For which decisions is Shared Decision Making considered appropriate? - A systematic review

Patients' emotional expressions and clinicians' responses in oncology - From recognition to exploration of concerns

Objectives

The objective of this study was to analyze patient's emotional expressions during the consultations and the responses of their oncologists to these expressions.

Methods

The study employed a mixed-method, observational, descriptive, and explanatory design. A total of 31 adult patients at different clinical stages, undergoing cancer treatment and 8 oncologists were included. Thirty-one routine outpatient oncology consultations were analyzed, after being transcribed and coded, using the Portuguese version of the Verona Coding Definitions of Emotional Sequences (VR-CoDES).

Results

The oncologists elicited and recognized patients' emotional concerns but they did not explore them in a way that encouraged patients to continue verbalizing their feelings. Oncologists provided more directive and guidance-oriented responses, focusing on cues related to physical pain and symptoms. Multilevel logistic regression analysis modeled the probability of oncologists' responses showing reduction of space in relation to patients' emotional cues/concerns, controlling for clustering and patients' clinical and socio-demographic variables. The type of cue and treatment influenced the oncologists' responses.

Conclusions

Communication skills training focused on the ability to better explore patients' emotions may help oncologists to provide more explicit and empathetic responses that validate the emotional content expressed during consultations. Practice Implications: Oncologists do not use the same responses as a standard with patients, thus adjusting them individually.

The person-centered medical care in pediatrics: A scoping review

INTRODUCTION AND OBJECTIVES

The medicine development demonstrates that the traditional bioethical medical care model is not the most adequate. On the other hand, the person-centered clinical method has been winning more space in the medical practice, since it is a humanized method of care that allows best results. In pediatrics, the patient-centered care works a little bit different, since it requires not only the physician-patient relation, but also the integration of the physician-family-patient relation. Thus, the patient-centered care in the pediatric area is understudied, as well as little practiced. In this context, this review has the objective to exposure the actual scenario of the patient-centered care in pediatrics.

MATERIALS AND METHODS

This is a scoping review carried out from the standards of Jonna Briggs Institute (JBI). The database PubMed, Science Direct and BVS were used to search studies between 2012 until 2024. The research was performed with the descriptors "Medicine", "Shared DecisionMaking", "Pediatrics", "Physician-PatientRelations" and "Patient-CenteredCare".

RESULTS

The research identified 27,272 articles, along with 79 met the criteria and were included. Each article was analyzed and allocated in the four pillars of the patient-centered care, which was described and related with the pediatric clinic.

CONCLUSIONS

The patient-centered care brings benefits to medical care, especially in the pediatric area. Among them, stands out the increased adherence to treatment, the lowest rates of medical errors, the greater integration of the interprofessional team, the more individual and patient-sensitive investigation, as well as the respect of beliefs and desires, making the results obtained better.

Improving Shared Decision-Making in Early Phase Clinical Trials and Palliative Care: A Prospective Study on the Impact of an Online Value Clarification Tool Intervention

OBJECTIVES

This study evaluated the impact of the OnVaCT intervention, a narrative-based Online Value Clarification Tool (OnVaCT), combined with communication training for oncologists, on shared decision-making (SDM) in discussions on potential early phase clinical trial participation and palliative care. These high-stakes decisions often challenge patients and oncologists in addressing patient values, a crucial component of SDM. We hypothesized that the intervention would improve oncologist-patient communication, specifically SDM application, and (consequently) reduce patient decisional conflict.

METHODS

In this prospective, multicentre pre-post clinical study, patients completed two surveys, and their recorded consultations on early phase clinical trials and palliative care were assessed by independent coders. Pre-intervention patients received usual care, while post-intervention patients used the OnVaCT. Oncologists underwent communication training between study phases. Endpoints included decisional conflict (primary), the extent to which oncologists, patients and relatives participate in SDM, consultation length, and patient decisions (secondary).

RESULTS

Decisional conflict (p = 0.394) did not differ between pre-test (n = 116, M = 30.0, SD = 16.9) and post-test (n = 99, M = 29.4, SD = 15.2). Oncologists significantly increased their SDM application post-intervention (p < 0.001; n = 129, M = 38.5, SD = 12.6) compared to pre-intervention (n = 163, M = 28.8, SD = 9.2), particularly when the OnVaCT was discussed. Other outcomes, including consultation length, remained stable.

CONCLUSIONS

The OnVaCT intervention enhanced SDM and supported value-based discussions, without prolonging consultations. Further research should explore whether additional implementation efforts could reduce decisional conflict and the intervention's potential impact on other patient-centred outcomes. Some decisions, however, may inherently involve unresolved conflict.

Cancer Patients' Experiences of Burden when Involved in Treatment Decision Making

PurposePatients are increasingly involved in decision making by their clinicians. Yet, there are concerns that involvement in decision making may cause emotional distress in patients. Little research has examined the nature of the burden experienced by patients confronted with a life-changing treatment decision. Therefore, we explored the nature and manifestations of burden experienced by patients with early-stage breast and prostate cancer regarding their involvement in decision making. We further aimed to identify patient-perceived causes and potential solutions for their experienced burden.MethodsWe used semi-structured interviews to explore the perspectives of patients with early-stage breast and prostate cancer. Patients (N = 24) were eligible if they were diagnosed in the past 6 mo and reported some degree of burden regarding their involvement in decision making. Two researchers independently inductively coded the interviews using thematic analysis.ResultsPatients described being burdened by the decision in various ways and at various moments in the decision-making process. Patients attributed their decision-related burden mainly to uncertainty, fear of making the wrong decision, insufficient guidance by their clinician, and feeling an overwhelming sense of responsibility for their treatment decision. Patients indicated various factors that mitigated their burden or facilitated decision making, including having sufficient time, the opportunity to discuss the choice with experts and/or family, and receiving advice or confirmation from family or the clinician.ConclusionThese findings suggest that decision-related burden could be caused by the uncertainty and anxiety patients experience and by a nonpreferred division of roles within the decision-making process.ImplicationsAccordingly, acknowledging patients' feelings by discussing the presence of uncertainty and distress might normalize the burden for patients. Moreover, clinicians could explore and adjust to patients' role preference in decision making and discuss what would facilitate the decision process for patients.HighlightsPatients experience emotional, cognitive, and physical burden from their involvement in decision making.Some of the burden appears to result from the way clinicians involve patients in decision making.In addition to information about options, benefits, and harms, patients require active support in their decision-making process.Clinicians could aim to avoid overfocus on patient autonomy and instead establish authentic, shared decisions, with a role for some clinician control if needed.

Navigating Power Imbalances and Stigma in Mental Healthcare. Patient-Reported Barriers and Facilitators to Participation in Shared Decision-Making in Mental Health Care, a Qualitative Meta-Summary

BACKGROUND

The use of shared decision-making (SDM) in mental healthcare has been viewed as at least as important as its use in non-mental healthcare settings, but it still does not routinely take place in this setting. To further explore SDM processes with people with lived experience, we provide a qualitative meta-summary on patient-reported barriers and facilitators to participation in SDM within the context of mental healthcare.

METHODS

Within the set of selected studies for a larger qualitative meta-summary, using five databases, we selected the studies that had surveyed patients with mental illness for further analysis in this paper. Search terms were based on the concepts: 'decision making', 'patient participation', 'patient perceptions' and 'study design' of patient reporting, including patient surveys, interviews and focus groups.

RESULTS

Out of the 90 studies that had been selected for the larger review, we selected 13 articles concerning mental illness for more detailed analysis in this review. In total, we identified 29 different influencing factors and we found 6 major barriers: 'Lack of choice', 'Not being respected as a person', 'Feeling stigma from physician', 'Disease burden', 'Power imbalance' and 'Low self-efficacy to participate'. 'Clear information provision about options', 'Being respected as a person, being taken into account', 'Good physician-patient relationship' and 'Belief in the importance of one's own role' were the main facilitators.

CONCLUSIONS

Stigma and self-stigma still seem to persist in mental healthcare and continue to suppress patients' self-efficacy to participate in SDM in this setting. There is much discussion of inclusion and diversity worldwide, and these themes are just as topical for patients with mental health problems. Further work seems necessary to eradicate all stigma and self-stigma in this setting when striving for care that could be 'as shared as possible'.

PATIENT AND PUBLIC CONTRIBUTION

The authors wish to thank Mr. Walter Geuens, a person with lived experience in mental healthcare, for his careful reading and thorough feedback on the final paper.

