Division of Cardiac Surgery

Shared Decision Making

In Shared Decision Making (SDM), patients and physicians engage in a conversation (or ideally multiple conversations), where physicians contribute information about the patient's disease process, its outlook and the treatment options with the risks and benefits clearly explained. Patients contribute information about how the disease process impacts their day-to-day life, and how their personal values and beliefs they have shape their healthcare goals. Together, the physician and the patient form a decision-making partnership, where they agree on a course of treatment that is evidence based and respectful of patient preferences and values.

Purpose
Before providing treatment, doctors must obtain an 'informed consent' from their patients. It is important to provide patients with detailed information about the risks, benefits and alternatives to the proposed treatment. While informed consent has been an established care requirement in healthcare for decades, recent studies show that fewer than 30% of patients understand the risks, benefits, and alternatives to any treatment being offered. Informed consent is all the more important when risks are high and alternative approaches to traditional treatment exist

Audience
Our research group has that shown frail patients have increased risks for cardiac surgery, that an unprecedented number of patients referred for cardiac surgery are significantly frail and they are undergoing more complex procedures. There is a demonstrated recognition by both healthcare  providers and patients of an immediate need to improve the decision making process among the frail and elderly that are referred for cardiac surgery.

Implications
The Institute of Medicine has stated that an SDM Program is a quality indicator in any medical intervention where there is clinical equipoise. Evidence to date shows that SDM programs ensure the ethical imperative of informed patient choice and consent is met, with a wide range of benefits for patients and their physicians.

Research efforts in Shared Decision Making

Qualitative Research

To date in the Division of Cardiac Surgery we have completed multiple focus groups with previous cardiac surgery patients and their care providers to determine the key elements of informed decision making.

Both patients and providers uniformly supported a formal shared decision making for patients referred for cardiac surgery. Groups were especially supportive of early engagement in the consent process and access to individualized risk assessments. 

Patients identified mortality, prolonged institutional care, renal failure and stroke as important outcomes in the decision making process to communicate risk to patients. 

Decision Aids

Our group has developed paper-based decision aids to support patients in the decision making process, through access to relevant information. 

Paper-based decision aids provide background information about the disease process (valvular or coronary disease), its natural history and the surgical treatment options, including relevant process of care information. The document is an individualized profile of patient demographics and comorbidities, including relevant diagnostics (degree of cardiac disease and heart function).

SDM Intervention

Initial results show that a formalized shared decision making approach with personalized decision aids improves comprehension, decisional quality and decisional conflict - without increasing anxiety or depression.  With the support of a TRIC grant, we are developing online decision aids, to be presented to patients through secure patient-provider portals that will allow an earlier discussion of risks, benefits and treatment options.      

Both clinicians and patients benefit from tools that estimate and effectively communicate the potential benefits and risks of treatment options. The philosophy of evidence-based medicine requires that clinicians incorporate not only the best available evidence, but also the patient’s values, preferences and circumstances in the decision making process. SDM formalizes an approach where the ultimate therapeutic choices are respectful and responsive to individual patient preferences, needs and values. A position taken by the Institute of Medicine in its landmark document, “Crossing the Quality Chasm”. Tailoring of care not only to the patient’s risk, but to the patient’s circumstances and preferences through shared deliberation represents the ideal realization of the philosophy of evidence-based medicine. 

Toward Optimal Decision Making among Vulnerable Patients Referred for Cardiac Surgery: A Qualitative Analysis of Patient and Provider Perspectives.