The bigger picture of shared decision making: A service design perspective using the care path of locally advanced pancreatic cancer as a case

Communication, understanding and engagement of patients with pancreatic cancer at time of diagnosis

BACKGROUND

Objectives: To investigate communication clarity and understanding at the time of pancreatic adenocarcinoma (PDAC) diagnosis and whether they can influence patient engagement and compliance.

METHODS

Consecutive PDAC patients were enrolled at the time of diagnosis after obtaining informed consent in a single-center study. The patients completed a validated scale (PHE-s®), and the understanding rate was assessed using standardized tools. Patient compliance was evaluated, and the correlation between the PHE-s®, understanding, and compliance was calculated.

RESULTS

Thirty patients were enrolled (15 female) with a mean age 64.4, 13 were metastatic. The mean visit time was 31 min, being longer if visiting doctor was an oncologist (p = 0.002). The engagement level was high in 70% of the patients, and all but one were compliant. The analysis of doctor-patient interactions showed a median of 121 conversational turns for doctors, 75 for patients, and 20 for caregivers (p < 0.0001), and the median percentage of speaking time was 77% for doctors, 13% for patients, and 2% for caregivers (p < 0.0001). Female caregivers spent more time speaking than did male caregivers (median 11.6% vs. 1.3%; p = 0.06). There were 290 instances of problematic understanding, most of which occurred during the taking of patients' personal medical history for doctors, while for patients and caregivers, these occurred mainly during the discussion of diagnosis/treatment (p < 0.0001). In a multivariable analysis, only origin from central or southern Italy was associated with high engagement (p = 0.0087).

CONCLUSION

In this first attempt to measure clarity of communication and engagement in patients with PDAC, typical features of conversation and problematic understanding emerged, which deserves further investigation.

Minimum and Optimal CA19-9 Response After Two Months Induction Chemotherapy in Patients With Locally Advanced Pancreatic Cancer: A Nationwide Multicenter Study

OBJECTIVE

This nationwide multicenter study aimed to define clinically relevant thresholds of relative serum CA19-9 response after 2 months of induction chemotherapy in patients with locally advanced pancreatic cancer (LAPC).

BACKGROUND

CA19-9 is seen as leading biomarker for response evaluation in patients with LAPC, but early clinically useful cut-offs are lacking.

METHODS

All consecutive patients with LAPC after 4 cycles (m)FOLFIRINOX or 2 cycles gemcitabine-nab-paclitaxel induction chemotherapy (±radiotherapy) with CA19-9 ≥5 U/mL at baseline were analyzed (2015-2019). The association of CA19-9 response with median OS (mOS) was evaluated for different CA19-9 cut-off points. Minimum and optimal CA19-9 response were established via log-rank test. Predictors for OS were analyzed using COX regression analysis.

RESULTS

Overall, 212 patients were included, of whom 42 (19.8%) underwent resection. Minimum CA19-9 response demonstrating a clinically significant median OS difference (12.7 vs. 19.6 months) was seen at ≥40% CA19-9 decrease. The optimal cutoff for CA19-9 response was ≥60% decrease (21.7 vs. 14.0 mo, P =0.021). Only for patients with elevated CA19-9 levels at baseline (n=184), CA19-9 decrease ≥60% [hazard ratio (HR)=0.59, 95% CI, 0.36-0.98, P =0.042] was independently associated with prolonged OS, as were SBRT (HR=0.42, 95% CI, 0.25-0.70; P =0.001), and resection (HR=0.25, 95% CI, 0.14-0.46, P <0.001), and duration of chemotherapy (HR=0.75, 95% CI, 0.69-0.82, P <0.001).

CONCLUSIONS

CA19-9 decrease of ≥60% following induction chemotherapy as optimal response cut-off in patients with LAPC is an independent predictor for OS when CA19-9 is increased at baseline. Furthermore, ≥40% is the minimum cut-off demonstrating survival benefit. These cut-offs may be used when discussing treatment strategies during early response evaluation.