Integration of Psychiatric Advance Directives Into the Patient-Accessible Electronic Health Record: Exploring the Promise and Limitations

Psychiatric advance directives (PAD), also known as advance statements or advance choice documents, are legal documents that enable people with mental health conditions to specify their treatment preferences in advance for possible future crises. Subtypes of PADs include crisis cards, joint crisis plans, and self-binding directives (also known as Ulysses contracts). These instruments are intended to improve service user involvement and need orientation in the care of mental crises and to avoid traumatization through unwanted treatment. The existing evidence suggests that people who complete a PAD tend to work more cooperatively with their clinician and experience fewer involuntary hospital admissions. Nevertheless, PADs have not been successfully mainstreamed into care due to multiple barriers to the implementation of PADs, mainly around the completion of PADs and their accessibility and use in crises. The reasons for this include the lack of support in the completion process and acceptance problems, especially on the part of professionals. The research to date primarily recommends support for service users from facilitators, such as peer support workers, and training for all stakeholders. In this article, we argue that while these approaches can help to solve completion and acceptance challenges, they are not sufficient to ensure access to PADs in crises. To ensure accessibility, we propose digital PADs, which offer considerable potential for overcoming these aforementioned barriers. Embedded in national health data infrastructures, PADs could be completed and accessed by service users themselves, possibly with the support of facilitators, and retrieved by any clinic in an emergency. We highlight the strengths and limitations of digital PADs and point out that the proposed solutions must be developed collaboratively and take into account digital inequalities to be effective support for people with serious mental health conditions.

Caregivers and multidisciplinary team members' perspectives on shared decision making in Duchenne muscular dystrophy: A qualitative study

BACKGROUND

As new therapies for Duchenne muscular dystrophy (DMD) are entering the market, shared decision making (SDM) will become increasingly important. Therefore, this study aimed to understand (1) Belgian stakeholders' knowledge and perceptions of SDM in DMD treatment decision making, (2) the current state of SDM implementation in DMD in Belgium, examining the role of all involved parties, and (3) the barriers and facilitators for SDM in DMD in the Belgian context.

METHODS

In this qualitative study, semi-structured interviews with the multidisciplinary team (MDT) of individuals with DMD (n = 18) and caregivers thereof (n = 11) were conducted in Belgium. Qualitative data was analyzed thematically using the framework method.

RESULTS

Most caregivers were unfamiliar with the term SDM, while MDT members were aware of it but struggled to define it consistent with existing literature. Despite acknowledging some drawbacks, participants valued SDM as an important process in DMD care, noting its presence in current practice. However, both MDT members and caregivers sometimes questioned the necessity of SDM due to limited treatment options available. Consequently, decision making predominantly relied on (child) neurologists sharing information and seeking consent from caregivers and individuals with DMD for a proposed treatment. Participants highlighted the important role of the MDT, with each professional contributing its unique expertise to SDM. To reduce existing barriers and enhance the SDM process, participants called for clear and transparent information regarding different treatment options, including clinical trials, and detailed information on how treatments might affect patients' daily life.

CONCLUSION

This study identified an increased need for easily understandable information, particularly regarding DMD care in general, but also about clinical trials covering new and emerging therapies. Developing specific evidence-based tools could support stakeholders' understanding of this information, thereby enhancing implementation of the SDM process in DMD care. Further, as the treatment landscape of DMD evolves, it will become increasingly important for patients to be supported by an MDT, as they can provide information on clinical trials (e.g., study coordinators), emotional support (e.g., psychologists, nurses), and decisional guidance (e.g., neurologist).

Implementation of a patient decision aid for discharge planning of hospitalized patients with stroke: aprocess evaluation using a mixed-methods approach

OBJECTIVES

To promote shared decision-making (SDM) during discharge planning of patients with stroke, a patient decision aid (PtDA) was implemented in seven Dutch hospitals. This mixed-methods process evaluation assessed: 1) PtDA use, 2) the SDM process, 3) facilitators and barriers influencing health care professional (HCP) adoption of the PtDA, and 4) HCP experiences with the PtDA.

METHODS

Rates of PtDA use were derived from hospital registries and PtDA log data. SDM levels in consultations were quantitatively assessed using OPTION-5 (score range 0-100); the SDM process was analyzed qualitatively. Facilitators and barriers were identified via the MIDI questionnaire. HCP experiences were explored through interviews.

RESULTS

PtDA use varied across hospitals, with 10-96 % of patients receiving it and 27-100 % of those ultimately using it. OPTION-5 scores were low in both pre-implementation (n = 68, median:0, Q1-Q3:0-0) and post-implementation consultations (n = 49, median:0, Q1-Q3:0-15). Barriers included lack of whole-team engagement and limited recognition of PtDA benefits. Frequent PtDA use was associated with HCP confidence and self-efficacy in SDM.

CONCLUSIONS

Successful PtDA implementation in stroke care requires whole-team engagement, emphasis on PtDA benefits, and enhancing HCP confidence and self-efficacy in SDM.

PRACTICE IMPLICATIONS

Highlighting positive SDM outcomes and patient benefits may encourage HCPs to adopt the PtDA.

Consent to advanced imaging in antenatal pulmonary embolism diagnostics: Prevalence, outcomes of nonconsent and opportunities to mitigate delayed diagnosis risk

BACKGROUND

Nonconsent to pulmonary vascular (or advanced) imaging for suspected pulmonary embolism (PE) in pregnancy can delay diagnosis and treatment, increasing risk of adverse outcomes. We sought to understand factors associated with consent and understand outcomes after nonconsent.

METHODS

This retrospective cohort study was undertaken across 21 community hospitals from October 1, 2021, through March 31, 2023. We included gravid patients undergoing diagnostics for suspected PE who were recommended advanced imaging. The primary outcome was verbal consent to advanced imaging. Diagnostic settings were nonobstetric (99% emergency departments [EDs]) and obstetrics (labor and delivery and outpatient clinics). Using quasi-Poisson regression, we calculated adjusted relative risks (aRRs) of consenting with 95% confidence intervals (CIs). We also reported symptom resolution and delayed imaging at follow-up and 90-day PE outcomes.

RESULTS

Imaging was recommended for 405 outpatients: median age was 30.5 years; 50% were in the third trimester. Evaluation was more common in nonobstetric (83%) than obstetric settings (17%). Overall, 314 (78%) agreed to imaging and 91 (22%) declined imaging. Consenting was more prevalent in obstetric settings compared with nonobstetric settings: 99% versus 73% (p < 0.001). When adjusted for demographic and clinical variables, including pretest probability, only obstetric setting was independently associated with consenting: aRR 1.26 (95% CI 1.09-1.44). Seventy-nine (87%) patients declining imaging had 30-day follow-up. Eight of 12 who reported persistent or worsening symptoms on follow-up were again recommended advanced imaging and consented. Imaging was negative. None who initially declined imaging were diagnosed with PE or died within 90 days.

CONCLUSIONS

One in five gravid patients suspected of PE declined advanced imaging, more commonly in nonobstetric (principally ED) settings than obstetric settings. Patients symptomatic on follow-up responded favorably to subsequent imaging recommendations without 90-day outcomes. Improving the communication and documentation of informed consent and securing close follow-up for nonconsenters may mitigate risks of missed and delayed PE diagnosis.

Looking beyond the eyes of the patient: The importance of effective communication in the treatment of age-related macular degeneration

PURPOSE

Patients with exudative and nonexudative age-related macular degeneration (AMD) can experience physical, mental, social, administrative or financial burden that are associated with the treatment of this progressive chronic disease. The role of healthcare providers in supporting patients who experience high treatment burden can be important, especially when it comes to effective communication. Despite previous research underlining the need to improve patient-provider communication in AMD care, patient experiences with communication, and how these are related to perceived treatment burden, remain underexplored.

METHODS

A survey was distributed among Dutch patients with AMD, which contained questions on several aspects of communication with the patient's ophthalmologist, such as the Quality Of communication Through the patients' Eyes (QUOTE-COMM, including task-, affect- and therapy-oriented communication) questionnaire. Patients were primarily enlisted through a patient association.

RESULTS

A total of 162 patients completed the questionnaire, of which 133 provided fully completed responses. While patients reported positive experiences with affect-oriented communication of their ophthalmologist, they rated task- and therapy-oriented communication as below their expectations. Most patients wished to receive (additional) information on AMD-related costs (71%), future perspectives (71%) and coping with negative emotions pertaining to the disease (68%). Both lower experience scores on task- and affect-oriented communication and lower self-efficacy were associated with higher administrative burden and mental burden among patients.

CONCLUSION

Our study shows that current communication, information provision and decision-making do not fully meet patients' needs and preferences. Enhancing patient-provider communication seems important, as effective dialogue is likely to diminish patients' perceived treatment burden.

Shared Decision-Making in Patients with an Abdominal Aortic Aneurysm or Peripheral Artery Disease: A Scoping Review

BACKGROUND

This review provides an overview of the literature on shared decision-making (SDM) in patients with abdominal aortic aneurysm (AAA) or peripheral artery disease (PAD) and identifies barriers and facilitators.

