1. Shared Decision Making
Workshop
Tutor Name
Slide set for half day workshop

2. Learning Outcomes
Define shared decision making and differentiate it from other consultation communication skills
Describe the evidence base / rationale for shared decision making
Describe a model for shared decision making
Perform core shared decision making skills used during a shared decision making discussion (based on the Model of SDM)
Identify when and describe how shared decision making could be used within their own role (individual and team level)
Describe how patient decision aids could support the shared decision making process

3. Workshop Agenda What we will cover 09:00 Welcome
09:05 Introduction to Shared Decision Making
10:00 Break
10:15 Core skills in SDM
10:45 SDM Skills Practice Session
11:45 Reflections on workshop and wrap-up
Recommended timings – can be changed as necessary
12:00 Finish

4. Shared Decision Making
Introduction to
Shared Decision Making

5. Work in 2 - 3s to discuss what ‘shared decision making’ means to you
What is shared decision making?
What we will cover
What we will cover
Work in 2 - 3s to discuss what ‘shared decision making’ means to you
( mins)
Pairs / groups to feedback response to the group. Facilitator to capture definitions / key words on a flip chart (if available). Helps attendees to see how SDM differs to what they do already – shared understanding at the outset

6. “ “n” What is shared decision making? What is shared decision making?
…involves patients and clinicians working together in partnership to make healthcare decisions. It involves sharing evidence based information and considering individual needs and preferences. It involves doing what is needed, no more, no less
“n”

7. Shared decision making
What is shared decision making?
What is shared decision making?
Shared decision making
Paternalistic style
Informed
choice

8. What is shared decision making? Shared Decision Making
What SDM is…
Partnership between HCPs and patient
Informing patient about options (using EBM) and
Making sure patient’s preferences are incorporated into treatment plan
HCP guiding the decision making process
What SDM is not…
Just information exchange
Telling patient about options, but not asking what matters most to patient
Informed consent (but SDM process can help with this)
Saying to a patient, “it’s your decision, it’s up to you to decide”

9. Two types of expertise Clinician Causes of disease
Diagnosis / prognosis
EBM
Treatments / tests
Outcomes
Experience

10. Two types of expertise Clinician Patient Causes of disease
Diagnosis / prognosis
EBM
Treatments / tests
Outcomes
Experience
Patient
Experience
Social circumstances
Personal circumstances
Attitude to risk
Preferences
What matters most

11. Two types of expertise Two types of expertise
Not doing ‘to’ patients, doing ‘with’ patients
Clinician
Causes of disease
Diagnosis / prognosis
EBM
Treatments / tests
Outcomes
Experience
Patient
Experience
Social circumstances
Personal circumstances
Attitude to risk
Preferences
What matters most
SDM

12. Best outcome for patient?
Case study
Case study
Best outcome for patient?
This is a real-life case scenario from an ENT setting. We would encourage facilitators to think about and include their own context specific case study / patient story, if available
An 82 yr old patient, diagnosed with laryngeal cancer. Treatment options included surgical removal of voice box or palliative care. What would you choose?

13. Best outcome for patient?
Case study
Case study
Best outcome for patient?
Survival
This is a real-life case scenario from an ENT setting. We would encourage facilitators to think about and include their own context specific case study / patient story, if available
An 82 yr old patient, diagnosed with laryngeal cancer. Treatment options included surgical removal of voice box. Get rid of the cancer

14. Best outcome for patient?
Case study
Case study
Best outcome for patient?
Survival
This is a real-life case scenario from an ENT setting. We would encourage facilitators to think about and include their own context specific case study / patient story, if available
An 82 yr old patient, diagnosed with laryngeal cancer. Treatment options included surgical removal of voice box. What is important to me?
Illiterate
Valued going to pub with friends
Speaking with grandchildren

15. Best outcome for patient?
Case study
Case study
Best outcome for patient?
‘Normal’ rest of life
Survival
This is a real-life case scenario from an ENT setting. We would encourage facilitators to think about and include their own context specific case study / patient story, if available
An 82 yr old patient, diagnosed with laryngeal cancer. Treatment options included surgical removal of voice box. Needs to speak.
Illiterate
Valued going to pub with friends
Speaking with grandchildren

16. Best outcome for patient?
Case study
Case study
Best outcome for patient?
‘Normal’ rest of life
Survival
This is a real-life case scenario from an ENT setting. We would encourage facilitators to think about and include their own context specific case study / patient story, if available
An 82 yr old patient, diagnosed with laryngeal cancer. Treatment options included surgical removal of voice box. Patient opted for palliative treatment.
Illiterate
Valued going to pub with friends
Speaking with grandchildren

