Shared Decision Making, Ethics, and Shared Responsibility
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1 Shared Decision Making, Ethics, and Shared Responsibility Ben Moulton, JD, MPH Senior Legal Advisor Lecturer in Health Law, Harvard School of Public Health September 29, 2011
2 Shared Decision Making (SDM) h the process of interactingi with ih patients who wish ih to be involved in arriving at an informed, values-based choice among two or more medically reasonable alternatives ¹ INFORMED There is a choice The options The benefits and harms of the options VALUES-BASED What s important to the patient The Clinician Information The Patient ¹AM A.M. O'Connor et al, Modifying Unwarranted Variations In Health Care: Shared Decision Making Using Patient Decision Aids Health Affairs, 7 October,
3 Evidence of the Problem Medical Practice Variation 40 Years of Research Documenting Inconsistent Care The DECISIONS Study A Portrait of How Americans Make Common Medical Decisions 3
4 Patients: Making Decisions in the Face of Avoidable Ignorance Clinicians: Poorly Diagnosing i Patients Preferences Poor Decision Quality 4
5 How Well Do Providers Predict Patient Preferences? Lee CN, Dominik R, Levin CA, Barry MJ, Cosenza C, O'Connor AM, Mulley AG Jr, Sepucha KR. Development of instruments to measure the quality of breast cancer treatment decisions. Health Expect Sep 1;13(3): Epub 2010 Jun 9. 5
6 Rhode Island Hospital Performed Surgery on Wrong Body Part for Fifth Time The Rhode Island Department of Health is investigating Rhode Island Hospital in Providence after the hospital admitted to operating on the wrong body part for another patient, marking at least the fifth wrong-site surgery at the hospital since Published: October 30th, 2009 AboutLawsuits.com 6
7 Patient Safety Wrong Site Surgery Wrong Patient Surgery How do we describe operating on a patient who would say NO to surgery if alternatives, risks, and benefits were well understood? 7
8 Is Informed Consent Real? In a survey of consecutive patients scheduled for an elective coronary revascularization procedure (PCI) at Yale New Haven Hospital in : 1998: 75% believed PCI would help prevent a myocardial if infarction i 71% believed PCI would help them live longer Less than half could name even one possible complication of PCI 85% were consented just before the procedure (by a fellow or a nurse practitioner) (Holmboe ES. JGIM 2000; 15:632) 8
9 Is Informed Consent Real? (2) From the latest meta-analysis in 2009 (61 trials, 25,388 patients): Sequential innovations in catheter-based treatment for non-acute coronary artery disease showed no evidence of an effect on death or myocardial infarction when compared to medical therapy. (Trikalinos TA. Lancet 2009; 373:911) 9
10 10
11 23 Patient vs. 25 Physician States 2 Hybrids Patient Standard Physician Standard Hybrid (NM & MN) 11
12 Cochrane Review of Decision Aids In 55 trials of decision aids addressing 23 different screening or treatment decisions, use has led to: Greater knowledge More accurate risk perceptions p Greater comfort with decisions Greater participation in decision-making Fewer people remaining undecided (O Connor et al. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD001431) Fewer patients choosing major surgery, prostate cancer screening tests 12
13 Health Policy Reasons for Adoption of SDM on Large Scale Ethical imperative atve to do the right thing Increased alignment of individual preferences, values, and lifestyle l with clinical i l decisions i Bridging g health disparities Conservative utilization of surgical interventions 13
14 Did the patient know a decision was being made? Did the patient know the pros and cons of the treatment options? Did the provider elicit the patient s preferences? Involvement Decision Quality Values Concordance Did the decision reflect the patient s goals and concerns? Knowledge Did the patient know what he or she needed to know? Sepucha KR, et al. Policy support for patient-centered care: the need for measurable improvements in decision quality. Health Affairs, (Millwood). 2004; Suppl Web Exclusives:VAR
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