METHODS

A systematic scoping review was conducted, in which 4 databases were systematically searched for the period January 2007 to November 2024. All articles were reviewed by 2 independent authors and asses for quality using the mixed-methods appraisal tool (MMAT).

RESULTS

The literature search yielded 15,738 articles, of which 50 met the inclusion criteria. Quality assessment via MMAT showed good quality in 70% of the studies. Various influencing factors were revealed on SDM in patients, physicians, consult content, and the system or organization of care.

CONCLUSIONS

Despite increased attention, implementing SDM in AAA and PAD patients remains challenging due to healthcare professionals' limited understanding of SDM. Patients seek active involvement but often feel inadequately engaged. There is a notable lack of research focusing on health care professionals and systemic influences on SDM.

Development of a clinical decision-support tool for management of adolescent knee pain (The MAP-Knee tool)

BACKGROUND

Adolescent knee pain was historically viewed as a self-limiting condition. Still, it may severely impact health-related quality of life and physical activity, and almost half of adolescents may continue to experience pain into adulthood. Currently, no tool is available to support the consultation and shared decision-making process when an adolescent suffering from non-traumatic knee pain presents at clinical practice. By supporting shared decision-making and tailoring management strategies, such a tool could optimize treatment delivery and improve the prognosis of this common condition.

OBJECTIVES

This study aimed to develop a clinical decision-support tool (The MAP-Knee Tool) to improve the management of adolescents with non-traumatic knee pain.

DESIGN

Development study with end-user testing.

METHOD

This multi-step study consisted of five steps ((1-4) initial development and (5) end-user testing with adolescents with or without non-traumatic knee pain and medical doctors). It ended with the first version of the MAP-Knee Tool for the six most common non-traumatic knee pain conditions. The tool includes four components: 1) tool for diagnosing, 2) credible explanations of the diagnoses based on two systematic literature searches and an Argumentative Delphi process with international experts, 3) prognostic factors based on an individual participant data meta-analysis, and 4) option grid including an unbiased presentation of management options based on the available evidence.

RESULTS

We included seven children/adolescents (8-15 years old) and seven medical doctors for the end-user testing. All four components were revised accordingly, and the text was condensed as the initial draft was too comprehensive.

CONCLUSIONS

We developed a clinical decision-support tool for clinicians and adolescents with non-traumatic knee pain based on a multi-step process, including end-user testing to support the consultation in clinical practice.

Saving Shared Decision-Making

The Agency for Healthcare Research and Quality encouraged a re-examination of the concept, process, and measurement of shared decision-making (SDM) in 2016. Progress, however, has been slow. One illustrative example is SDM's relationship with the concept of equipoise: there remains little consensus on what equipoise means in the context of SDM, creating confusion about when SDM is and is not indicated. In this paper, we describe the ways in which this focus on equipoise in SDM is counter-productive and argue that equipoise is neither a necessary nor sufficient criterion in determining the need for SDM. Moreover, we suggest that what is needed to move the field of SDM forward is a shift away from focusing on when SDM is needed to instead focusing on how best to accomplish SDM across a variety of contexts by advancing the science of SDM implementation.

Scoping review indicates heterogeneous methods for developing and integrating patient decision aids in the context of clinical practice guidelines

OBJECTIVES

To review the methods used to develop and integrate patient decision aids (PDAs) based on the recommendations of clinical practice guidelines (CPGs).

STUDY DESIGN AND SETTING

We conducted a scoping review covering bibliographic databases (PubMed, Embase; searched until December 2023), gray literature, references, and expert consultations to identify eligible documents. Documents published from 2000 onwards and describing methods related to guideline-based PDA development or linking CPGs and PDAs were included. Two reviewers independently selected and analyzed the documents. Results were synthesized and presented narratively.

RESULTS

Based on 24 included documents, we categorized their methods into 4 topics. For topic (1), the selection of CPG recommendations for which PDAs are (most) needed, we found a total of 14 selection factors across n = 11 documents, with uncertainty/variability in patient preferences and trade-offs between options being the most frequently mentioned. Topic (2) (n = 24) covers methods for developing and/or updating guideline-based PDAs, such as forming a multidisciplinary development group, using CPGs and their evidence summaries along with other sources as the evidence base, and using digital solutions for semi-automated development and updating. Topic (3) (n = 12) covers methods for PDA quality assessment and/or user testing, such as finalizing and approving the PDAs after a review and feedback process from the CPG group and an iterative user testing process. Topic (4) (n = 20) covers methods for linking CPGs and PDAs, often through digital strategies.

CONCLUSION

We identified heterogeneous methods for developing and integrating PDAs based on CPG recommendations. Empirical testing is required to determine the most useful and practically feasible (combination of) methods. CPG organizations should focus on establishing adequate methods for linking CPG and PDA development to foster shared decision-making.

Pharmacoequity measurement framework: A tool to reduce health disparities

Pharmacoequity is a health system and policy goal of ensuring equitable access to high-quality medications for all individuals, regardless of factors such as race, ethnicity, socioeconomic status, or resource availability to reduce health disparities. Although measurement frameworks have been widely used in health equity contexts, a focused framework for pharmacoequity remains a critical gap. In this article, we introduce a novel pharmacoequity measurement framework anchored in the patient medication-use journey. The framework includes the following domains: (1) access to health care services, (2) prescription generation, (3) primary medication nonadherence, (4) secondary medication nonadherence, and (5) medication monitoring. For each domain, we provide examples of outcome measures and potential data sources that can be used for evaluation. We also outline an implementation workflow of the pharmacoequity measurement framework that population health stakeholders can use across various settings (eg, health systems, health plans). The framework provides a structured approach to identify existing gaps in the path toward achieving pharmacoequity and lay the foundation for targeted interventions. Additionally, it enables ongoing monitoring of progress toward achieving pharmacoequity while identifying interventions that are effective, scalable, and sustainable.

Factors influencing shared decision-making on hospital wards as perceived by healthcare professionals: A qualitative study

OBJECTIVES

The extent to which healthcare professionals apply Shared Decision Making (SDM) on hospital wards is still unknown. The aim was to explore the current knowledge of SDM among healthcare professionals and the experienced factors influencing SDM on the wards of Dutch hospitals, regarding both treatment and care decisions.

SETTING

Twelve hospital wards in two university medical centres and one teaching hospital.

DESIGN

Explorative qualitative design including semi-structured interviews with healthcare professionals working on hospital wards.

RESULTS

23 Healthcare professionals of 12 different wards were interviewed about their knowledge and the factors influencing SDM on their hospital ward. Most healthcare professionals had heard about SDM, but their understanding of the concept of SDM differed. Influencing factors were found on three levels. Organizational factors: lack of a clear vision, various approaches of ward rounds, time, and the organizational structure. Patient-related factors: the situation of the patient, participation of relatives and perceptual differences. Healthcare professional-related factors: motivation, experience, workload, continuity of care, familiarity with the patient, interprofessional communication, tools, and education.

CONCLUSION

All healthcare professionals recognize the importance of SDM and involving the patient in healthcare decisions, because they feel it enhances the quality of care and prioritizes patient-centered care. Nevertheless, healthcare professionals frequently encounter barriers in this setting. To facilitate SDM on hospital wards in the Netherlands, it is beneficial to embed SDM in the inpatient setting and establish a clear structure for interprofessional SDM regarding both treatment and care decisions, in which physicians, nurses and patients play an essential role.

Experiences and Perceptions of People With Advanced Cancer and Their Family Caregivers of Shared Decision-Making in Palliative Cancer Care

AIM

To explore the experiences and perceptions of people with advanced cancer and their family caregivers of shared decision-making, including how they and nurses are involved.

DESIGN

Exploratory interview study.

METHODS

Semistructured, individual interviews conducted in 2023 were analysed using reflexive thematic analysis.

RESULTS

Twenty-four participants (15 people with cancer and 9 caregivers) participated in this study. The analysis generated five themes; (1) Decisions are ultimately about living or dying, (2) Desires and expectations for involvement in decision-making, (3) Uncertainty about potential and capacity for shared decision-making, (4) Good quality information and communication are key for involvement and (5) Nurses' contributions are unclear.

CONCLUSION

Overall, our participants were unsure about how decision-making about the complex and existential decisions in palliative cancer care was shared, or how it included them, or nurses.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

People receiving care could benefit from more clarity on what shared decision-making is, how they can be involved and how nurses can facilitate and support shared decision-making.

IMPACT

Part of the nursing role is to support and involve people with cancer and family caregivers in decisions about treatment and care. Our findings suggest that people receiving care may be unclear about the concept of shared decision-making, and so also about how nurses potentially or actually support decision-making. Our study further clarifies the challenges and possibilities for involving all stakeholders in shared decision-making. This additional insight may help in future development and implementation of shared decision-making.