17. Evidence for shared decision making
Cochrane Review of 105 studies, 31,043 participants, with decision aids focusing on 50 different decisions (Stacey et al, 2017)
Key benefits for patients
Improved knowledge of options
Better informed and clearer about what matters to them
More accurate expectations of benefits / harms
Greater involvement

18. Policy & Regulatory Requirements Policy & regulatory requirements
We encourage facilitators to think about how SDM fits in with their own context e.g. are there clinical guidelines that they use that promote choice? Is SDM in line with the organisation’s or team’s goals / targets / principles? Will SDM help to support informed consent procedures? etc A team / organisation specific slide could be added after this slide

19. Shared Decision Making
Prudent Healthcare Agenda – Wales
ADD PRUDENT HEALTHCARE SLIDE
Explain how SDM can help to achieve the Prudent Healthcare Agenda in Wales. Team / Organisation specific slides could also be added here
Shared Decision Making

20. When is SDM appropriate?
Prompt attendees to think about situations before displaying them on next slide

21. When is SDM appropriate? When is SDM appropriate?
No treatments are 100% reliable and 100% side effect free
Few clinical situations where there is only one course of action in all cases (and always option of care not cure)
When there are a number of options leading to different outcomes or uncertainty in evidence
‘Preference sensitive’ decisions
Right decision will depend on patient’s input – what’s right for them?
Prompt attendees to think about situations before displaying them on next slide

22. When is SDM appropriate? Some examples of SDM situations
Mastectomy or lumpectomy with radiotherapy for early breast cancer
Repeat c-section or vaginal birth after previous c-section
Medication / physiotherapy or knee replacement for osteoarthritis of the knee
Contraception options
Statins or diet and weight loss to reduce CVD disease risk
Advance directives e.g. cardiopulmonary resuscitation
Dialysis and transplantation options for chronic kidney disease
Facilitators are encouraged to edit this slide or add another slide to demonstrate context specific examples

23. When is SDM appropriate?
Some examples of SDM situations
Every time investigations and treatments are discussed with patients
Clinician ‘the guide’
Patient ‘the expert on their world’

24. Shared Decision Making
Core skills in
Shared Decision Making

25. “ “n” What is shared decision making? What is shared decision making?
…involves patients and clinicians working together in partnership to make healthcare decisions. It involves sharing evidence based information and considering individual needs and preferences. It involves doing what is needed, no more, no less
“n”

26. “ Why do we need a model? What is shared decision making?
Prompt attendees to think about why a model is helpful “

27. Why have a model? Choice Talk Conceptualises SDM
Provides structure (even more useful if more difficult)
Organises discussion
Different skills for different phases
Standardises approach
Makes it teachable

28. Patient decision support tools
Model of SDM
Model of SDM
Three talk Model of SDM - Elwyn et al, 2012, JGIM
Decision Talk
Option Talk
Choice Talk
Initial preferences
Informed preferences
Patient decision support tools
Inside or outside consultation
Three key steps in SDM

29. Choice Talk Choice Talk Core Skills Step back Introduce choice
Explain why choice exists
Check reaction
Defer closure
Reassure that it is a collaborative process

30. Choice Talk – example phrases Choice Talk – example phrases
Introducing choice
“Were you aware that there were different options?”
“There is more than one way to deal with this problem and the evidence shows that some treatments suit some people more than others”
“I’m interested in what matters to you, and that is why I am going to describe the options that are available and then you can tell me which one you prefer” 

31. Choice Talk – example phrases Choice Talk – example phrases
Explain why choice exists
“Each option has different outcomes…some will matter more to you than other people”
“Different treatments have different results and the chances of experiencing side effects vary”

32. Option Talk Option Talk Core Skills Check existing knowledge
List options (high level)
Describe options (detail)
Benefits and harms
Provide decision support (optional)
Consider emerging preferences to tailor
Summarise

33. Option Talk – example phrases Option Talk - example phrases
Check existing knowledge
“What’s your understanding of your diagnosis?”
“What have you been thinking about your diagnosis?”
“Are you already aware of how this problem could be treated?”
“And what are the main questions on your mind?”

34. Option Talk – example phrases Option Talk - example phrases
List options (High level)
”There are three key treatment options in this situation, let me list these first, and then I will describe them in more detail”
“These options will have different implications for different people, so I want to describe…”
Describe options (detail)/Benefits and harms
“The main risks of the first option are, and the main risks of the second option are…”
“Let’s look at the most relevant risks and benefits of each option are…let me know if I go too quickly or if you don’t understand”
”What are you thinking about the options that I have told you?”

