Shared decision making in older patients with symptomatic severe aortic stenosis: a systematic review

This review provides an overview of the status of shared decision making (SDM) in older patients regarding treatment of symptomatic severe aortic stenosis (SSAS). The databases Embase, Medline Ovid, Cinahl and Cochrane Dare were searched for relevant studies from January 2002 to May 2018 regarding perspectives of professionals, patients and caregivers; aspects of decision making; type of decision making; application of the six domains of SDM; barriers to and facilitators of SDM. The systematic search yielded 1842 articles, 15 studies were included. Experiences of professionals and informal caregivers with SDM were scarcely found. Patient refusal was a frequently reported result of decision making, but often no insight was given into the decision process. Most studies investigated the ‘decision’ and ‘option’ domains of SDM, yet no study took all six domains into account. Problem analysis, personalised treatment aims, use of decision aids and integrating patient goals in decisions lacked in all studies. Barriers to and facilitators of SDM were ‘individualised formal and informal information support’ and ‘patients’ opportunity to use their own knowledge about their health condition and preferences for SDM’. In conclusion, SDM is not yet common practice in the decision making process of older patients with SSAS. Moreover, the six domains of SDM are not often applied in this process. More knowledge is needed about the implementation of SDM in the context of SSAS treatment and how to involve patients, professionals and informal caregivers.

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Professionals’ views on shared decision-making in severe aortic stenosis

Heart ◽

10.1136/heartjnl-2021-320194 ◽

2021 ◽

pp. heartjnl-2021-320194

Author(s):

Judith J A M van Beek-Peeters ◽

Jop B L van der Meer ◽

Miriam C Faes ◽

Annemarie J B M de Vos ◽

Martijn W A van Geldorp ◽

...

Keyword(s):

Decision Making ◽

Aortic Stenosis ◽

Shared Decision Making ◽

Nurse Practitioners ◽

Patient Participation ◽

Severe Aortic Stenosis ◽

Shared Responsibility ◽

Health Improvement ◽

Decision Making Process ◽

Shared Decision

ObjectiveTo provide insight into professionals’ perceptions of and experiences with shared decision-making (SDM) in the treatment of symptomatic patients with severe aortic stenosis (AS).MethodsA semistructured interview study was performed in the heart centres of academic and large teaching hospitals in the Netherlands between June and December 2020. Cardiothoracic surgeons, interventional cardiologists, nurse practitioners and physician assistants (n=21) involved in the decision-making process for treatment of severe AS were interviewed. An inductive thematic analysis was used to identify, analyse and report patterns in the data.ResultsFour primary themes were generated: (1) the concept of SDM, (2) knowledge, (3) communication and interaction, and (4) implementation of SDM. Not all respondents considered patient participation as an element of SDM. They experienced a discrepancy between patients’ wishes and treatment options. Respondents explained that not knowing patient preferences for health improvement hinders SDM and complicating patient characteristics for patient participation were perceived. A shared responsibility for improving SDM was suggested for patients and all professionals involved in the decision-making process for severe AS.ConclusionsProfessionals struggle to make highly complex treatment decisions part of SDM and to embed patients’ expectations of treatment and patients’ preferences. Additionally, organisational constraints complicate the SDM process. To ensure sustainable high-quality care, professionals should increase their awareness of patient participation in SDM, and collaboration in the pathway for decision-making in severe AS is required to support the documentation and availability of information according to the principles of SDM.

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A LEARNING CURVE FOR SHARED DECISION MAKING: THE IMPACT OF PHYSICIAN EXPERIENCE ON DECISION AID EFFICACY IN SEVERE AORTIC STENOSIS

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(18)33187-5 ◽

2018 ◽

Vol 71 (11) ◽

pp. A2646 ◽

Cited By ~ 1

Author(s):

Megan Coylewright ◽

Elizabeth O'Neill ◽

Ariel Sherman ◽

Megan J. Gerling ◽

Kaavya Adam ◽

...