REPORTING METHOD

COREQ. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: Adds to knowledge and understanding of the complexity of shared decision-making in palliative cancer care and how nurses can contribute to this and advancing a person-centred approach.

PATIENT OR PUBLIC CONTRIBUTION

A patient and public involvement group participated in all phases of planning and conducting this study.

Development of a survey-based stacked ensemble predictive model for autonomy preferences in patients with periodontal disease

OBJECTIVES

This study aimed to develop a model to predict the autonomy preference (AP) and satisfaction after tooth extraction (STE) in patients with periodontal disease. Understanding of individual AP and STE is essential for improving patient satisfaction and promoting informed decision-making in periodontics.

METHODS

A stacked ensemble machine learning model was used to predict patient AP and STE based on the results of a survey that included demographic information, oral health status, AP index, and STE. Data from 421 patients with periodontal disease were collected from two university dental hospitals and evaluated for ensemble modeling in the following predictive models: random forest, naïve Bayes, gradient boost, adaptive boost, and XGBoost.

RESULTS

The models demonstrated good predictive performance, with XGBoost demonstrating the highest accuracy for both AP (0.78) and STE (0.80). The results showed that only 7.6 % of patients had high AP, which tended to decrease with age and varied significantly according to education level and severity of treatment, categorized as supportive periodontal treatment, active periodontal treatment, or extraction and/or dental implant procedures. Additionally, the majority of patients (67.7 %) reported high STE levels, highlighting the effectiveness of the model in accurately predicting AP, which was further supported by the significant correlation between accurately predicted AP levels and high STE outcomes.

CONCLUSIONS

The successful utilization of a stacked ensemble model to predict patient AP and STE demonstrates the potential of machine learning to improve patient-centered care in periodontics. Future research should extend to more diverse patient populations and clinical conditions to validate and refine the predictive abilities of such models in broader healthcare settings.

CLINICAL SIGNIFICANCE

The machine learning-based predictive model effectively enhances personalized decision-making and improves patient satisfaction in periodontal treatment.

Bridging the care gap: patients' needs and experiences regarding shared decision-making in radiotherapy

Background and purpose

Shared decision-making (SDM), a collaborative process in which patients and physicians jointly determine further treatment, has been associated with numerous positive effects. However, its implementation into routine clinical practice faces challenges. In radiotherapy (RT) it may have additional challenges, since patients are referred from another oncologist, often "to undergo RT". The aim of this study is to understand patients' preferences and experiences regarding SDM at an academic RT clinic, and to identify targets for SDM implementation in RT.

Materials and methods

We adapted an earlier survey sent out by the Dutch Cancer Patient Organizations Federation to fit the RT setting. The survey was distributed via letters and social media to (former) patients who had their intake between 2020 and 2022.

Results

1799 participants completed the survey, of whom 88,3% mentioned to always or often prefer SDM. 23,1% of participants reported experiencing a choice, and 50% of these participants experienced multiple options. The most commons reason for preferring SDM was bodily autonomy (n = 1114) and against SDM was wanting to decide themselves instead (n = 11). Participants with a higher educational attainment were more likely to prefer and experience SDM. Older participants were more likely to experience multiple options.

Conclusion

Our findings reaffirm that most cancer patients prefer SDM, and extend these findings to RT. However, we found a large gap between patients' desire for SDM, and the SDM experienced in our RT institute. SDM implementation strategies are needed and should focus on overcoming RT-specific and patient-reported barriers and opportunities.

Decision-making about palliative sedation for patients with cancer: a qualitative study in five European countries linked to the Palliative sedation project

BACKGROUND

Palliative sedation refers to the proportional use of titrated medication which reduces consciousness with the aim of relieving refractory suffering related to physical and psychological symptoms and/or existential distress near the end of life. Palliative sedation is intended to be an end of life option that enables healthcare professionals to provide good patient care but there remains controversy on how it is used. Little is known about decision-making processes regarding this procedure. The aim of this study was to explore decision-making processes in palliative sedation based on the experiences and perceptions of relatives and healthcare professionals.

METHODS

We conducted a qualitative interview study with dyads (a bereaved relative and a healthcare professional) linked to 33 deceased patient with cancer who had palliative sedation, in seven in-patient palliative care settings in five countries (Belgium, Germany, Italy, the Netherlands, and Spain). A framework analysis approach was used to analyse the data.

RESULTS

Two main themes are defined: 1) Decision-making about palliative sedation is a complex iterative process, 2) Decision-making is a shared process between the patient, healthcare professionals, and relatives. Decision-making about palliative sedation appears to follow an iterative process of shared information, deliberation, and decision-making. The patient and healthcare professionals are the main stakeholders, but relatives are involved and may advocate for, or delay, the decision-making process. Starting palliative sedation is reported to be an emotionally difficult decision for all parties.

CONCLUSIONS

As decision-making about palliative sedation is a complex and iterative process, patients, relatives and healthcare professionals need time for regular discussions. This requires a high level of engagement by healthcare professionals, that takes into account patients' wishes and needs, and helps to facilitate decision-making.

Pharmacoequity measurement framework: A tool to reduce health disparities

Pharmacoequity is a health system and policy goal of ensuring equitable access to high-quality medications for all individuals, regardless of factors such as race, ethnicity, socioeconomic status, or resource availability to reduce health disparities. Although measurement frameworks have been widely used in health equity contexts, a focused framework for pharmacoequity remains a critical gap. In this article, we introduce a novel pharmacoequity measurement framework anchored in the patient medication-use journey. The framework includes the following domains: (1) access to health care services, (2) prescription generation, (3) primary medication nonadherence, (4) secondary medication nonadherence, and (5) medication monitoring. For each domain, we provide examples of outcome measures and potential data sources that can be used for evaluation. We also outline an implementation workflow of the pharmacoequity measurement framework that population health stakeholders can use across various settings (eg, health systems, health plans). The framework provides a structured approach to identify existing gaps in the path toward achieving pharmacoequity and lay the foundation for targeted interventions. Additionally, it enables ongoing monitoring of progress toward achieving pharmacoequity while identifying interventions that are effective, scalable, and sustainable.

People living with chronic pain in Canada face difficult decisions and decisional conflict concerning their care: data from the national DECIDE-PAIN survey

BACKGROUND

Shared decision-making is an imperative in chronic pain care. However, we know little about the decision-making process, especially in primary care where most chronic pain care is provided. We sought to understand decisional needs of people living with chronic pain in Canada.

METHODS

We conducted a population-based cross-sectional online survey of random samples of adults living in Canada with chronic noncancer pain and registered with the Leger Marketing panel. We followed the International Association for Study of Pain definition of chronic pain (i.e., persistent or recurrent pain lasting longer than three months). We used a stratified proportional random sampling based on the population and chronic pain prevalence of each province to achieve representativeness. Based on the Ottawa Decision Support Framework, we collected data on difficult decisions (i.e., decision with more than one option and no clear best option) related to their chronic pain condition, the level of decisional conflict associated with the most difficult decisions (i.e., Decisional Conflict Scale), the assumed and preferred role during the decision-making process (i.e., Control Preferences Scale), and respondents' characteristics. We used descriptive quantitative analyses of survey responses.

RESULTS

Of the 31,545 invited panellists, 2,666 met the eligibility criteria, and 1,649 respondents from the 10 Canadian provinces completed the survey. Respondents had diverse socio-demographic profiles. Mean age was 51.8 years (SD = 16.3). Half were men (51.4%), most lived in urban areas (87.8%), mean pain duration was 8.5 years (SD = 9.6), and respondents reported an average number of painful body regions of 2.3 (SD = 1.5). We observed that 96.7% of respondents faced at least one difficult decision across their care pathways. These difficult decisions were related to numerous issues from the medical consultation, diagnosis, treatment, and daily life. Almost half of respondents made their most difficult decision with a primary care physician. One third of respondents experienced a high level of clinically significant decisional conflict (Decisional Conflict Scale score ≥ 37.5). Two-thirds of respondents self-reported having a collaborative role during their decision while three-quarters wanted this role.

CONCLUSIONS

People living with chronic pain in Canada have unmet decisional needs and need support to make optimal decisions to manage their chronic pain. Our findings will guide future development of interventions to implement shared decision-making, especially to support primary care where discussions about difficult decisions often occur.

Factors Associated With Surgical Management in Gallbladder Cancer-A Surveillance, Epidemiology, and End Results Medicare-Based Study

INTRODUCTION

Gallbladder cancer (GBC) incidence is rising, yet prognosis remains poor. Oncological resection of stage T1b or higher improves survival, yet many patients do not receive appropriate resection. This study aims to evaluate factors that may attribute to this discrepancy using the Surveillance, Epidemiology, and End Results-Medicare (SEER-Medicare) database.

