1. Shared decision making
Realistic Prescribing

2. The background Introduction - Dr Scott Jamieson (GP)
Case study 1 - Polypharmacy – making decisions together. Dr Alison Clement (AMD & GP)
Sharing the decision in practice - Aids to support the conversation - Arlene Coulson (Lead Clinical Pharmacist) & Fran Benison (Patient and Public Forum for Medicines Representative)
Case study 2 - Sharing the decision in out-patient settings - Lee-Ann McDermott (Specialist Clinical Pharmacist) & Sue Cole (Patient and Public Forum for Medicines Representative) 
Case study 3 - Sharing the decision in an acute setting - Karen Lowdon (Specialist Clinical Pharmacist)
The intro to the session

3. Declarations MBChB MRCGP DRCOG DRSRH DPD
Full time GP, Practice Quality Lead
OOH Dundee ¼ full-time
GP Rep to NHS Tayside Medicines Advisory Group & Area Drugs & Therapeutics Committee
Angus HSCP Prescribing Lead; Chair NHS Tayside Non-Medicines Advisory Group
RCGP E Scotland Faculty Board; RCGP Scottish Council Rep
RCGP GP Rep to SIGN
RCGP Scotland Executive Officer (Quality Improvement)
University of Cardiff marker - DPD

4. The collaboration Discussion points with the Panel
Are we doing enough to promote these opportunities?
How can we make all decisions closer to a true choice?
What experiences do we all have?
How do we know we are getting it right? What’s the measurable impact?
What would be ‘Realistic evaluation’?
Sign posting to the discussion section

5. Shared decision making Optimal patient care Evidence-led Patient led
Outline of what SDM is
Shared decision
making
Evidence-led
Patient led
Optimal patient care

6. A few examples

7. All evidence based medicine is undermined by…

8. Uncertainty
Does the evidence relate to this patient? These instances are becoming increasingly common as more people live longer with multiple chronic conditions and care becomes more complicated. Clinical decisions may involve screening or treatment with new toxic drugs in older patients; timely use of adjuvant, palliative, or pain care; or prioritising care at the end of life. Shared decision making is essential in the care of patients in these complicated situations. For clinicians, being able to and choosing to spend time on understanding what truly matters to patients when making decisions together is an achievement that makes the work of clinicians meaningful and rewarding

9. We must afford the time to SDM
We must afford the time to SDM. It might be a planned discussion, but often it isn’t. How do we cope with these challenges..? The organisation needs to react and afford time… in all clinical settings.

10. Polypharmacy – making decisions together Alison Clement

11. Brenda (70yrs), previous stroke
27 tablets daily + 3 creams + 2 eyedrops + 1 liquid laxative
Painkillers, antidepressants, constipation, blood pressure control.
Can’t face another tablet
I am going to tell you about 3 of my patients who are experiencing polypharmacy and the different decisions they have made as to whether or not to take statins following a stroke. There is evidence that statins reduce the risk of a further stroke and patients discharged from hospital following a stroke or mini-stroke are usually prescribed them. However there is much in the media about the side-effects and whether patients continue to wish to take them depends very much on the person. Starting with Brenda. Brenda had quite a severe stroke in her 60s. She lives in the community and is cared for by her husband. We regularly review her medicines and she has had several changes trying to get control of her symptoms such as pain, depression and constipation. Recently I mentioned statin treatment – she decided she could not face taking another tablet.

12. John (also 70yrs), mini-stroke years ago
Now has metastatic cancer – spread to the bones
Symptoms well controlled under supervision of Macmillan nurse, 8 tablets daily
Just retired, feels well, wants to continue with what is working for him
On reading John’s notes before meeting him he seemed quite frail, he has had cancer for a few years which despite treatments has now spread to the bones. I thought it may be time to start reducing the tablet burden of 8 tablets daily to focus on symptom control. However on meeting him quite a different picture emerged. His symptoms are well controlled, his Macmillan nurse monitors things, he has just retired as was finding a part-time job a bit tiring, but is living life to the full and wishes to continue with the medicines that are working for him – why change them.

13. Andrew (45yrs) stroke aged 41yrs
Came into nursing home and had been told had few months to live due to a tumour
1 year on and no evidence of any deterioration, 8 tablets daily reduced from 10
Glad he made the decision to continue his stroke prevention treatments
When I first met Andrew he had been recently told he had a non-curative tumour which would mean that his life was limited and he would therefore require 24 hour care. 1 year on we have reduced his 10 tablets to 8 and his symptoms are controlled. He is glad he made the decision to continue his stroke prevention medication as it appears his prognosis is not as bad as initially thought. Were he to have stopped his stroke prevention medications he may have been more likely to suffer a further stroke and therefore a deterioration in his level of independence which is the most important thing for him.

