Common BARRIERS

  • Shared decision making takes too much time

    My patients aren’t interested in shared decision making

    Shared decision making is too complex for patients

    Time & Resources

    As Dr. West references, finding the time to perform robust SDM in the course of a typical day is challenging with the burdens of documentation that already encroach on time spent with patients. Optimizing available time hinges on employing established decision aids. A recent ASCO review article details the barriers and opportunities of introducing these decision aids in oncology practice.

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    Patient Characteristics

    As part of its six domains of healthcare quality, the Institute of Medicine defines patient centered care as providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. It further describes “values” as a patient’s concerns, expectations, and choices regarding health care, based on a full and accurate understanding of care options.

    In 2017, ASCO released its criteria for High-Quality Clinical Pathways in Oncology that included evidence-based options to account for differences in patient characteristics and/or preferences (ie, comorbidities, prior diagnoses and treatments, risks of treatment related toxicities, scheduling and financial).

    Yet despite the movement toward these value-based frameworks, many clinicians struggle to engage patients in the process or have concerns about whether patients are unable to comprehend the complexity of treatment decisions, especially pertaining to cancer care.

    In a 2016 abstract at the World Conference on Lung Cancer, authors conducted a survey examining SDM and Patient Decision Aids in lung cancer with the following results:

    • 69% faced a difficult
      decision

    • 73% desired SDM with
      oncologist

    • 55% believed they experienced SDM, yet largely perceive a need for improvement in the decision process

    But even if the willingness is there, do patients understand the purpose of their treatments? In our survey, 95% of patients interviewed indicated they understood what their HCP conveyed to them about treatment. However, separate studies show that the majority of patients don’t understand the purpose or expected outcome of treatment:

    • Only 5% of patients had an accurate understanding of their illness

    • 80% of incurable patients receiving chemotherapy believed the treatment was curative

    • 72% of patients indicated that they wanted their doctor to discuss prognosis with them, but only 17% reported being told

    For lung cancer patients, the barriers that impede engagement are numerous:

    • Emotional repercussions of a cancer diagnosis (loss of control)

    • Lack of assertiveness

    • Inexperience with the healthcare delivery system

    The importance of  “goals of care” discussions cannot be overstated. For lung cancer patients, these discussions support:

    • Better patient QOL
    • A reduction in the use of nonbeneficial medical care
    • Goal consistent care
    • Positive family outcomes
    • Reduced costs/cost-effective treatment choices

    Misconceptions

    Knowledge is power. The more information we have, the better able we are to weigh the positives and negatives of new opportunities and strategies to improve health care delivery. A 2014 summary of a keynote address presented at the 2013 International Conference on Communication in Healthcare, was published in PEC to highlight 12 common myths about SDM:

    12

    Myths About Shared Decision Making

    • 1
      SDM is a Passing Fad
    • 2
      Clinician is Removed from
      the Decision-Making
    • 3
      Not all Patients Want SDM
    • 4
      Not Everyone
      is Able to Do it Well
    • 5
      Patients Lack Confidence
      to Participate in SDM
    • 6
      SDM is too Time Consuming
    • 7
      We Already Do SDM
    • 8
      SDM Only Requires
      Providing a Decision Tool
    • 9
      SDM is Incompatible
      with Practice Guidelines
    • 10
      SDM is Exclusive to
      Physician-Patient Relationship
    • 11
      SDM is Expensive
    • 12
      SDM Does Not Allow for
      Emotional Accommodations
    Adapted from :

    Twelve myths about shared decision making

    Patient Reported Barriers

    Barriers cited by both providers and patients are often the same, but the most common barriers reported by lung cancer patients interviewed included:

    • Emotional stress interfering with the ability to fully understand, process, and make decisions around information shared by the provider
    • Difficulty understanding complex information and personal implications
    • Not enough time with the physician

    Barriers from BOTH the Patient’s and Provider’s Perspective are Similar!

  • Quick Quiz

    Which of these barriers do you consider the greatest impediment to introducing SDM into practice:

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