35. Option Talk – example phrases Option Talk - example phrases
Check reaction (again) and judge emerging preferences
Allow silence – encourages questions
Watch non-verbal cues
Involve others – family, friends if present
“What are you thinking about the options that I have told you?”

36. Option Talk Option Talk Core Skills Check existing knowledge
List options (high level)
Describe options (detail)
Benefits and harms
Provide decision support (optional)
Consider emerging preferences to tailor
Summarise

37. Patient decision support tools
Patient decision aids
Patient decision support tools
Tools designed to support the SDM process
Provide evidence based information about options (likely outcomes)
Helps patient to think about preferences and weigh up different options
Support not replace the discussion
SDM skills are more important than tools

38. Brief in-consultation decision aid
Patient decision aids
Patient decision support tools
Detailed decision aid
Brief in-consultation decision aid
Personalised sheets
Slides include examples of patient decision aids. We encourage facilitators to identify decision aids that are relevant to their own clinical setting

39. Patient decision support tools
Patient decision aids
Patient decision support tools
Slides include examples of patient decision aids. We encourage facilitators to identify decision aids that are relevant to their own clinical setting

40. Decision (planning) Talk Decision Talk
Core Skills
Focus on preferences – what’s important to you?
Listen to preferences
Integrate preferences
Moving to a decision or planning for a future decision
Offer review

41. Decision Talk – example phrases
Decision (planning) Talk – example phrases
Decision Talk – example phrases
Focussing on preferences
“So what are you thinking at this stage?”
“Do you have an initial preference about the options I outlined?”
“What are your goals and priorities for your treatment?”
“Have you (any) concerns about (any) of the options?”
“What matters most to you?”
“Which option would fit in best with your lifestyle / family / job?”
“Would you like time to think about the options?”

42. Making Choices Together has produced a leaflet to encourage individuals to tell their clinicians what is important to them and to ask 3 questions to find out more about their options. This can act as a useful prompt for both patients and clinicians

43. Decision Talk – example phrases
Importance of silence in the consultation
Decision Talk – example phrases
11 seconds…

44. Decision Talk – example phrases
Importance of silence in the consultation
Decision Talk – example phrases
11 seconds…median time to clinician interrupting patient in a consultation (Ospina et al, 2018, JGIM)
Patient’s agenda elicited in only 36% of consultations
Importance of silence in a consultation
Just because it’s silent for the clinician, does not mean it is ‘silent’ for the patient – their head will be full of thoughts
Listening to understand, not always to reply

45. Practice Session

46. Practice Session- 60 minutes
Get into groups of 3
Open Scenario 1 envelope
Assign each person a role – Clinician, Patient, Observer
Read your allocated role description and scenario
Conduct a brief consultation & then discuss how it went with your group – observer provide feedback
After 20 minutes, move onto Scenario 2, change roles
After 20 minutes, move onto Scenario 3, change roles
Everyone should take a turn at being the Clinician, Patient & Observer
The timing of this session (60 minutes) is based on the use of 3 scenarios
Encourage the attendees to spend minutes acting out the consultation, leaving 5-10 minutes for the observer to feedback.

47. Workshop reflections

48. SDM into routine clinical settings?
Implementing SDM in clinical settings
Implementation of SDM in clinical settings Q
What works and what doesn’t work to embed
SDM into routine clinical settings?
Quality improvement methods
Primary & secondary care
Worked with teams, patients, and healthcare organisations
Remind attendees that SDM implementation can be challenging – if there is time at the end of the session, facilitator could ask attendees to reflect on some possible barriers / facilitators
Direct attendees to read this paper to find out more about the commonly encountered barriers and possible solutions
Paper link
Also included in handout folder
Joseph-Williams et al, Implementing shared decision making in the NHS: lessons from the MAGIC programme. BMJ 2017;357

49. Multiple factors influencing SDM Multiple factors influencing SDM
What has been covered today versus the full range of factors influencing implementation – awareness of barriers / facilitators
Joseph-Williams et al. Implementing shared decision making in the NHS: lessons from the MAGIC Programme. BMJ, 2017;357:j1744

50. Some points to consider
SDM is not a standardised process
Every discussion will vary
SDM is rarely one patient, one clinician, one consultation
Distributed across time and people
SDM may not result in complete agreement
Makes it more likely that final decision is informed by two types of expertise
Avoid viewing patients as ‘non-compliant’ and clinicians as ‘overly paternalistic’
If patients have a different opinion, or if clinician makes recommendations based on patient’s preferences

51. People will forget what you said…but people will never forget how you made them feel“ X”
Maya Angelou