Toward a new paradigm of care: a surgical leaders' Delphi consensus on the organizational factors of the new pancreas units (E-AHPBA PUECOF study)

Pancreas units represent new organizational models of care that are now at the center of the European debate. The PUECOF study, endorsed by the European-African Hepato-Pancreato-Biliary Association (E-AHPBA), aims to reach an expert consensus by enquiring surgical leaders about the Pancreas Units' most relevant organizational factors, with 30 surgical leaders from 14 countries participating in the Delphi survey. Results underline that surgeons believe in the need to organize multidisciplinary meetings, nurture team leadership, and create metrics. Clinical professionals and patients are considered the most relevant stakeholders, while the debate is open when considering different subjects like industry leaders and patient associations. Non-technical skills such as ethics, teamwork, professionalism, and leadership are highly considered, with mentoring, clinical cases, and training as the most appreciated facilitating factors. Surgeons show trust in functional leaders, key performance indicators, and the facilitating role played by nurse navigators and case managers. Pancreas units have a high potential to improve patients' outcomes. While the pancreas unit model of care will not change the technical content of pancreatic surgery, it may bring surgeons several benefits, including more cases, professional development, easier coordination, less stress, and opportunities to create fruitful connections with research institutions and industry leaders.

Nationwide Use and Outcome of Surgery for Locally Advanced Pancreatic Cancer Following Induction Chemotherapy

BACKGROUND

Several international high-volume centers have reported good outcomes after resection of locally advanced pancreatic cancer (LAPC) following chemo(radio)therapy, but it is unclear how this translates to nationwide clinical practice and outcome. This study aims to assess the nationwide use and outcome of resection of LAPC following induction chemo(radio)therapy.

PATIENTS AND METHODS

A multicenter retrospective study including all patients who underwent resection for LAPC following chemo(radio)therapy in all 16 Dutch pancreatic surgery centers (2014-2020), registered in the mandatory Dutch Pancreatic Cancer Audit. LAPC is defined as arterial involvement > 90° and/or portomesenteric venous > 270° involvement or occlusion.

RESULTS

Overall, 142 patients underwent resection for LAPC, of whom 34.5% met the 2022 National Comprehensive Cancer Network criteria. FOLFIRINOX was the most commonly (93.7%) used chemotherapy [median 5 cycles (IQR 4-8)]. Venous and arterial resections were performed in 51.4% and 14.8% of patients. Most resections (73.9%) were performed in high-volume centers (i.e., ≥ 60 pancreatoduodenectomies/year). Overall median volume of LAPC resections/center was 4 (IQR 1-7). In-hospital/30-day major morbidity was 37.3% and 90-day mortality was 4.2%. Median OS from diagnosis was 26 months (95% CI 23-28) and 5-year OS 18%. Surgery in high-volume centers [HR = 0.542 (95% CI 0.318-0.923)], ypN1-2 [HR = 3.141 (95% CI 1.886-5.234)], and major morbidity [HR = 2.031 (95% CI 1.272-3.244)] were associated with OS.

CONCLUSIONS

Resection of LAPC following chemo(radio)therapy is infrequently performed in the Netherlands, albeit with acceptable morbidity, mortality, and OS. Given these findings, a structured nationwide approach involving international centers of excellence would be needed to improve selection of patients with LAPC for surgical resection following induction therapy.

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.

Improving shared decision-making about cancer treatment through design-based data-driven decision-support tools and redesigning care paths: an overview of the 4D PICTURE project

Background

Patients with cancer often have to make complex decisions about treatment, with the options varying in risk profiles and effects on survival and quality of life. Moreover, inefficient care paths make it hard for patients to participate in shared decision-making. Data-driven decision-support tools have the potential to empower patients, support personalized care, improve health outcomes and promote health equity. However, decision-support tools currently seldom consider quality of life or individual preferences, and their use in clinical practice remains limited, partly because they are not well integrated in patients' care paths.

Aim and objectives

The central aim of the 4D PICTURE project is to redesign patients' care paths and develop and integrate evidence-based decision-support tools to improve decision-making processes in cancer care delivery. This article presents an overview of this international, interdisciplinary project.

Design methods and analysis

In co-creation with patients and other stakeholders, we will develop data-driven decision-support tools for patients with breast cancer, prostate cancer and melanoma. We will support treatment decisions by using large, high-quality datasets with state-of-the-art prognostic algorithms. We will further develop a conversation tool, the Metaphor Menu, using text mining combined with citizen science techniques and linguistics, incorporating large datasets of patient experiences, values and preferences. We will further develop a promising methodology, MetroMapping, to redesign care paths. We will evaluate MetroMapping and these integrated decision-support tools, and ensure their sustainability using the Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) framework. We will explore the generalizability of MetroMapping and the decision-support tools for other types of cancer and across other EU member states.

Ethics

Through an embedded ethics approach, we will address social and ethical issues.

Discussion

Improved care paths integrating comprehensive decision-support tools have the potential to empower patients, their significant others and healthcare providers in decision-making and improve outcomes. This project will strengthen health care at the system level by improving its resilience and efficiency.

