CHC Think Tank Deep Dive Summary: Decision Aids as Relationship-Building Tools
In November 2022, we discussed challenges in patient decision aids in shared decision-making with Dr. Prakash Jayakumar, Assistant Professor in Surgery and Perioperative Care, Director of Value-Based Health Care and Outcome Measurement at The University of Texas at Austin's Dell Medical School.
The conundrum:
How to guide clinicians and patients toward the use of decision aids to foster a trusting relationship as a foundation of effective shared decision-making.
Background:
The concept of shared decision-making comprises:
- Knowledge sharing
- Understanding preferences, values, and needs, and
- Effective communication strategies
Patient decision aids are tools to help apply shared decision-making at the point of care.
Challenges
There are two ongoing design challenges in this space:
Challenge 1
Some clinicians may believe they "do" shared decision-making well. Others may look to decision aids to "do the work for them." This may contribute to missed opportunities to build relationships and tailor the level of knowledge to the individual's decision preferences, while uncovering stories, journeys, and goals, and tailoring communication strategies to arrive at richer and more meaningful and trusting clinical encounters.
Challenge 2
Decision aids tend to focus on knowledge and presentation of data with missed opportunities regarding synthesis and visualization for the conveyance of comprehensive, biopsychosocial health options.
Pre-Meeting Discussion:
David commented:
"...rational approaches alone may be insufficient. Just as behavioral economics (Kahneman/Taversky) has supplanted classical economics and behavioral ethics has supplanted classical ethics—both based on the “fast” or “autopilot”, irrational aspects of human thoughts—it’s time to emphasize the non-rational, autopilot aspects of health. In this regard, the most useful tools will be those that prompt people to rethink things and apply their slow, or critical thinking, to be sure that their expressed preferences are based on what matters most to them and not clouded by common misconceptions."
Heather added:
"I wonder if motivational interviewing is an appropriate tool for shared decision-making. In clinical settings…might it be useful to encourage people to “slow down” and really think about their options and preferences (and also give clinicians an opening to correct misperceptions and misinformation)?”
PJ chimed in:
“Going a few layers deeper beyond knowledge, communication, and goal and preference setting toward thinking about optimizing heuristics and enabling patients to come to arrive at their decisions while minimizing cognitive [errors].”
Conceptualize decision aids as tools to create richer discussions/Decision aid as a relationship-building tool
| Takeaways | Recommendations | Implementation/Examples |
|---|---|---|
| Clarify the role of the tool | It's not a test or gatekeeping tool |
"Let's look at this together" "This will help me serve you in this process" "After you use this tool, we'll discuss what to do next." |
| Part of a larger context | Help manage the ebb and flow of tension |
Consider time, place, and touchpoints: What is the path to a comfortable and healthy decision? Learn to manage the tension level |
| Narrative medicine | Invite the patient to tell their own story in the way they want to tell it | "What's the most important thing for me to know about your situation right now?" |
A decision aid is a tool that reminds us that healthy decisions can be difficult
| Takeaways | Recommendations | Implementation/Examples |
|---|---|---|
| Automatic thoughts are not easily reoriented | Address the irrational along with the rational | Motivational interviewing techniques |
| Pair the tool with human interaction | Social cues can be helpful | Tie the aid to: Decision coach, peer support |
More than knowledge sharing or "patient education"
| Takeaways | Recommendations | Implementation/Examples |
|---|---|---|
| Calming and inspiring | Alleviate worry and despair |
Anticipate and alleviate potential sources of distress Offer confidence and hope |
| Facilitate clear thinking |
Anticipate misconceptions, misinterpretations, and misinformation Gently orient* to an accurate and healthy interpretation of symptoms |
"Tell me more about what you've heard about..." |
| Navigation of uncertainty | Limit and accommodate uncertainty |
Information synthesis and visualization crafted for a healthy mindset |
Decision aids as values clarification tools
| Takeaways | Recommendations | Implementation/Examples |
|---|---|---|
| Get to the core identities and goals | Find out what matters most |
What is important to you? "What do you hope to be able to do in X amount of time?" |
| Limit decision conflict | Advance toward a decision, not to one choice or another |
How do you prefer to decide? "What will help you make a choice to XYZ?" |
*More information on orientation
Orientation and guiding can use both direct and indirect communication.
Direct: "Your knee will not be the same as it was before the injury."
Indirect: "We are really good at this surgery and even when patients do everything that is asked of them, their knee is never as it was before."
This can also be done by telling a story about a patient that is similar to the current patient. "I had a man in his 60s, tough as nails, always on the go, never afraid to put in the work. This surgery was really hard for him..."