Advanced Practice Perspectives
In this column, we will hear from an increasingly represented and crucial
component of hematology/oncology care: advanced practice professionals
(APPs). In this edition, Joseph Tariman, PhD, discusses how health care has
evolved into the shared decision-making era and how APPs are involved.
Welcome to the Era of
Shared Decision-Making
SHARE-d
DecisionMaking
The Agency for Healthcare Research and Quality’s SHARE Approach is a
five-step process for shared
decision-making that includes exploring and comparing the benefits, harms, and
risks of each option through
meaningful dialogue about
what matters most to the
patient.
STEP 1
S
eek your patient’s
participation.
STEP 2
H
elp your patient explore
and compare treatment
options.
STEP 3
A
ssess your patient’s
values and preferences.
STEP 4
R
each a decision with your
patient.
STEP 5
E
valuate your patient’s
decision.
Source: Agency for Healthcare
Research and Quality. “The SHARE
Approach.” Accessed June 7, 2016,
from www.ahrq.gov/professionals/
education/curriculum-tools/
shareddecisionmaking/index.html.
18
ASH Clinical News
As health-care delivery continues to
evolve, moving away from the “paternalistic” model of medicine, the role of the
advanced practice professional (APP)
in caring for patients with hematologic
malignancies is becoming more complex.
We are in the era of shared decisionmaking (SDM), in which APPs act as
patient advocates, patient educators, and
liaisons between the health-care team and
the patient (and his or her caregivers and
support team).
Although it is a relatively new concept, the collaborative, patient-centered
SDM model has been widely adopted by
clinicians and patients.1,2 The goal of this
model is to make treatment decisions
with the patient to achieve outcomes that
matter most to the patient. Whether or
not that goal is met can be determined
by many factors, including the patients’
willingn ess to participate in treatment
decisions and the medical institution’s approach to SDM.
While SDM is now considered to be
the dominant model of health-care delivery,2 its development is not yet complete.
The Rise of the SDM Model
In the 1960s, the prevailing model of
health-care delivery was the paternalistic
model – patients would defer to doctors
regarding any treatment decisions.
Later, health-care consumerism and
health-care expenditures increased, and
the patient-consumer started to say, “If
I’m spending this much money for my
health care, I should have a say in how I’m
being treated.” That idea gave rise to the
informed model in the 1970s. Though the
physician was still making the treatment
decisions, he or she spent more time
educating the patient about the treatment.
Adequately informed, the patient felt like
part of the decision-making process.
By the early 2000s, the health-care
system changed to create “the perfect
storm” in which SDM could take hold: the
number of treatment options expanded,
physicians found themselves having to
explain what those options were, and
patients were spending more on their
health care.
SDM also was bolstered by the
implementation of the Affordable Care
Act (ACA), which included a provision
that encourages greater use of SDM “to
facilitate collaborative processes between
patients, caregivers or authorized representatives, and clinicians … and the incorporation of patient preferences and values
into the medical plan.”3 The ACA’s SDM
provision recognizes the value of patient
decision aids and of involving informed
patient preference when there is no clear
clinical evidence to support one treatment
option over another.
To be truly
effective, shared
decision-making
has to be implemented and
supported from
the top down.
The SDM Building Blocks
The SDM model, published by Charles, et
al in Social Science and Medicine in 1997,
has four essential elements:4
1. There are at least two participants: a
health-care provider and a patient.
2. Both parties share information.
3. Both parties take steps to build
consensus about the preferred
treatment (medications, symptom
management, side-effect
management, etc.).
4. The health-care provider and
the patient must reach a mutual
agreement about which treatment to
implement.
The first three essential elements are easier
to attain than the last, but that mutual
agreement is central to the SDM philosophy. In fact, preliminary evidence has
shown that when patients are actively involved in the decision-making process and
are able to reach mutual agreement with
their health-care providers, their treatment
adherence, satisfaction levels, psychological
well-being, and outcomes all improve.5
Unfortunately, the last piece of the
SDM puzzle is often overlooked. APPs
and physicians may make the mistake of
assuming that the patient has automatically agreed to the treatment plan once
he or she leaves the clinic. We need to be
deliberate, though, in explicitly asking the
patient whether he or she really understands and agrees with the treatment plan.
SDM and the APP
The number of treatment options available
for our patients with hematologic malignancies may overwhelm them. Patients
want to discuss those different options as
they weigh what works best for them. That
responsibility often lies with APPs.
Hematology/oncology APPs participating in SDM continuously strive to reach
patient-driven treatment decisions, helping
patients navigate the complexities of cancer
treatment decisions and their own personal
values. These types of decisions require
active participation from both parties and
preservation of patient autonomy.
In my experiences, that can often be as
simple as allowing enough time for discussion and deliberation about the treatment
choices. (Although, given time constraints,
this is often easier said than done.) The
APP also needs to set aside time to evaluate
patients’ outcomes throughout the treatment course, asking, “Is the patient satisfied
with the decisions we made? Are there any
regrets?” Gathering information ahead of
time to share in a multidisciplinary team
meeting and providing the patient with
patient decision aids or other educational
materials can also be helpful.
It is difficult to consistently achieve
that fourth element of SDM – more so
than many health-care providers might
think. Agreement should not be assumed
– it should be explicitly verbalized.
July 2016