Shared Decision Making and the Use of Decision Aids

Abstract

Background: In shared decision making (SDM), the patient and the physician reach decisions in partnership. We conducted a trial of SDM training for physicians who treat patients with cancer.

Methods: Physicians who treat patients with cancer were invited to participate in a cluster-randomized trial and carry out SDM together with breast or colon cancer patients who faced decisions about their treatment. Decision-related physician-patient conversations were recorded. The patients filled out questionnaires immediately after the consultations (T1) and three months later (T2). The primary endpoints were the patients' confidence in and satisfaction with the decisions taken. The secondary endpoints were the process of decision making, anxiety, depression, quality of life, and externally assessed physician competence in SDM. The physicians in the intervention group underwent 12 hours of training in SDM, including the use of decision aids.

Results: Of the 900 physicians invited to participated in the trial, 105 answered the invitation. 86 were randomly assigned to either the intervention group or the control group (44 and 42 physicians, respectively); 33 of the 86 physicians recruited at least one patient for the trial. A total of 160 patients participated in the trial, of whom 55 were treated by physicians in the intervention group. There were no intergroup differences in the primary endpoints. Trained physicians were more competent in SDM (Cohen's d = 0.56; p<0.05). Patients treated by trained physicians had lower anxiety and depression scores immediately after the consultation (d = -0.12 and -0.14, respectively; p<0.10), and markedly lower anxiety and depression scores three months later (d = -0.94 and -0.67, p<0.01).

Conclusion: When physicians treating cancer patients improve their competence in SDM by appropriate training, their patients may suffer less anxiety and depression. These effects merit further study.

Figure 1

Flow diagram of patients included and excluded SDM, shared decision making; T, time point

Figure 2

Means for individual items of the Observing Patient Involvement (OPTION) Scale 1: The clinician draws attention to an identified problem as one that requires a decision making process. 2: The clinician states that there is more than one way to deal with the identified problem (’equipoise’). 3: The clinician assesses patient’s preferred approach to receiving information to assist decision making (e.g. discussion in consultations, read printed material, assess graphical data, use videotapes or other media. 4: The clinician lists ’options’, which can include the choice of ’no action’. 5: The clinician explains the pros and cons of options to the patient (taking ’no action’ is an option). 6: The clinician explores the patient’s expectations (or ideas) about how the problem(s) are to be managed. 7: The clinician explores the patient’s concerns (fears) about how problem(s) are to be managed. 8: The clinician checks that the patient has understood the information. 9: The clinician offers the patient explicit opportunities to ask questions during decision making process. 10: The clinical elicits the patient’s preferred level of involvement in decision making. 11: The clinician indicates the need for a decision making (or deferring) stage. 12: The clinician indicates the need to review the decision (or deferment)