Keyword(s):

Decision Making ◽

Aortic Stenosis ◽

Learning Curve ◽

Shared Decision Making ◽

Decision Aid ◽

Severe Aortic Stenosis ◽

Shared Decision ◽

The Impact

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Barriers and facilitators for shared decision making in older patients with multiple chronic conditions: a systematic review

BMC Geriatrics ◽

10.1186/s12877-021-02050-y ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Ruth E. Pel-Littel ◽

Marjolein Snaterse ◽

Nelly Marela Teppich ◽

Bianca M. Buurman ◽

Faridi S. van Etten-Jamaludin ◽

...

Keyword(s):

Decision Making ◽

Shared Decision Making ◽

Health Professionals ◽

Chronic Conditions ◽

Older Patients ◽

Informal Caregivers ◽

Poor Health ◽

Barriers And Facilitators ◽

Multiple Chronic Conditions ◽

Shared Decision

Abstract Background The aim of this study was to describe barriers and facilitators for shared decision making (SDM) as experienced by older patients with multiple chronic conditions (MCCs), informal caregivers and health professionals. Methods A structured literature search was conducted with 5 databases. Two reviewers independently assessed studies for eligibility and performed a quality assessment. The results from the included studies were summarized using a predefined taxonomy. Results Our search yielded 3838 articles. Twenty-eight studies, listing 149 perceived barriers and 67 perceived facilitators for SDM, were included. Due to poor health and cognitive and/or physical impairments, older patients with MCCs participate less in SDM. Poor interpersonal skills of health professionals are perceived as hampering SDM, as do organizational barriers, such as pressure for time and high turnover of patients. However, among older patients with MCCs, SDM could be facilitated when patients share information about personal values, priorities and preferences, as well as information about quality of life and functional status. Informal caregivers may facilitate SDM by assisting patients with decision support, although informal caregivers can also complicate the SDM process, for example, when they have different views on treatment or the patient’s capability to be involved. Coordination of care when multiple health professionals are involved is perceived as important. Conclusions Although poor health is perceived as a barrier to participate in SDM, the personal experience of living with MCCs is considered valuable input in SDM. An explicit invitation to participate in SDM is important to older adults. Health professionals need a supporting organizational context and good communication skills to devise an individualized approach for patient care.

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Abstract 397: Shared Decision Making In Cardiology: Measures Of Shared Decision Making In Patients With Severe Aortic Stenosis Considering Valve Replacement

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/hcq.13.suppl_1.397 ◽

2020 ◽

Vol 13 (Suppl_1) ◽

Author(s):

KD Valentine ◽

Felisha Marques ◽

Alexandra Selberg ◽

Laura Flannery ◽

Nathaniel Langer ◽

...

Keyword(s):

Decision Making ◽

Cardiac Surgery ◽

Aortic Stenosis ◽

Shared Decision Making ◽

Valve Replacement ◽

Severe Aortic Stenosis ◽

Interventional Cardiology ◽

Decision Making Process ◽

Concomitant Disease ◽

Shared Decision

Objective: To identify the degree to which shared decision making (SDM) is occurring for patients with severe aortic stenosis (AS) considering aortic valve replacement (AVR) as measured by the Shared Decision Making Process (SDMP) measure. Methods: Patient eligibility was ascertained via the electronic medical record. Eligible patients were between 18-85, spoke English, were diagnosed with severe AS, either had no prior AVR or had AVR more than 6 months prior, and were at low to intermediate risk for surgical AVR (SAVR). Patients were ineligible if they had a concomitant disease of the aorta or another heart valve that required intervention. Eligible patients were approached in either the Interventional Cardiology or Cardiac Surgery clinic after the respective visit and asked to complete the Shared Decision Making Process (SDMP) Measure, which includes 6 questions with a total score ranging from 0-4. The questions focus on if options were presented (yes/no), preferences elicited (yes/no), and if the pros and cons of transcatheter AVR (TAVR) and SAVR were discussed (“a lot”, “some”, “a little”, or “not at all”). A higher score indicates greater shared decision making occurred. Results: Of 60 enrolled patients, 59 (98%) returned their survey. Most patients were recruited after the visit with an interventional cardiologist (68%, 40 of 59). The average age was 72 years (SD=7 years), all patients were white, 67.8% (40 of 59) were men, and 82.1% (46 of 56) had more than a high school education. There was a trend toward patients reporting higher SDMP scores if patients were recruited in the cardiac surgery clinic (M=3.0, SD=0.7) when compared to those recruited in the interventional cardiology clinic (M=2.6, SD=1.1; t(57)=1.4, p=.164, d=.39). Nearly all (96.6%, 57 of 59) patients stated they were presented with different options to treat their AS and 88.1% (52 of 59) reported discussing the pros of TAVR while 78.0% (46 of 59) discussed SAVR “some” or “a lot.” Conversely, fewer patients stated they discussed the cons of TAVR (57.6%, 34 of 59) or SAVR (49.2%, 29 of 59) “some” or “a lot.” Most patients stated they were asked what they wanted to do to treat their AS (64.4%, 38 of 59). Conclusions: One third of patients did not recall being asked for their preference—a key component of shared decision making conversations. Given the importance of patients being well informed in this preference sensitive decision context, future work should seek to understand both how this multidisciplinary approach may benefit patients, and how to ensure the downsides of options and patient preferences are discussed during the visit.