MATERIALS AND METHODS

SEER Medicare (2008-2015) patients with GBC stage T1b or higher were classified as receiving cholecystectomy alone (CCY) or cholecystectomy and liver/biliary resection (oncologic resection). Outcomes and overall survival were compared, before and after propensity score matching on baseline characteristics, using Chi-square and Wilcoxon rank-sum tests for categorical and continuous variables, respectively.

RESULTS

We identified 1129 patients of which 830 underwent CCY (58.3% early stage/41.7% late stage) while 299 had complete resection (54.2% early stage/45.8% late stage). CCY patients were more often female (73.4% versus 65.6%; P = 0.0104), ≥80 y old (48.2% versus 22.4%; P < 0.0001), frail (44.5% versus 27.1%; P < 0.0001), treated by general surgeons (98.1% versus 84.9%; P < 0.0001) versus surgical oncologists, not undergoing chemotherapy (72.3% versus 54.5%; P < 0.0001), managed at nonacademic hospitals (51.2% versus 28.4%; P < 0.0001). After matching, oncologic resection demonstrated improved overall survival compared to CCY at 1-y (69.2% versus 47.2%; P < 0.0001), 3-y (42.8% versus 21.1%; P < 0.0001), and 5-y (37.5% versus 17.4%; P < 0.0001).

CONCLUSIONS

Most GBC patients may not be receiving appropriate oncological resection, especially patients who are female, older, frail, operated on by a general surgeon, not undergoing chemotherapy, or managed at nonacademic hospitals. Even when adjusting for patient factors, complete resection is associated with overall survival outcomes at multiple endpoints. Limiting sex, age, and frail status as factors and involving surgical oncologists or receiving management at academic centers may increase oncologic resection rates and thus improve survival for GBC patients.

Have a vital end-user been overlooked? Developing a shared decision intervention for patients with potential pancreatic cancer regarding the choice of surgery

Objective

To develop a patient decision aid facilitating shared decision making for patients with potential pancreatic cancer deciding about no treatment, surgical or medical treatment.

Methods

Based on a user-centred design by Wittemann et al., we developed a shared decision making intervention in three phases: 1) Understanding decision needs 2) Development of a patient decision aid (PtDA) based on a generic template 3) Assessment of the intervention from interviews with patients (n = 11), relatives (n = 11), nurses (n = 4) and surgeons (n = 2) analysed with thematic analysis, and measuring patients' perceptions of choice of options with the Decisional Conflict Scale.

Results

Results showed varying experiences with the use of the PtDA, with surgeons not finding PtDA useful as it was impractical and constraining with patients' conversations. There was no difference in patients' perceptions in choosing options for those being presented vs those patients not being presented for the PtDA.

Conclusion

The format and structure of the PtDA was not feasible for the surgeons as fundamental users in the present clinic.

Innovation

This study highlights the urgent need to consider clinical context before introducing a predefined tool and shows the importance of a multistakeholder approach. Research should focus on finding means to successful implement shared decision making.

Health Care Provider Perspectives on Shared Decision Making With Parents and Adolescents

Little is known about health care provider perspectives on sharing decisions in a parent-adolescent-provider triad. This perspective is needed to develop tools for supporting shared decision-making (SDM) in a triad that involves an adolescent. To assess this perspective, we conducted individual interviews with pediatric health care providers. Trained study staff interviewed health care providers who work with adolescents with chronic conditions about their medical decision-making experience and key components of SDM. Interviews were transcribed, coded, and analyzed using thematic content analysis. Our analysis elicited 3 major themes: (1) roles of each triad member; (2) key aspects of triadic SDM components; and (3) essentials for triadic SDM with an adolescent. Providers discussed the importance of alignment between parents and adolescents and facilitating such alignment through preference discussions. We found that providers want to engage adolescents with chronic conditions and their parents and achieve alignment between these 2 parties, during shared medical decisions.

Fostering Shared Decision-Making Between Patients and Health Care Professionals in Clinical Practice Guidelines: Protocol for a Project to Develop and Test a Tool for Guideline Developers

BACKGROUND

Clinical practice guidelines (CPGs) are designed to assist health care professionals in medical decision-making, but they often lack effective integration of shared decision-making (SDM) principles to reflect patient values and preferences, particularly in the context of preference-sensitive CPG recommendations. To address this shortcoming and foster SDM through CPGs, the integration of patient decision aids (PDAs) into CPGs has been proposed as an important strategy. However, methods for systematically identifying and prioritizing CPG recommendations relevant to SDM and related decision support tools are currently lacking.

OBJECTIVE

The aim of the project is to develop (1) a tool for systematically identifying and prioritizing CPG recommendations for which SDM is considered particularly relevant and (2) a platform for PDAs to support practical SDM implementation.

METHODS

The project consists of 6 work packages (WPs). It is embedded in the German health care context but has an international focus. In WP 1, we will conduct a scoping review in bibliographic databases and gray literature sources to identify methods used to foster SDM via PDAs in the context of CPGs. In WP 2, we will conduct semistructured interviews with CPG experts to better understand the concepts of preference sensitivity and identify strategies for fostering SDM through CPGs. WP 3, a modified Delphi study including surveys and focus groups with SDM experts, aims to define and operationalize preference sensitivity. Based on the results of the Delphi study, we will develop a methodology for prioritizing key questions in CPGs. In WP 4, the tool will be developed. A list of relevant items to identify CPG recommendations for which SDM is most relevant will be created, tested, and iteratively refined, accompanied by the development of a user manual. In WP 5, a platform for creating and digitizing German-language PDAs will be developed to support the practical application of SDM during clinical encounters. WP 6 will conclude the project by testing the tool with newly developed and revised CPGs.

RESULTS

The Brandenburg Medical School Ethics Committee approved the project (165122023-ANF). An international multidisciplinary advisory board is involved to guide the tool development on CPGs and SDM. Patient partners are involved throughout the project, considering the essential role of the patient perspective in SDM. As of February 20, 2024, we are currently assessing literature references to determine eligibility for inclusion in the scoping review (WP 1). We expect the project to be completed by December 31, 2026.

CONCLUSIONS

The tool will enable CPG developers to systematically incorporate aspects of SDM into CPG development, thereby providing guideline-based support for the patient-practitioner interaction. Together, the tool for CPGs and the platform for PDAs will create a systematic link between CPGs, SDM, and PDAs, which may facilitate SDM in clinical practice.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/57611.

Artificial-Intelligence Cloud-Based Platform to Support Shared Decision-Making in the Locoregional Treatment of Breast Cancer: Protocol for a Multidimensional Evaluation Embedded in the CINDERELLA Clinical Trial

BACKGROUND

Shared decision-making (SDM) plays a crucial role in breast cancer care by empowering patients and reducing decision regret. Patient decision aids (PtDAs) are valuable tools for facilitating SDM, now available in digital and artificial intelligence (AI)-powered formats to offer increasingly personalized contents. The ongoing CINDERELLA clinical trial (ClinicalTrials.gov: NCT05196269) evaluates an innovative AI cloud-based approach using a web platform and a mobile application (CINDERELLA APProach) versus the conventional approach to support SDM in breast cancer patients undergoing locoregional treatment. This protocol outlines a trial-based multidimensional evaluation, encompassing economic, financial, implementability, and environmental considerations associated with the CINDERELLA APProach.

METHODS

A within-trial cost-consequence and cost-utility analysis from a societal perspective will be performed using patient-level data on outcomes and resource use. The latter will be valued in monetary terms using country-specific unit costs or patient valuations. A budget impact analysis will be performed over 1 and 5 years from the budget holder perspectives. The CINDERELLA APProach implementability will be assessed through an evaluation of its usability, acceptability, organizational impact, and overall feasibility. The environmental impact will be quantitatively assessed across several dimensions, such as quantity, appropriateness, and emissions, supplemented by qualitative insights. Overall, data for the evaluation will be gathered from patient questionnaires, interviews with patients and managers, focus groups with healthcare professionals, and app electronic data.

DISCUSSION

A thorough understanding of the broad consequences of the CINDERELLA APProach may foster its successful translation into real-world settings, hopefully benefiting breast cancer patients and clinical practice.

Lessons learned from implementing a digital rehabilitation care planning platform to improve care access for patients with work disability: qualitative process evaluation of the RehaPro-SERVE study

BACKGROUND

Inpatient rehabilitation therapies can be applied for in Germany by patients of working age to support their return to work. However, there are some problems that impede an easy and uncomplicated application process. An interdisciplinary case management approach for rehabilitation care planning was developed to facilitate the access to rehabilitation. Case conferences (CCs) were held with relevant stakeholders and took place on a digital communication platform. We conducted a qualitative process evaluation to understand the implementation of the intervention and to identify contextual factors as well as mechanisms for a successful implementation in the context of primary care.