Preoperative chemotherapy, radiotherapy and surgical decision-making in patients with borderline resectable and locally advanced pancreatic cancer

Surgical resection combined with systemic chemotherapy is the cornerstone of treatment for patients with localized pancreatic cancer. Upfront surgery is considered suboptimal in cases with extensive vascular involvement, which can be classified as either borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In these patients, FOLFIRINOX or gemcitabine plus nab-paclitaxel chemotherapy is currently used as preoperative chemotherapy and is eventually combined with radiotherapy. Thus, more patients might reach 5-year overall survival. Patient selection for chemotherapy, radiotherapy and subsequent surgery is based on anatomical, biological and conditional parameters. Current guidelines and clinical practices vary considerably regarding preoperative chemotherapy and radiotherapy, response evaluation, and indications for surgery. In this Review, we provide an overview of the clinical evidence regarding disease staging, preoperative therapy, response evaluation and surgery in patients with borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In addition, a clinical work-up is proposed based on the available evidence and guidelines. We identify knowledge gaps and outline a proposed research agenda.

A scoping review into the explanations for differences in the degrees of shared decision making experienced by patients

OBJECTIVES

In order to improve the degree of shared decision making (SDM) experienced by patients, it is necessary to gain insight into the explanations for the differences in these degrees.

METHODS

A scoping review of the literature on the explanations for differences in the degree of SDM experienced by patients was conducted. We assessed 21,329 references. Ultimately, 308 studies were included. The explanations were divided into micro, meso, and macro levels.

RESULTS

The explanations are mainly related to the micro level. They include explanations related to the patient and healthcare professionals, the relationship between the patient and the physician, and the involvement of the patient's relatives. On the macro level, explanations are related to restrictions within the healthcare system such as time constraints, and adequate information about treatment options. On the meso level, explanations are related to the continuity of care and the involvement of other healthcare professionals.

CONCLUSIONS

SDM is not an isolated process between the physician and patient. Explanations are connected to the macro, meso, and micro levels.

PRACTICE IMPLICATIONS

This scoping review suggests that there could be more focus on explanations related to the macro and meso levels, and on how explanations at different levels are interrelated.

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.

Decision aids to assist patients and professionals in choosing the right treatment for kidney failure

Background

Kidney services vary in the way they involve people with kidney failure (PwKF) in treatment decisions as management needs change. We discuss how decision-science applications support proactively PwKF to make informed decisions between treatment options with kidney professionals.

Methods

A conceptual review of findings about decision making and use of decision aids in kidney services, synthesized with reference to: the Making Informed Decisions-Individually and Together (MIND-IT) multiple stakeholder decision makers framework; and the Medical Research Council-Complex Intervention Development and Evaluation research framework.

Results

This schema represents the different types of decision aids that support PwKF and professional reasoning as they manage kidney disease individually and together; adjustments at micro, meso and macro levels supports integration in practice.

Conclusion

Innovating services to meet clinical guidelines on enhancing shared decision making processes means enabling all stakeholders to use decision aids to meet their goals within kidney pathways at individual, service and organizational levels.

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.

Impact of multicentre diagnostic workup in patients with pancreatic cancer on repeated diagnostic investigations, time-to-diagnosis and time-to-treatment: A nationwide analysis

BACKGROUND

Due to the centralization of pancreatic surgery, patients with suspected pancreatic cancer may undergo diagnostic workup in both a non-pancreatic centre and a pancreatic centre, i.e. multicentre workup. This retrospective study assessed whether multicentre diagnostic workup is associated with repeated diagnostics, delayed time-to-diagnosis, delayed time-to-treatment, survival and whether variation existed among pancreatic cancer networks.

METHODS

This nationwide study included all patients diagnosed with non-metastatic pancreatic ductal adenocarcinoma (PDAC) in 2015, registered by the Netherlands Cancer Registry. A delayed time-to-diagnosis was defined as ≥3 weeks from initial hospital visit to final diagnosis. A delayed time-to-treatment was defined as ≥6 weeks from the first hospital visit to start of first tumour treatment. Multilevel logistic regression analyses and survival analyses were performed.

