The Essential Handbook For Gp Training And Education Reference

[Victoria Steigerwald]

CoverNote: The SHARE Approach is a 1-day training program developed by the Agency for Healthcare Research and Quality (AHRQ) to help health care professionals work with patients to make the best possible health care decisions. It supports shared decisionmaking through the use of patient-centered outcomes research (PCOR).

The SHARE Approach: Essential Steps of Shared Decisionmaking outlines five steps health care professionals can take to ensure that they are effectively implementing shared decisionaking with patients during clinical encounters. The steps were designed to incorporate the essential elements that have been defined for shared decisionmaking.2

This tool was designed to help you incorporate the SHARE Approach from the Agency for Healthcare Research and Quality (AHRQ) into your practice. It describes each step in the SHARE Approach, and offers sample conversation starters for you to consider as you engage in meaningful discussions with your patients about their health care options.

The SHARE Approach usually begins with inviting your patient to be a part of the decisionmaking process. As you implement the SHARE Approach, you may find that some of the steps overlap with one another. That is okay.

The steps are intended to serve as prompts to help ensure you are engaging your patients in their health care decisions through meaningful dialogue about the benefits, harms, and risks of their health care options, and what matters most to them. Use the checklist offered at the end of this document to check off the steps that you used with your patient.

Studies suggest that many health care professionals believe that patients are not interested in participating in their health care decisionmaking.3-5 While patients may not want to play a prominent role in problem-solving, evidence suggests that most patients want more information than they are routinely given by health care professionals, and many would like to be involved in decisionaking about their health care.3,5

Many patients are not aware that they can and should participate in their health care decisionmaking. Additionally, many patients are not aware of the uncertainty in medicine, and that the outcomes of various treatments can be unpredictable at an individual level.

Note: Some patients may not want, or be ready, to participate.5-7 The active decision not to participate in the decisionmaking process, or to delegate the decision to the provider or a caregiver, should be respected.

Many health care decisions have multiple treatment options, including the option of no care. Often no single option is clearly superior. Use evidence-based decisionmaking resources to compare the treatment options.

Letting your patients know that there are options available (including watchful waiting), and guiding them through both benefits and risks of each option, can help your patients feel their views are valued and needed.

Some of your patients may gather their own information from the Internet, word of mouth, or other sources. It is important to explore what your patient may already know or understand about his or her condition and options.

It is critical to present both the benefits and risks of each option. These can be presented in the form of trade-offs. For example, "Medicine [xxx] is more expensive than the one you are currently taking, but you will only have to take it once a day."

Numbers can be a big part of discussing risk and communicating information about the potential benefits and harms of treatments. Communicating numbers can be challenging because even people with high health literacy can have low health numeracy. Refer to Communicating Numbers to Your Patients: A Reference Guide for Health Care Providers (Tool 5) for more information.

Use evidence-based decision aids and other decision resources to facilitate patient decisionmaking. Decision resources can be presented to your patient in advance of the visit, during the visit, or sent home with your patient to review and consider after his or her visit.

Along with prescribing clinicians, other members of the interdisciplinary health care team may be tasked with helping patients and their caregivers in a shared decisionmaking process. They may provide decision tools and resources to help facilitate patient decisionmaking.

After presenting the information, it is important to make sure that your patient understands the information you have shared. Ask your patient to explain in his or her own words what the options are.

If your patient appears apprehensive or actively disagrees, offer additional information or try presenting the information in a different way. Being able to use different approaches, such as Web-based decision aids, printed handouts, or handwritten drawings, will help you adapt to the different ways in which people learn and process information.

Studies have shown that most health care providers are not aware of the outcomes that matter most to patients.6,11 Moreover, a number of studies have shown that patient treatment decisions change after patients become well informed about their options and the associated risks.8,11,12

Clinicians should ensure that the dialogue reflects important information about the options (e.g., specific procedures, risks, and benefits) and that a patient's preferences are acknowledged. This may impact greatly on achieving satisfactory health outcomes and patient satisfaction.14

Making a decision, particularly for complex and potentially life-altering health care conditions, may take time. This is especially true when treatment decisions are irreversible, such as surgery. Patients may not identify their preferred option until they have had time to think it over or speak with others. Patients may also want to talk with family members, friends, or their caregivers before making a decision.

This additional time provides a good opportunity to share with patients decision support materials, such as AHRQ consumer summaries and interactive decision aids, or other evidence-based resources, that they can take home and discuss with others.

For patients facing life-threatening conditions, some of the decisions will be irreversible, so careful consideration prior to making a decision is critical (e.g., a decision for mastectomy versus lumpectomy in early stage breast cancer).

The patient, not the health care provider, is generally responsible for implementing many of the decisions made during a clinical encounter, particularly decisions made in a primary care setting (e.g., making necessary lifestyle changes or taking medications as prescribed).

___ I invited my patient to participate in the decisionmaking process.

___ I explained the importance of my patient's role in the decisionmaking process.

___ I discussed the essential issues about my patient's condition.

___ I presented all of the reasonable treatment/intervention options to my patient.

___ I discussed the risks and benefits of each option with my patient.

___ I asked my patient to review relevant decision tools (booklets/videos/Web sites).

___ I asked my patient to teach back what was discussed.

___ My patient demonstrated an understanding of the options.

___ I encouraged my patient to talk about what matters most to him or her.

___ I listened actively to my patient and asked open-ended questions.

___ I asked my patient how his or her decision might impact their daily life.

___ I acknowledged and agreed with my patient on what matters most to him or her.

___ I asked my patient what option he or she preferred.

___ I asked my patient if he or she needed additional information or wanted to consult others before making a decision.

___ My patient and I agreed on the decision.

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