METHODS

The process evaluation included interviews with primary care physicians (PCPs), patients and stakeholders involved in the intervention process. Reflexive thematic analysis was used to analyse the data. Emerging themes were structured according to the Donabedian framework of structure, process and outcomes.

RESULTS

A total of 18 interviews were conducted. Important results included the desire for more patient involvement and case management. Patients especially valued the opportunity to receive support from a social worker. Limitations of the platform related to usability and limited opportunities for stakeholder communication. Despite training for PCPs, several problems arose regarding the clarity of the intervention process. Patients were satisfied with their application process and the treatments offered, while PCPs reported an increase in workload.

CONCLUSIONS

A digitalisation of the application procedure for rehabilitation and further treatment options is acceptable to patients and personal support of a social worker is particularly valued. However, patients should be included in the CC in terms of a shared decision-making process. The digital platform requires sufficient training and adjustments have to be made to enhance usability and to improve the efficiency of the process for PCPs. Overall, the exchange between the various stakeholders in the CC is considered particularly useful in more complex cases.

TRIAL REGISTRATION

DRKS German Clinical Trials Register, DRKS0 00242 07. Registered on 22 March 2021.

Communication, Shared Decision-making and Goals of Care in the ICU through Electronic Health Records: A Scoping Review

Introduction

The care of critically ill patients involves communication and shared decision-making with families and determination of goals of care. Analyzing these aspects through electronic health records (EHRs) can support research in ICUs, associating them with outcomes. This review aims to explore studies that examine these topics.

Methods

A scoping review was conducted through a systematic literature search of articles in PubMed, Web of Science, and Embase databases using MESH terms up to 2024, conducted in ICU settings, focusing on communication with families, shared decision-making, goals, and end-of-life care.

Results

A total of 10 articles were included, divided into themes: Records and family, and records in quality improvement projects. Variables based on records with common characteristics were identified. Outcome analysis was performed through questionnaires to family members, healthcare professionals or by analyzing care processes. The studies revealed associations between family members' perceptions and mental health symptoms and documented elements such as communication, therapeutic limitations, social and spiritual support. Studies evaluating quality communication improvement projects did not show significant impact on documented care, except for those that assessed improvements based on palliative care.

Conclusion

The analysis of documented care for critically ill patients can be conducted from various perspectives. Processes amenable to improvement, such as communication with family members, definition of goals of care, limitations, shared decision-making, evaluated through EHRs, are associated with mental health symptoms and perceptions of families of critically ill patients. Documentation-based studies can contribute to improvements in patient- and family-centered care in the ICU.

How to cite this article

de Aquino VW, da Silveira GF, Boniatti MM, Terres MS. Communication, Shared Decision-making and Goals of Care in the ICU through Electronic Health Records: A Scoping Review. Indian J Crit Care Med 2024;28(10):977-987.

Exploring Patients' Perceptions of One-step Surgery for Primary Cutaneous Melanoma: A Qualitative Study

High-frequency ultrasonography (> 20 MHz) has allowed for preoperative measurement of melanoma thickness and thus a one-step surgery strategy. The potential benefits of one-step surgery to patients remain unexplored. From June 2022 to August 2023, 2 dermatologists conducted semi-structured individual interviews with patients who had undergone HFUS examination allowing the choice for one-step surgery (group A) and with patients who had had standard two-step surgery (group B). Analysis of interviews with 21 patients (age range 31-81 years) revealed 5 main themes: (a) understanding the diagnosis, highlighting the significance of clear and comprehensive medical explanations; (b) personal factors considered in treatment decisions, including preferences for minimizing surgical procedures; (c) making choices, bearing responsibility, thus showcasing different levels of patient involvement in decision-making; (d) high- frequency ultrasonography reassurance emphasizing the role of medical reassurance, and (e) patient satisfaction, discussing surgical outcomes and the decision-making process. The majority of participants expressed a clear preference for one-step surgery, perceived as a pragmatic and fast surgical strategy while minimizing interventions. In conclusion, the results emphasize the importance of patient-centred care. These insights can guide improved preoperative consultations and enhance shared decision-making between healthcare professionals and patients regarding melanoma treatment strategies.

How option-listing influences decision-making in orthopedic consultations: a conversation analytic study

OBJECTIVES

Examine which practices orthopedists use to do option-listing, a technique that can facilitate shared decision-making (SDM).

METHODS

A conversation analytic study of 35 orthopedic consultations with newly referred patients with hip and/or knee osteoarthritis.

RESULTS

Orthopedists implement option-listing in consultations using two organizational principles: 1) A fixed order of options that constitutes a scale (based on the severity of treatment). Presenting this scale (in two possible orders) encodes this fixed order; 2) Options are presented in relation to each other, rather than as individual options to be discussed incrementally. This format provides orthopedists with interactional slots to formulate their professional stance by presenting options as considered but rejected. Patients co-construct this list by taking a recipient role and not responding to the individual items of the list.

CONCLUSIONS

Option-listing can facilitate SDM, allowing patients to choose amongst options. A drawback is that, while the organizational principles of option-listing allow orthopedists to express a professional opinion, they also place patients in an interactional position in which they have to address the orthopedists' epistemic stance. On the other hand, patients can use the scale to propose their own preferences.

PRACTICAL IMPLICATIONS

Awareness of the interactional consequences of option-listing might optimize SDM.

Shared Decision-Making and Cardiovascular Complications of Androgen Deprivation Therapy: an Educational Initiative for Oncology Team Members in Colorado, USA

Patients with prostate cancer may experience side effects of androgen deprivation therapy (ADT) such as cardiovascular (CV) complications. Oncology team members should actively communicate with patients about these complications. On the other hand, shared decision-making (SDM) has been shown to improve patient-physician communication. We developed brochures focused on CV complications of ADT and SDM. We proceeded to deliver these brochures to participating oncology offices and then carried out a survey of team members in these offices. We obtained responses from 31 oncology team members. Our survey revealed that about half of the participants (48%) rarely applied SDM in their oncology practice, and only about one-third (32%) sometimes applied SDM. After reading our brochures, the majority of respondents could correctly answer questions about SDM and CV complications of ADT. Improvement in scores after reading our materials was significant for both CV complications of ADT and SDM (e.g., CV complications of ADT: z = 6.153, p-value < 0.001, and SDM z = 6.456, p-value < 0.001). Implementation of SDM and an improved awareness of the CV complications of ADT can lead to significant benefits. It is therefore important to take steps to further raise such implementation and awareness among oncology team members in other geographic locations and clinical settings.

Surgical Decision-Making: Who Should Be Offered Sacrocolpopexy?

INTRODUCTION AND HYPOTHESIS

Women undergoing surgery for apical pelvic organ prolapse have several medically sound options for specific surgical approaches.

METHODS

We review the principles of shared decision-making as they pertain to surgery for prolapse. We review the literature supporting the superior sacrocolpopexy as a durable treatment for prolapse and the factors that may differentiate it from other repairs in risk and benefit.

RESULTS

We emphasize the importance of collaboration between patients and surgeons in surgical decision-making.

CONCLUSION

All medically appropriate patients who desire reconstructive surgery for prolapse should be offered sacrocolpopexy.

The role of time in involving patients with cancer in treatment decision making: A scoping review

BACKGROUND

Time is often perceived as a barrier to shared decision making in cancer care. It remains unclear how time functions as a barrier and how it could be most effectively utilized.

OBJECTIVE

This scoping review aimed to describe the role of time in patient involvement, and identify strategies to overcome time-related barriers.

METHODS

Seven databases were searched for any publications on patient involvement in cancer treatment decisions, focusing on how time is used to involve patients, the association between time and patient involvement, and/or strategies to overcome time-related barriers. Reviewers worked independently and in duplicate to select publications and extract data. One coder thematically analyzed data, a second coder checked these analyses.

RESULTS

The analysis of 26 eligible publications revealed four themes. Time was a resource 1) to process the diagnosis, 2) to obtain/process/consider information, 3) for patients and clinicians to spend together, and 4) for patient involvement in making decisions.

DISCUSSION

Time is a resource throughout the treatment decision-making process, and generic strategies have been proposed to overcome time constraints.

PRACTICE VALUE

Clinicians could co-create decision-making timelines with patients, spread decisions across several consultations, share written information with patients, and support healthcare redesigns that allocate the necessary time.