RESULTS

In total, 931 patients with non-metastatic PDAC were included. Overall, 175 patients (19%) underwent a multicentre diagnostic workup, which was significantly associated with repeated diagnostic investigations (OR = 6.31, 95% CI 4.13-9.64, P < 0.0001), a delayed time-to-diagnosis (OR = 2.66 95% CI 1.74-4.06, P < 0.001), and a delayed time-to-treatment (OR = 1.93 95% CI 1.12-3.31, P = 0.02), but not with decreased survival (HR = 1.09 95% CI 0.83-1.44; P = 0.532). Variation in outcomes per network was observed, especially for time-to-treatment, though the ICC was not statistically significant (P = 0.065).

CONCLUSION

Multicentre diagnostic workup for patients with PDAC is associated with repeated diagnostic investigations, a delayed time-to-diagnosis and delayed time-to-treatment compared to patients with monocentre workup. To reduce costs and improve treatment times, efforts should be made to improve network coordination, for example via network care pathways.

Implementation of a novel shared decision-making intervention in women with chronic hypertension in pregnancy: multiple-site multiple-method investigation

BACKGROUND

Many women with chronic hypertension are conflicted about antihypertensive medication during pregnancy and some are non-adherent to prescribed medication.

OBJECTIVES

Codesign, implement and evaluate a novel shared decision-making (SDM) intervention for use with pregnant women with chronic hypertension.

SETTING AND PARTICIPANTS

Pregnant women with chronic hypertension and their principal healthcare professionals (obstetricians, midwives, and physicians), at three National Health Service hospital trusts with different models of care.

MAIN OUTCOME MEASURES

The RE-AIM framework guided the evaluation. Primary: Decisional conflict scale, medication intention survey and women's acceptability. Secondary: Healthcare professionals' acceptability and the barriers and facilitators to SDM implementation with pregnant women with chronic hypertension.

RESULTS

Fifty women participated. Nearly half (46 %; n = 23) of women were from Black and Asian backgrounds. The SDM intervention was effective at reducing decisional conflict (mean reduction from baseline 42 %, 95 % CI 35-49, p ≤ 0.05). In 36 women (72 %), the reduction was of clinical importance. 24 women (48 %) were uncertain about or planned not to take antihypertensives prior to the SDM intervention, compared to two women (4 %) after the intervention. The intervention was acceptable to women and healthcare professionals. 10 of 14 healthcare professionals felt that the in-consultation aid facilitated SDM in current antenatal contexts, a similar proportion (10/14) felt the length of consultations hindered SDM.

CONCLUSION

A novel codesigned SDM intervention reduced decisional conflict and increased women's intention to take antihypertensive agents during pregnancy. This intervention could be adopted into practice for women making pregnancy decisions where there is uncertainty around the medication management option.

Shared Decision-Making in Pancreatic Surgery

Objective

The objective of this study is to determine the factors influencing pancreatic surgery patients' perceptions of the shared decision-making process (SDM).

Background

Decision-making in pancreatic surgery is complicated by the risk of morbidity and mortality and risk of early recurrence of disease. Improvement in SDM has the potential to improve the receipt of goal- and value-concordant care.

Methods

This cross-sectional survey included patients who underwent pancreatic surgery. The following components were studied in relation to SDM: modified satisfaction with decision scale (SWD), modified decisional regret scale (DRS), quality of physician and patient interaction, and the impact of quality of life (FACT-Hep). Correlations were computed using Pearson's correlation score and a regression model.

Results

The survey completion rate was 72.2% (of 40/55) and the majority (72.5%) of patients underwent pancreaticoduodenectomy. There were significant positive relationships between the SDM measure and (DRS, SWD; r = 0.70, P < 0.001) and responses to questions regarding how well the patient's actual recovery matched their expectations before treatment (r = 0.62, P < 0.001). The quality of the physician-patient relationship correlated with how well recovery matched expectations (r = 0.53, P = 0.002). SDM measure scores were significant predictors of the decision evaluation measure (R2(adj) = 0.48, P < 0.001), FACT-Hep (R2(adj) = 0.15, P < 0.001), and recovery expectations measure (R2(adj) = 0.37, P < 0.001).

Conclusions

Improved SDM in pancreatic surgery is associated with more realistic recovery expectations, decreased decisional regret, and improved quality of life.

