, their personal utility values (ie,either cure focus or quality of life focus), competing comorbidities, and deciding what is best.

Next:Finding a decision aidFinding a decision aid

In a busy practice, decision aids can facilitate the process of shared decision-making. These tools assist patients in participating in the decision-making process and provide them information regarding their treatment options. Decision aids help patients clarify and communicate the utility values they associate with different features of the treatment options, as well as illuminate their preferences (bit.ly/QIsummitpaper).

When information is presented in a graphic or “theatric” form, patients may more quickly grasp the key aspects of their medical situation. A good decision aid describes the health condition and the benefits and harms of each option in balanced detail. Review for content (not too complex) and for accuracy. Incorporate into your clinical practice, especially for conditions you encounter regularly.

 

APPs’ role in counseling

APPs can manage a variety of urologic conditions that often require extensive counseling and can do so with relative autonomy. This may be a component of their independent practice or in collaboration with their physician colleagues. For instance, examples include conditions such as an elevated PSA or BPH management, patients who require active surveillance for prostate cancer, or the emerging population of patients with small renal masses. Additionally, this APP contribution to urologic practice allows for increased productivity by enabling the urologic surgeon to perform other tasks and the ability for the APP to offer a wider array of services; for example, a small renal mass clinic.

Consider creating and implementing a shared decision-makingmodel of your own. Consider decision aids as part of that model, as many can be incorporated seamlessly and efficiently into the patient encounter.

I say, advocate for an individualized approach and make shared decision-makinga reality in your clinical practice!

 

As always, please feel free to share your perspective by emailing me at UT@advanstar.com.