The role of the purposeful shared decision making model in vascularized composite allotransplantation

For some patients who have lost the lower part of an arm, hand transplant offers the possibility of receiving a new limb with varying degrees of sensation and function. This procedure, Vascularized Composite Allotransplantation (VCA), is demanding for patients and their care community and comes with significant risks. As a high-stakes decision, patients interested in VCA are subject to extensive clinical evaluation and eligibility decision making. Patients and their care community must also decide if hand transplant (versus other approaches including rehabilitative therapies with or without prosthesis) is right for them. This decision making is often confusing and practically and emotionally fraught. It is complicated in four ways: by the numerous beneficial and harmful potential effects of hand transplant or other options, the number of people affected by VCA and the diverse or conflicting positions that they may hold, the practical demands and limitations of the patient's life situation, and the existential significance of limb loss and transplant for the patient's being. Patients need support in working through these treatment determining issues. Evaluation does not provide this support. Shared decision making (SDM) is a method of care that helps patients think, talk, and feel their way through to the right course of action for them. However, traditional models of SDM that focus on weighing possible beneficial and harmful effects of treatments are ill-equipped to tackle the heterogeneous issues of VCA. A recent model, Purposeful SDM extends the range of troubling issues that SDM can help support beyond opposing effects, to include conflicting positions, life situations, and existential being. In this paper we explore the pertinence of these issues in VCA, methods of SDM that each require of clinicians, the benefits of supporting patients with the breadth of issues in their unique problematic situations, implications for outcomes and practice, and extend the theory of the Purposeful SDM model itself based on the issues present in hand transplant decision making.

Driving factors in treatment decision-making of patients seeking medical assistance for infertility: a systematic review

BACKGROUND

ART differs in effectiveness, side-effects, administration, and costs. To improve the decision-making process, we need to understand what factors patients consider to be most important.

OBJECTIVE AND RATIONALE

We conducted this systematic review to assess which aspects of ART treatment (effectiveness, safety, burden, costs, patient-centeredness, and genetic parenthood) are most important in the decision-making of patients with an unfulfilled wish to have a child.

SEARCH METHODS

We searched studies indexed in Embase, PubMed, PsycINFO, and CINAHL prior to November 2023. Discrete choice experiments (DCEs), surveys, interviews, and conjoint analyses (CAs) about ART were included. Studies were included if they described two or more of the following attributes: effectiveness, safety, burden, costs, patient-centeredness, and genetic parenthood.Participants were men and women with an unfulfilled wish to have a child. From each DCE/CA study, we extracted the beta-coefficients and calculated the relative importance of treatment attributes or, in case of survey studies, extracted results. We assessed the risk of bias using the rating developed by the Grading of Recommendations Assessment, Development and Evaluation working group. Attributes were classified into effectiveness, safety, burden, costs, patient-centeredness, genetic parenthood, and others.

OUTCOMES

The search identified 938 studies of which 20 were included: 13 DCEs, three survey studies, three interview studies, and one conjoint analysis, with a total of 12 452 patients. Per study, 47-100% of the participants were women. Studies were assessed as having moderate to high risk of bias (critical: six studies, serious: four studies, moderate: nine studies, low: one study). The main limitation was the heterogeneity in the questionnaires and methodology utilized. Studies varied in the number and types of assessed attributes. Patients' treatment decision-making was mostly driven by effectiveness, followed by safety, burden, costs, and patient-centeredness. Effectiveness was rated as the first or second most important factor in 10 of the 12 DCE studies (83%) and the relative importance of effectiveness varied between 17% and 63%, with a median of 34% (moderate certainty of evidence). Of eight studies evaluating safety, five studies valued safety as the first or second most important factor (63%), and the relative importance ranged from 8% to 35% (median 23%) (moderate certainty of evidence). Cost was rated as first or second most important in five of 10 studies, and the importance relative to the other attributes varied between 5% and 47% (median 23%) (moderate certainty of evidence). Burden was rated as first or second by three of 10 studies (30%) and the relative importance varied between 1% and 43% (median 13%) (low certainty of evidence). Patient-centeredness was second most important in one of five studies (20%) and had a relative importance between 7% and 24% (median 14%) (low certainty of evidence). Results suggest that patients are prepared to trade-off some effectiveness for more safety, or less burden and patient-centeredness. When safety was evaluated, the safety of the child was considered more important than the mother's safety. Greater burden (cycle cancellations, number of injections, number of hospital visits, time) was more likely to be accepted by patients if they gained effectiveness, safety, or lower costs. Concerning patient-centeredness, information provision and physician attitude were considered most important, followed by involvement in decision-making, and treatment continuity by the same medical professional. Non-genetic parenthood did not have a clear impact on decision-making.

WIDER IMPLICATIONS

The findings of this review can be used in future preference studies and can help healthcare professionals in guiding patients' decision-making and enable a more patient-centered approach.

Shared decision-making in palliative cancer care: A systematic review and metasynthesis

BACKGROUND

Shared decision-making is a key element of person-centred care and promoted as the favoured model in preference-sensitive decision-making. Limitations to implementation have been observed, and barriers and limitations, both generally and in the palliative setting, have been highlighted. More knowledge about the process of shared decision-making in palliative cancer care would assist in addressing these limitations.

AIM

To identify and synthesise qualitative data on how people with cancer, informal carers and healthcare professionals experience and perceive shared decision-making in palliative cancer care.

DESIGN

A systematic review and metasynthesis of qualitative studies. We analysed data using inductive thematic analysis.

DATA SOURCES

We searched five electronic databases (MEDLINE, EMBASE, PsycINFO, CINAHL and Scopus) from inception until June 2023, supplemented by backward searches.

RESULTS

We identified and included 23 studies, reported in 26 papers. Our analysis produced four analytical themes; (1) Overwhelming situation of 'no choice', (2) Processes vary depending on the timings and nature of the decisions involved, (3) Patient-physician dyad is central to decision-making, with surrounding support and (4) Level of involvement depends on interactions between individuals and systems.

CONCLUSION

Shared decision-making in palliative cancer care is a complex process of many decisions in a challenging, multifaceted and evolving situation where equipoise and choice are limited. Implications for practice: Implementing shared decision-making in clinical practice requires (1) clarifying conceptual confusion, (2) including members of the interprofessional team in the shared decision-making process and (3) adapting the approach to the ambiguous, existential situations which arise in palliative cancer care.

Patient readiness for shared decision making about treatment: Conceptualisation and development of the ReadySDM

INTRODUCTION

Shared decision making (SDM) requires an active role of both clinicians and patients. We aimed to conceptualise patient readiness for SDM about treatment, and to develop a patient questionnaire to assess readiness.

METHODS

We used the results of a scoping review and a qualitative study to inform the patient readiness construct. We conducted five additional rounds of data collection to finalise the construct definition and develop the Patient Readiness for SDM Questionnaire (ReadySDM ) in an oncological setting: (1) longitudinal interviews with patients with cancer during and after a treatment decision-making process; (2) a pilot study among experts, clinicians, and patients for feedback on the concept and items; (3) a field test among (former) patients with cancer to test item format and content validity, and to reduce the number of items; (4) cognitive interviews with people with low literacy to test the comprehensibility of the questionnaire; and (5) a field test among (former) patients who faced a cancer treatment decision in the last year, to test the content validity of the final version of the questionnaire.

RESULTS

A total of 251 people participated in the various rounds of data collection. We identified eight elements of patient readiness for SDM about treatment: (1) understanding of and attitude towards SDM; (2) information skills; (3) skills in communicating and claiming space; (4) self-awareness; (5) consideration skills; (6) self-efficacy; (7) emotional distress; and (8) experienced time. We developed the 20-item ReadySDM to retrospectively measure these elements in an oncological setting.

CONCLUSION

We conducted a thorough procedure to conceptualise patient readiness and to develop the ReadySDM . The questionnaire aims to provide novel insights into ways to enhance SDM in daily practice.

PATIENT OR PUBLIC CONTRIBUTION

Multiple people with lived experience were involved in various phases of the study. They were asked for input on the study design, the conceptualisation of readiness, and the development of the questionnaire.

Shared Decision Making in Perinatal Care

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Patient preferences in geriatric wards, a survey of health care professionals' practice, experience and attitudes

PURPOSE

We aimed to identify whether health care professionals (HCP) examine their patient and next-of-kin preferences, and to study whether medical decisions follow these preferences.

METHOD

A cross-sectional web-based survey was conducted with multidisciplinary HCP from 12 geriatric wards in the South-Eastern Norway Regional Health Authority.

RESULTS

Of the 289 HCPs responding (response rate 61%), mean age 37.8 years (SD 11.3), 235 (81.3%) women, 12.4 (SD 9.6) years of experience and 67 (23.2%) medical doctors, only half report clarifying patients' preferences. The majority reported that they did not inform, involve and treat in line with such preferences. However, 53% believe that HCP, patients and next-of-kin should make clinical decisions together.

