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Shared decisions

The art of healthcare

Bartol, Tom APRN

doi: 10.1097/01.NPR.0000520828.91534.e5
Department: NP Insights
Free

Tom Bartol is an advanced practice RN at Richmond Area Health Center, HealthReach Community Health Centers, Richmond, Me., and is a member of the Editorial Advisory Board of The Nurse Practitioner.

The author has disclosed that he has no financial relationships related to this article.

Questions or comments? E-mail bartolnp@gmail.com.

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Care guidelines, quality measures, and evidence-based medicine lead to an appearance that the practice of healthcare is an exact science with one right way to do things. However, the evidence we know is only a sliver of reality, and it is constantly developing and changing. Science is simply a guide to healthcare that, combined with the art of healthcare, leads to the actual practice. Decisions require finesse and dialogue, ascertaining what is appropriate for each individual patient, but taking into account the unique characteristics of each individual.

The science of healthcare is not static. Twenty-five years ago, evidence-based medicine told us that beta-blockers were contraindicated for patients with heart failure (HF). Now, evidence-based medicine recommends beta-blockers as the treatment of choice for patients with HF.1 Science (the evidence) is only what we know at the moment. Our knowledge (the evidence we know) will change over time.

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Who is the consumer?

In most business transactions, the consumer makes a choice about a product or service and then pays for it. In healthcare, who really is the consumer? Is it the patient, the clinician, or the insurance company? The patient receives the services, the clinician orders the service to be “purchased,” and the insurance company is usually the one paying the bill. All three fill roles of the consumer, but which of the three is actually making the decision about care?

The payment system also makes healthcare unique. If auto insurance worked like health insurance, covering maintenance and repairs (as well as accidents, injury, and damage), things would change. The consumer would bring a car to the mechanic who would determine what is needed, perhaps a transmission rebuild, new brakes, an oil change, or a wheel alignment. There is no discussion of price. The insurer may require a prior authorization before some things can be completed, but the consumer, with a goal of keeping the car in running order, would simply pay a $20 copay and be done.

With this type of auto insurance, we would see more auto mechanics doing more “procedures,” putting more new parts into cars, doing more diagnostic tests, and developing new innovations for automobile maintenance. The market would drive up costs by increasing insurance premiums. This could result in less incentive to take care of cars because maintenance and repairs would be covered by insurance. None of this would insure that cars are safer or last longer.

Medical diagnostics and treatments can become routine, often lacking the thought and discussion that would go into a purchase of a similar cost item in any other part of our lives. Consider purchasing a new TV, car, or computer. The process would involve gathering information about costs, benefits, and alternative products, then comparing them to make an informed choice. Clinical tests and treatments can be ordered with the click of a button, sometimes without adequate consideration of the implications of what is ordered or without the input of the person receiving it.

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Better care with interactive decisions

If the individual receiving a service (in this case healthcare) is not actively involved in making informed decisions regarding care and is also not spending money for the cost of the care, the resulting services may not be in the best interest of that person. This can lead to excessive and inappropriate testing and treatment as well as unnecessary care, overtreatment, and harm. Healthcare has traditionally been a passive process for the patient.

The clinician is seen with all of the knowledge and directs the care. Sometimes, the patient is given a choice of which procedure or treatment to move forward with but is often not given the option or potential benefits of not receiving treatment. More care, tests, procedures, and medications have led medical errors and unnecessary treatment to be the third leading cause of death in the United States.2

Guidelines are based on populations of individuals with pooled risks based on average or mean results to determine treatments. In the clinical setting, we do not treat populations; we treat individuals with unique risks, goals, values, and preferences. There is no one best treatment for every patient. Each patient deserves to make an informed choice based on potential benefits and risks in the context of his or her goals, values, and preferences.

The individual needs to be involved in making these decisions just like in any other life decision, such as investments, education, purchases, and car repairs. Healthcare must not be an assembly line where everyone with a certain condition or symptom is treated the same. It is based on science, but the practice of healthcare is an art. Science cannot determine the most appropriate diagnostics or treatments without knowing the desires of the patient, and the patient cannot know what he or she wants from healthcare without information.

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Giving the patient a perspective

Shared decision-making provides patients with a perspective from which to make a decision. It helps the patient understand the purpose of diagnostics and treatments as well as the implications of results before the test or treatment is carried out. It gives the patient a sense of how much a treatment might be helpful or harmful. Shared decision-making goes beyond telling a patient what is recommended to sharing information and data regarding the patient's risks and the amount of risk reduction that might be expected with treatment.

Sharing decisions with patients creates new challenges for clinicians. The process can take more time, and the clinician needs to have information available to share with the patient to evaluate risks and provide perspective on the effects of the test or treatment. For example, a 50% risk reduction means something different if the baseline risk is 2% and reduced to 1% compared with a baseline risk of 40% reduced to 20%.

Various tools are available to help both the clinician and patient understand the information. Sources such as The NNT Group (www.thennt.com), the Harding Center for Risk Literacy Fact Boxes, Mayo Clinic Shared Decision Making National Resource Center, the Agency for Healthcare Research and Quality, and the Ottawa Hospital Patient Decision Aids can provide information in an easily understandable format.3-7

These sources provide illustrations and explanations regarding the different risks and benefits of various diagnostics, procedures, and treatments. Searching online for nearly any diagnostic or treatment will reveal research findings, which can then be converted into practical information that can be shared with the patient.8

While clinical guidelines, expert panels, and evidence-based standards tend to steer healthcare toward an automated, scientific process with concrete answers, their implementation can lose sight of the individual and unique patient. We must weave the evidence we know with the patient's goals, values, and preferences to make decisions regarding healthcare. This means assessing individual risks, exploring the evidence with the patient, and comparing options in light of the patient's values and preferences to allow the patient to reach a decision.

This can present challenges, but it can also bring opportunities for patients to take responsibility. In my practice, I have found patients appreciate receiving information and becoming involved in the decision-making process.

The choices we make depend on our goals, values, and preferences for what we want. When we practice shared decision-making—the art of healthcare—patients make the choices that best suit them, not us.

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REFERENCES

1. Yancy CW, Jessup M, Bozkurt B, et al 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2016;134:e282–e293.
2. Makary MA, Daniel M. Medical error—the third leading cause of death in the US. BMJ. 2016;353:i2139.
3. The NNT Group. Quick summaries of evidence-based medicine. 2017. http://www.thennt.com.
4. Harding Center for Risk Literacy. Fact boxes. 2017. http://www.harding-center.mpg.de/en/health-information/fact-boxes.
    5. Mayo Clinic. Mayo Clinic Shared Decision Making National Resource Center. 2017. http://shareddecisions.mayoclinic.org.
      6. Agency for Healthcare Research and Quality. The SHARE Approach. 2017. http://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/index.html.
        7. The Ottowa Hospital. Patient decision aids. 2015. https://decisionaid.ohri.ca/azlist.html.
        8. Bartol T. Thoughtful use of diagnostic testing: making practical sense of sensitivity, specificity, and predictive value. Nurse Pract. 2015;40(8):10–12.
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