Shared decision-making in the Netherlands: Progress is made, but not for all. Time to become inclusive to patients

Dutch initiatives targeting shared decision-making (SDM) are still growing, supported by the government, the Federation of Patients' Organisations, professional bodies and healthcare insurers. The large majority of patients prefers the SDM model. The Dutch are working hard to realise improvement in the application of SDM in daily clinical practice, resulting in glimpses of success with objectified improvement on observed behavior. Nevertheless, the culture shift is still ongoing. Large-scale uptake of SDM behavior is still a challenge. We haven't yet fully reached the patients' needs, given disappointing research data on patients' experiences and professional behavior. In all Dutch implementation projects, early adopters, believers or higher-educated persons have been overrepresented, while patients with limited health literacy have been underrepresented. This is a huge problem as 25% of the Dutch adult population have limited health literacy. To further enhance SDM there are issues to be addressed: We need to make physicians conscious about their limited application of SDM in daily practice, especially regarding preference and decision talk. We need to reward clinicians for the extra work that comes with SDM. We need to be inclusive to patients with limited health literacy, who are less often actually involved in decision-making and at the same time more likely to regret their chosen treatment compared to patients with higher health literacy.

Systems thinking and designerly tools for medical device design in engineering curricula

Background

In this paper we focus on medical device development (MDD) in Industrial Design Engineering (IDE) academia. We want to find which methods our MDD-students currently use, where our guidance has shortcomings and where it brings added value.

Methods

We have analysed 19 master and 3 doctoral MDD-theses in our IDE curriculum. The evaluation focusses around four main themes: 1) regulatory 2) testing 3) patient-centricity and 4) systemic design.

Results

Regulatory aspects and medical testing procedures seem to be disregarded frequently. We assume this is because of a lack of MDD experience and the small thesis timeframe. Furthermore, many students applied medical-oriented systemic tools, which enhances multiperspectivism. However, we found an important lack in the translation to the List of Specifications and to business models of these medical devices. Finally, students introduced various participatory techniques, but seem to struggle with implementing this in the setting of evidence-based medicine.

The Decision-Making Process for Palliative Sedation for Patients with Advanced Cancer-Analysis from a Systematic Review of Prospective Studies

BACKGROUND

The involvement of patients in decision making about their healthcare plans is being emphasized. In the context of palliative sedation, it is unclear how these decisions are made and who are involved in. The aim of the study is to understand how this decision-making is taken.

METHOD

Information from a systematic review on clinical aspects of palliative sedation prospective studies were included. PubMed, CINAHL, Cochrane, MEDLINE, and EMBASE were searched (January 2014-December 2019). Data extraction and analysis regarded: (a) When and by whom the decision-making process is initiated; (b) patient involvement; (c) family involvement and (d) healthcare involvement.

RESULTS

Data about decision making were reported in 8/10 included articles. Palliative sedation was reported in 1137 patients (only 16 of them were non-cancer). Palliative sedation was introduced by the palliative care team during the disease process, at admission, or when patients experienced refractory symptoms. Only two studies explicitly mentioned the involvement of patients in decision making. Co-decision between families and the regular health care professionals was usual, and the health care professionals involved had been working in palliative care services.

CONCLUSION

Patient participation in decision making appeared to be compromised by limited physical or cognitive capacity and family participation is described. The possibility of palliative sedation should be discussed earlier in the disease process.

The bigger picture of shared decision making: A service design perspective using the care path of locally advanced pancreatic cancer as a case

PURPOSE

Solutions to improve the implementation of shared decision making (SDM) in oncology often focus on the consultation, with limited effects. In this study, we used a service design perspective on the care path of locally advanced pancreatic cancer (LAPC). We aimed to understand how experiences of patients, their significant others, and medical professionals over the entire care path accumulate to support their ability to participate in SDM.

PARTICIPANTS AND METHODS

We used qualitative interviews including design research techniques with 13 patients, 13 significant others, and 11 healthcare professionals, involved in the diagnosis or treatment of LAPC. The topic list was based on the literature and an auto-ethnography of the illness trajectory by a caregiver who is also a service design researcher. We conducted a thematic content analysis to identify themes influencing the ability to participate in SDM.

RESULTS

We found four interconnected themes: (1) Decision making is an ongoing and unpredictable process with many decision moments, often unannounced. The unpredictability of the disease course, tumor response to treatment, and consequences of choices on the quality of life complicate decision making; (2) Division of roles, tasks, and collaboration among professionals and between professionals and patients and/or their significant others is often unclear to patients and their significant others; (3) It involves "work" for patients and their significant others to obtain and understand information; (4) In "their disease journey," patients are confronted with unexpected energy drains and energy boosts, that influence their level of empowerment to participate in SDM.

CONCLUSION

The service design perspective uncovered how the stage for SDM is often set outside the consultation, which might explain the limited effect currently seen of interventions focusing on consultation itself. Our findings serve as a starting point for (re)designing care paths to improve the implementation of SDM in oncology.