DISCUSSION

Our findings indicate a lack of engagement in conversation and inclusion of patient preferences when providing health interventions in geriatric wards. Measures for change of culture are needed.

Validating a model for predicting breast cancer and nonbreast cancer death in women aged 55 years and older

BACKGROUND

To support mammography screening decision making, we developed a competing-risk model to estimate 5-year breast cancer risk and 10-year nonbreast cancer death for women aged 55 years and older using Nurses' Health Study data and examined model performance in the Black Women's Health Study (BWHS). Here, we examine model performance in predicting 10-year outcomes in the BWHS, Women's Health Initiative-Extension Study (WHI-ES), and Multiethnic Cohort (MEC) and compare model performance to existing breast cancer prediction models.

METHODS

We used competing-risk regression and Royston and Altman methods for validating survival models to calculate our model's calibration and discrimination (C index) in BWHS (n = 17 380), WHI-ES (n = 106 894), and MEC (n = 49 668). The Nurses' Health Study development cohort (n = 48 102) regression coefficients were applied to the validation cohorts. We compared our model's performance with breast cancer risk assessment tool (Gail) and International Breast Cancer Intervention Study (IBIS) models by computing breast cancer risk estimates and C statistics.

RESULTS

When predicting 10-year breast cancer risk, our model's C index was 0.569 in BWHS, 0.572 in WHI-ES, and 0.576 in MEC. The Gail model's C statistic was 0.554 in BWHS, 0.564 in WHI-ES, and 0.551 in MEC; IBIS's C statistic was 0.547 in BWHS, 0.552 in WHI-ES, and 0.562 in MEC. The Gail model underpredicted breast cancer risk in WHI-ES; IBIS underpredicted breast cancer risk in WHI-ES and in MEC but overpredicted breast cancer risk in BWHS. Our model calibrated well. Our model's C index for predicting 10-year nonbreast cancer death was 0.760 in WHI-ES and 0.763 in MEC.

CONCLUSIONS

Our competing-risk model performs as well as existing breast cancer prediction models in diverse cohorts and predicts nonbreast cancer death. We are developing a website to disseminate our model.

Patient Preferences in Diagnostic Imaging: A Scoping Review

BACKGROUND

As new diagnostic imaging technologies are adopted, decisions surrounding diagnostic imaging become increasingly complex. As such, understanding patient preferences in imaging decision making is imperative.

OBJECTIVES

We aimed to review quantitative patient preference studies in imaging-related decision making, including characteristics of the literature and the quality of the evidence.

METHODS

The Pubmed, Embase, EconLit, and CINAHL databases were searched to identify studies involving diagnostic imaging and quantitative patient preference measures from January 2000 to June 2022. Study characteristics that were extracted included the preference elicitation method, disease focus, and sample size. We employed the PREFS (Purpose, Respondents, Explanation, Findings, Significance) checklist as our quality assessment tool.

RESULTS

A total of 54 articles were included. The following methods were used to elicit preferences: conjoint analysis/discrete choice experiment methods (n = 27), contingent valuation (n = 16), time trade-off (n = 4), best-worst scaling (n = 3), multicriteria decision analysis (n = 3), and a standard gamble approach (n = 1). Half of the studies were published after 2016 (52%, 28/54). The most common scenario (n = 39) for eliciting patient preferences was cancer screening. Computed tomography, the most frequently studied imaging modality, was included in 20 studies, and sample sizes ranged from 30 to 3469 participants (mean 552). The mean PREFS score was 3.5 (standard deviation 0.8) for the included studies.

CONCLUSIONS

This review highlights that a variety of quantitative preference methods are being used, as diagnostic imaging technologies continue to evolve. While the number of preference studies in diagnostic imaging has increased with time, most examine preventative care/screening, leaving a gap in knowledge regarding imaging for disease characterization and management.

Pancreatic Cancer Health Disparity: Pharmacologic Anthropology

Pancreatic cancer (PCa) remains a formidable global health challenge, with high mortality rates and limited treatment options. While advancements in pharmacology have led to improved outcomes for various cancers, PCa continues to exhibit significant health disparities, disproportionately affecting certain populations. This paper explores the intersection of pharmacology and anthropology in understanding the health disparities associated with PCa. By considering the socio-cultural, economic, and behavioral factors that influence the development, diagnosis, treatment, and outcomes of PCa, pharmacologic anthropology provides a comprehensive framework to address these disparities and improve patient care.

What does shared decision making ask from doctors? Uncovering suppressed qualities that could improve person-centered care

OBJECTIVE

Shared decision making (SDM) is infrequently seen in clinical practice despite four decades of efforts. We propose a need to explore what SDM asks from doctors in terms of enabling competencies and necessary, underlying qualities, and how these can be nurtured or suppressed in medical training.

DISCUSSION

Key SDM tasks call for doctors to understand communication and decision mechanisms to carry them out well, including reflecting on what they know and do not know, considering what to say and how, and listening unprejudiced to patients. Different doctor qualities can support accomplishing these tasks; humility, flexibility, honesty, fairness, self-regulation, curiosity, compassion, judgment, creativity, and courage, all relevant to deliberation and decision making. Patient deference to doctors, lack of supervised training opportunities with professional feedback, and high demands in the work environment may all inflate the risk of only superficially involving patients.

CONCLUSIONS

We have identified ten professional qualities and related competencies required for SDM, with each to be selected based on the specific situation. The competencies and qualities need to be preserved and nurtured during doctor identity building, to bridge the gap between knowledge, technical skills, and authentic efforts to achieve SDM.

Decision Aids in the ICU: a scoping review

OBJECTIVE

The purpose of this scoping review was to synthesise the effectiveness and acceptability of decision aids for critically ill patients and family members in the intensive care unit (ICU).

METHODS

A systematic search of four electronic databases and grey literature was undertaken to identify relevant studies on the application of decision aids in the ICU, without publication date restriction, through March 2023. The methodological framework proposed by Arksey and O'Malley was used to guide the scoping review.

RESULTS

Fourteen papers were ultimately included in this review. However, only nine decision aids were available, and it is noteworthy that many of these studies focused on the iterative development and testing of individual decision aids. Among the included studies, 92% (n=13) were developed in North America, with a primary focus on goals of care and life-sustaining treatments. The summary of the effect of decision aid application revealed that the most common indicators were the level of knowledge and code status, and some promising signals disappeared in randomised trials.

CONCLUSIONS

The complexity of treatment decisions in the ICU exceeds the current capabilities of existing decision aids. There is a clear gap in decision aids that are tailored to different cultural contexts, highlighting the need to expand the scope of their application. In addition, rigorous quality control is very important for randomised controlled trial, and indicators for assessing the effectiveness of decision aids need to be further clarified.

Patient-related characteristics considered to affect patient involvement in shared decision making about treatment: A scoping review of the qualitative literature

OBJECTIVE

To identify patient-related characteristics considered to affect patient involvement in shared decision making (SDM) about treatment.

METHODS

We conducted a scoping review of qualitative studies. We searched for literature across seven databases until March 2022, and included qualitative studies that focused on associations between patient-related characteristics and SDM about treatment in adults. We analyzed studies using an inductive thematic approach.

RESULTS

The search yielded 5948 articles, of which 70 were included. We identified many different patient-related characteristics, which we grouped into four categories related to: (1) the individual who is facing the decision, (2) the decision, (3) the relationship between the patient and the clinician and others involved in the decision, and (4) the healthcare context.

CONCLUSIONS

Studies report a variety of patient-related characteristics that may affect patient involvement in SDM. Amongst others, patients may need to feel informed, to understand their role in SDM, and be able to communicate. Involvement may be challenging with characteristics such as perceived time pressure, poor patient-clinician relationships, emotional distress, and severe illness.

PRACTICE IMPLICATIONS

In order to truly involve patients in SDM, we might need to focus on characteristics such as patient emotions and relationship building, besides information provision and values clarification.

Not Too Little, Not Too Much: Optimizing More Versus Less Locoregional Treatment for Older Patients With Breast Cancer

Although undertreatment of older women with aggressive breast cancers has been a concern for years, there is increasing recognition that some older women are overtreated, receiving therapies unlikely to improve survival or reduce morbidity. De-escalation of surgery may include breast-conserving surgery over mastectomy for appropriate candidates and omitting or reducing extent of axillary surgery. Appropriate patients to de-escalate surgery are those with early-stage breast cancer, favorable tumor characteristics, are clinically node-negative, and who may have other major health issues. De-escalation of radiation includes reducing treatment course length through hypofractionation and ultrahypofractionation regimens, reducing treatment volumes through partial breast irradiation, omission of radiation for select patients, and reducing radiation dose to normal tissues. Shared decision making, which aims to facilitate patients making decisions concordant with their values, can guide health care providers and patients through complicated decisions optimizing breast cancer care.