14. Sharing the decision in practice - aids to support the conversation Arlene Coulson, Lead Clinical Pharmacist Fran Benison, Patient and Public Forum for Medicines

15. Could these decision aids help to prepare patients?
How do we measure the impact?

16. Benefits
Risks

17. “Right to Ask”

18. Patient Empowerment PATIENT AND PUBLIC FORUM FOR REALISTIC MEDICINES
How do we measure the impact of these cards?
PATIENT AND PUBLIC FORUM FOR REALISTIC MEDICINES
1. Feedback with patient education materials - local and national
2.Attendance at different meetings/
national conferences
3.Testing materials for development of patient apps
4. Developing information for Public Access website
5. Recording for video clips/patient scenarios
6. Raising issues from a patient perspective e.g. medicines waste/discharge processes
PATIENT AND PUBLIC FORUM FOR REALISTIC MEDICINES
1. Feedback with patient education materials - local and national
2.Attendance at different meetings/
national conferences
3.Testing materials for development of patient apps
4. Developing information for Public Access website
5. Recording for video clips/patient scenarios
6. Raising issues from a patient perspective e.g. medicines waste/discharge processes

19. Shared decision making in the out-patient setting: An example from Pharmacist Led Rheumatology Review Clinics Lee Ann McDermott, Specialist Rheumatology Pharmacist

20. Encouraging the patient to ask the right questions
Shared decision making involves:
Encouraging the patient to ask the right questions
Some patients may need this information provided to them through discussion, this takes time and must be explained in a manner they understand (? Use Teach back method)
- they may not know what questions to ask that would help them make a decision about their treatment

21. Scenario Patient with rheumatoid arthritis
- treatment needs escalated to try and achieve disease control

22. Shared decision making in the out-patient setting: Sue Cole, Patient and Public Forum for Medicines and Rheumatology patient

23. Diagnosed with Rheumatoid Arthritis in 2007
Given DMARDS to dampen down immune system
Methotrexate & Hydroxchloroquine intolerant
Consultant offered a new biologic as next step....
2012 Certolizumab aka Cimzia made dramatic difference
Have to weigh up new symptoms/side effects with being able to lead as active and pain-free life as possible.

24. Shared decision making in the acute setting Karen Lowdon, Specialist Clinical Pharmacist

25. Case study 3 93 year old lady P/C dyspnoea and general decline
known CKD, AF & IHD
o/a iron deficient anaemia due to PV bleeding
Gynae review and transvaginal USS as in-patient indicated thickened endothelium and a conservative management approach was deemed most appropriate

26. “Fundamental to the doctor and patient relationship is the requirement that a patient with capacity to decide should be informed about the treatment options open to him or her; the risks and benefits of each option; and be supported to make their choice about which treatment best meets their needs”
The above quote from the Realistic medicines CMO annual report 2016/17 is key to patient empowerment, self management and shared decision making.

28. When considering this lady’s risk factors for suffering a cardio-embolic event in the context of AF, her CHA2DS2-Vasc score = 3 which is considered moderate – high risk and, therefore, should be considered for anticoagulation.
The above Cate’s plot is a visual tool which can be used with patients during the decision-making process, discussing the benefits and associated risks of treatment.
Based on this lady’s risk stratification and a CHA2DS2-Vasc score = 3;
For 1000 people with AF, without anticoagulation, over a 1 year period on average 37 will have an AF-related stroke (as depicted by the red faces in this illustration). Meaning 963 will not have an AF-related stroke (green faces)
If all 1000 patients take an anticoagulant over 1 year, on average 25 (of the 37) will be saved from having an AF-related stroke (as depicted by the yellow faces) meaning 12 individuals will still suffer an event despite treatment.

29. A further Cate’s plot is available to quantify bleeding risk.
If 1000 people with AF and a HAS-BLED score of 3 chose not to take anticoagulation, over 1 year on average;
9 will have a major bleed as indicated by the red faces will not have a bleed
If anticoagulation is selected, an extra 15 people will have a major bleed

30. The collaboration Discussion points with the Panel
Are we doing enough to promote these opportunities?
How can we make all decisions closer to a true choice?
What experiences do we all have?
How do we know we are getting it right? What’s the measurable impact?
What would be ‘Realistic evaluation’?
Sign posting to the discussion section

31. Thank you