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Decision-Making of Older Patients in Context of the Doctor-Patient Relationship: A Typology Ranging from “Self-Determined” to “Doctor-Trusting” Patients

International Journal of Family Medicine ◽

10.1155/2013/478498 ◽

2013 ◽

Vol 2013 ◽

pp. 1-10 ◽

Cited By ~ 14

Author(s):

Jennifer Wrede-Sach ◽

Isabel Voigt ◽

Heike Diederichs-Egidi ◽

Eva Hummers-Pradier ◽

Marie-Luise Dierks ◽

...

Keyword(s):

Decision Making ◽

Shared Decision Making ◽

Information Seeking ◽

Older Patients ◽

Self Determination ◽

Shared Decision ◽

Patient Relationship ◽

Doctor Patient Relationship ◽

Good Doctor ◽

Patient Decision Making

Background. This qualitative study aims to gain insight into the perceptions and experiences of older patients with regard to sharing health care decisions with their general practitioners. Patients and Methods. Thirty-four general practice patients (≥70 years) were asked about their preferences and experiences concerning shared decision making with their doctors using qualitative semistructured interviews. All interviews were analysed according to principles of content analysis. The resulting categories were then arranged into a classification grid to develop a typology of preferences for participating in decision-making processes. Results. Older patients generally preferred to make decisions concerning everyday life rather than medical decisions, which they preferred to leave to their doctors. We characterised eight different patient types based on four interdependent positions (self-determination, adherence, information seeking, and trust). Experiences of a good doctor-patient relationship were associated with trust, reliance on the doctor for information and decision making, and adherence. Conclusion. Owing to the varied patient decision-making types, it is not easy for doctors to anticipate the desired level of patient involvement. However, the decision matter and the self-determination of patients provide good starting points in preparing the ground for shared decision making. A good relationship with the doctor facilitates satisfying decision-making experiences.

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It may help you to know. . .": The early phase qualitative development of a rheumatoid arthritis goal elicitation tool

The Journal of Rheumatology ◽

10.3899/jrheum.201615 ◽

2021 ◽

pp. jrheum.201615

Author(s):

Julie Kahler ◽

Ginnifer Mastarone ◽

Rachel Matsumoto ◽

Danielle ZuZero ◽

Jacob Dougherty ◽

...

Keyword(s):

Rheumatoid Arthritis ◽

Decision Making ◽

Shared Decision Making ◽

Treatment Guidelines ◽

Training Session ◽

Clinic Visit ◽

Shared Decision ◽

Communication Tool ◽

Group Setting ◽

Patient Goals

Objective Treatment guidelines for rheumatoid arthritis (RA) include a patient-centered approach and shared decision making which includes a discussion of patient goals. We describe the iterative early development of a structured goal elicitation tool to facilitate goal communication for persons with RA and their clinicians. Methods Tool development occurred in three phases: 1) clinician feedback on the initial prototype during a communication training session; 2) semi-structured interviews with RA patients; and 3) community stakeholder feedback on elements of the goal elicitation tool in a group setting and electronically. Feedback was dynamically incorporated into the tool. Results Clinicians (n=15) and patients (n=10) provided feedback on the tool prototypes. Clinicians preferred a shorter tool de-emphasizing goals outside of their perceived treatment domain or available resources, highlighted the benefits of the tool to facilitate conversation but raised concern regarding current constraints of the clinic visit. Patients endorsed the utility of such a tool to support agenda setting and prepare for a visit. Clinicians, patients, and community stakeholders reported the tool was useful but identified barriers to implementation that the tool could itself resolve. Conclusion A goal elicitation tool for persons with RA and their clinicians was iteratively developed with feedback from multiple stakeholders. The tool can provide a structured way to communicate patient goals within a clinic visit and help overcome reported barriers, such as time constraints. Incorporating a structured communication tool to enhance goal communication and foster shared decision making may lead to improved outcomes and higher quality care in RA.

