Shared decision-making for postoperative analgesia: A semistructured qualitative study

Effect of shared decision-making in patients with breast cancer undergoing breast reconstruction surgery: A systematic review and meta-analysis

Objective

Patients with breast cancer who must undergo breast mastectomy are offered different types of breast reconstruction surgeries. Shared decision-making (SDM) is an important emerging intervention in the decision-making process of patients. This study aimed to evaluate the effects of SDM in patients with breast cancer undergoing breast reconstruction surgery.

Methods

Databases, including China National Knowledge Infrastructure, Wanfang, Chinese Biomedical Database, VIP, PubMed, Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and Embase, were searched for articles on the application of SDM in patients undergoing breast reconstruction. The literature search retrieval time limit was from inception to February 29, 2024, with Chinese and English language restrictions. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was used for reporting this work. The randomized controlled trial (RCT) quality was assessed using The Cochrane Collaboration's tool for assessing risk of bias and quasi-randomized trials using Joanna Briggs Institute's critical appraisal tools. The SDM effects on decisional conflict, regret, knowledge, participation, and satisfaction, anxiety, and depression were assessed. Revman5.4 software was used for the meta-analysis.

Results

In total, 18 papers out of 854 records identified from the database search met the eligibility criteria, including 16 articles in English and two articles in Chinese. There were 12 RCTs and six quasi-randomized trials. The meta-analysis results revealed that SDM could reduce decisional conflict [mean difference (MD), -4.49; 95% confidence interval (CI) (-6.70, -2.27); P < 0.001], decisional regret [MD, -6.06; 95% CI (-9.51, -2.61); P < 0.001], and depression [standardized mean difference (SMD), -0.67; 95% CI (-0.99, -0.35); P < 0.001] in patients who underwent breast reconstruction surgery. In addition, SDM can improve decisional participation [SMD, 0.30; 95% CI (0.11, 0.49); P = 0.002] and decisional knowledge [SMD, 0.43; 95% CI (0.11, 0.75); P = 0.009], but with no significant improvement in decisional satisfaction [SMD, 0.30; 95% CI (-0.35, 0.94); P = 0.37] and anxiety [SMD, -0.09; 95% CI (-0.22, 0.04); P = 0.17]. The subgroup analysis of country/region showed that the interventional effect of SDM in Western countries [MD, -3.84; 95% CI (-4.16, -3.52); P < 0.001] was stronger than that in Eastern countries [MD, -1.81; 95% CI (-2.32, -1.30); P < 0.001], and the interventional effect of Booklet group [MD, -6.92; 95% CI (-8.90, -4.94); P < 0.001] was stronger than that of Computer-based group [MD, -3.23; 95% CI (-3.50, -2.96); P < 0.001].

Conclusions

SDM shows positive effects in many aspects in patients with breast reconstruction, including reducing decisional conflict, decisional regret, and depression, whilst improving decisional participation and decisional knowledge. Moreover, SDM seems has better effectiveness in Western countries than that in Eastern countries and the implement of Booklet has better effectiveness than that of Computer-based modality. However, our study shows that SDM has no benefit in terms of decisional satisfaction and anxiety.

Systematic review registration

CRD42024525662.

Anesthesiologists and Community Engagement: A Scoping Review of the Literature

Millions of individuals require anesthesia services each year. Although anesthesia-associated mortality rates have declined, anesthetic-related morbidity remains high, particularly among vulnerable populations. Disparities in perioperative screening, optimization, surveillance, and follow-up contribute to worse outcomes in these populations. Community-engaged collaborations may be the essential ingredient needed for anesthesiologists to improve disparities in anesthetic outcomes and prioritize the needs of patients and communities. This scoping review seeks to examine the available literature on community engagement among anesthesiologists to identify gaps and seek opportunities for future work. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). OVID MEDLINE, Scopus, and Web of Science Core Collection were searched to identify sources that used or recognized community-engaged strategies and involved the work of anesthesiologists. Sources were selected based on inclusion criteria and consistent data were extracted from each paper for compilation in a data chart. The initial search generated 1230 articles of which 16 met criteria for inclusion in the review. An updated search of the literature and reference scan of included sources resulted in 7 additional articles being included. The sources were grouped according to overarching themes and methods used and ultimately categorized according to the spectrum of public participation developed by the International Association for Public Participation (IAP2). This spectrum includes 5 levels: inform, consult, involve, collaborate, and empower. This review identified 5 sources at the inform level, 8 studies in consult, 0 in involve, 7 in collaborate, and 3 in empower. Results indicate that most initiatives representing deeper levels of community engagement, at the collaborate or empower level, occur internationally. Efforts that occur in the United States tend to emphasize engagement of individual patients rather than communities. There is a need to pursue deeper, more meaningful community-engaged efforts within the field of anesthesiology at a local and national level.

Shared Decision-Making in Acute Pain Services

PURPOSE OF REVIEW

The implementation of shared decision-making (SDM) in acute pain services (APS) is still in its infancies especially when compared to other medical fields.

RECENT FINDINGS

Emerging evidence fosters the value of SDM in various acute care settings. We provide an overview of general SDM practices and possible advantages of incorporating such concepts in APS, point out barriers to SDM in this setting, present common patient decisions aids developed for APS and discuss opportunities for further development. Especially in the APS setting, patient-centred care is a key component for optimal patient outcome. SDM could be included into everyday clinical practice by using structured approaches such as the "seek, help, assess, reach, evaluate" (SHARE) approach, the 3 "MAking Good decisions In Collaboration"(MAGIC) questions, the "Benefits, Risks, Alternatives and doing Nothing"(BRAN) tool or the "the multifocal approach to sharing in shared decision-making"(MAPPIN'SDM) as guidance for participatory decision-making. Such tools aid in the development of a patient-clinician relationship beyond discharge after immediate relief of acute pain has been accomplished. Research addressing patient decision aids and their impact on patient-reported outcomes regarding shared decision-making, organizational barriers and new developments such as remote shared decision-making is needed to advance participatory decision-making in acute pain services.

Autonomous patient consent for anaesthesia without preoperative consultation: a qualitative feasibility study including low-risk procedures

Background

Informed consent for anaesthesia is mandatory and requires provision of information and subsequent consent during consultation between anaesthesiologist and patient. Although information can be provided in an electronic format, it is unknown whether this a valid substitute for a consultation. We explored whether provision of digital information is equivalent to oral consultation and whether it enables patients to give electronic informed consent (e-consent) for anaesthesia.

Methods

Qualitative feasibility study using semi-structured interviews in 20 low-risk adults scheduled for minor surgery under general anaesthesia or procedural sedation at a university hospital. Data were analysed using a thematic content analysis approach. During the interviews, patients followed an application that provides information and subsequent e-consenting.

Results

The mean age was 50 yr and patients had good digital skills. Fifteen patients (75%) had previous experience of anaesthesia. The digital application provided enough information for all patients, but eight (40%) preferred consultation with an anaesthesiologist, mainly for personal contact. Patients had different information needs, with previous experiences leading to lower information needs. Nineteen patients had sufficient information to consent autonomously. Most patients considered separate anaesthesia consent superfluous to the surgical consent.

Conclusion

The digital application provided sufficient information and patients valued the information offered and the advantage of processing information at their own pace. This information made patients feel empowered to autonomously consent to anaesthesia without consultation. Remarkably, consent for anaesthesia was considered unimportant, because patients felt they had 'no choice' if they wanted to undergo surgery.

Systematic Development of Patient Decision Aids: An Update from the IPDAS Collaboration

BACKGROUND

The 2013 update of the evidence informing the quality dimensions behind the International Patient Decision Aid Standards (IPDAS) offered a model process for developers of patient decision aids.

OBJECTIVE

To summarize and update the evidence used to inform the systematic development of patient decision aids from the IPDAS Collaboration.

METHODS

To provide further details about design and development methods, we summarized findings from a subgroup (n = 283 patient decision aid projects) in a recent systematic review of user involvement by Vaisson et al. Using a new measure of user-centeredness (UCD-11), we then rated the degree of user-centeredness reported in 66 articles describing patient decision aid development and citing the 2013 IPDAS update on systematic development. We contacted the 66 articles' authors to request their self-reports of UCD-11 items.

RESULTS

The 283 development processes varied substantially from minimal iteration cycles to more complex processes, with multiple iterations, needs assessments, and extensive involvement of end users. We summarized minimal, medium, and maximal processes from the data. Authors of 54 of 66 articles (82%) provided self-reported UCD-11 ratings. Self-reported scores were significantly higher than reviewer ratings (reviewers: mean [SD] = 6.45 [3.10]; authors: mean [SD] = 9.62 [1.16], P < 0.001).

CONCLUSIONS

Decision aid developers have embraced principles of user-centered design in the development of patient decision aids while also underreporting aspects of user involvement in publications about their tools. Templates may reduce the need for extensive development, and new approaches for rapid development of aids have been proposed when a more detailed approach is not feasible. We provide empirically derived benchmark processes and a reporting checklist to support developers in more fully describing their development processes.[Box: see text].

Parental involvement in decision making about intracranial pressure monitor placement in children with traumatic brain injury

OBJECTIVE

Little is known about how parents of children with traumatic brain injury (TBI) participate or feel they should participate in decision making regarding placing an intracranial pressure (ICP) monitor. The objective of this study was to identify the perspectives and decisional or information needs of parents whose child sustained a TBI and may require an ICP monitor.

METHODS

This was a qualitative study at one US level I pediatric trauma center. The authors conducted in-depth semistructured interviews with 1) parents of critically injured children who have sustained a TBI and 2) clinicians who regularly care for children with TBI.

RESULTS

The authors interviewed 10 parents of 7 children (60% were mothers and 80% were white) and 28 clinicians (17 ICU clinicians and 11 surgeons). Overall, the authors found concordance between and among parents and clinicians about parental involvement in ICP monitor decision making. Parents and clinicians agreed that decision making about ICP monitoring in children who have suffered TBI is not and should not be shared between the parents and clinicians. The concordance was represented in 3 emergent themes. Parents wanted transparency, communication, and information (theme 2), but the life-threatening context of this decision (theme 1) created an environment where all involved reflected a clear preference for paternalism (theme 3).

CONCLUSIONS

The clear and concordant preference for clinician paternalistic decision making coupled with the parents' needs to be informed suggests that a decision support tool for this decision should be clinician facing and should emphasize transparency in collaborative decision making between clinicians.