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Involvement of people with dementia in making decisions about their lives: a qualitative study that appraises shared decision-making concerning daycare

BMJ Open ◽

10.1136/bmjopen-2017-018337 ◽

2017 ◽

Vol 7 (11) ◽

pp. e018337 ◽

Cited By ~ 4

Author(s):

Leontine Groen-van de Ven ◽

Carolien Smits ◽

Fuusje de Graaff ◽

Marijke Span ◽

Jan Eefsting ◽

...

Keyword(s):

Decision Making ◽

Qualitative Study ◽

Shared Decision Making ◽

Critical Points ◽

Informal Caregivers ◽

Case Managers ◽

Shared Decision ◽

People With Dementia ◽

Informed Preferences ◽

Adapted Process

ObjectiveTo explore how people with dementia, their informal caregivers and their professionals participate in decision making about daycare and to develop a typology of participation trajectories.DesignA qualitative study with a prospective, multiperspective design, based on 244 semistructured interviews, conducted during three interview rounds over the course of a year. Analysis was by means of content analysis and typology construction.SettingCommunity settings and nursing homes in the Netherlands.Participants19 people with dementia, 36 of their informal caregivers and 38 of their professionals (including nurses, daycare employees and case managers).ResultsThe participants’ responses related to three critical points in the decision-making trajectory about daycare: (1) the initial positive or negative expectations of daycare; (2) negotiation about trying out daycare by promoting, resisting or attuning to others; and (3) trying daycare, which resulted in positive or negative reactions from people with dementia and led to a decision. The ways in which care networks proceeded through these three critical points resulted in a typology of participation trajectories, including (1) working together positively toward daycare, (2) bringing conflicting perspectives together toward trying daycare and (3) not reaching commitment to try daycare.ConclusionShared decision making with people with dementia is possible and requires and adapted process of decision making. Our results show that initial preferences based on information alone may change when people with dementia experience daycare. It is important to have a try-out period so that people with dementia can experience daycare without having to decide whether to continue it. Whereas shared decision making in general aims at moving from initial preferences to informed preferences, professionals should focus more on moving from initial preferences to experienced preferences for people with dementia. Professionals can play a crucial role in facilitating the possibilities for a try-out period.

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Crafting Care That Fits: Workload and Capacity Assessments Complementing Decision Aids in Implementing Shared Decision Making (Preprint)

10.2196/preprints.13763 ◽

2019 ◽

Author(s):

Thomas H Wieringa ◽

Manuel F Sanchez-Herrera ◽

Nataly R Espinoza ◽

Viet-Thi Tran ◽

Kasey Boehmer

Keyword(s):

Decision Making ◽

Shared Decision Making ◽

Chronic Conditions ◽

Decision Aids ◽

Multiple Chronic Conditions ◽

Shared Decision ◽

Patient Centered ◽

Patient Goals ◽

Minimally Disruptive Medicine ◽

Workload Capacity

UNSTRUCTURED About 42% of adults have one or more chronic conditions and 23% have multiple chronic conditions. The coordination and integration of services for the management of patients living with multimorbidity is important for care to be efficient, safe, and less burdensome. Minimally disruptive medicine may optimize this coordination and integration. It is a patient-centered approach to care that focuses on achieving patient goals for life and health by seeking care strategies that fit a patient’s context and are minimally disruptive and maximally supportive. The cumulative complexity model practically orients minimally disruptive medicine–based care. In this model, the patient workload-capacity imbalance is the central mechanism driving patient complexity. These elements should be accounted for when making decisions for patients with chronic conditions. Therefore, in addition to decision aids, which may guide shared decision making, we propose to discuss and clarify a potential workload-capacity imbalance.

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