Best Practices in Patient-Centered Care and Shared Decision Making

Susan Shepard, MSN, RN, Senior Director, Patient Safety and Risk Management Education, The Doctors Company

Medicine has increasingly placed an emphasis on patient-centered care as a way to improve outcomes. The patient-centered approach considers the individual’s needs, priorities, beliefs, culture, occupation, education, and learning styles.

Patient shared decision making (PSDM) is a technique that incorporates each patient’s needs and priorities into the treatment plan by combining medical evidence, the provider’s clinical expertise, and the patient’s and family’s unique values and preferences. It encourages the clinician to fully engage with patients and families on treatment decisions and results in patients who are better informed.

This open and shared communication method encourages the clinician to consider multiple factors during discussion with the patient about healthcare options. As they discuss management strategies, the clinician asks the patient what he or she wants from care. This allows the patient to express concerns about the treatment.

A patient-centered approach using PSDM can also help the clinician determine the patient’s comprehension of the material. The clinician uses communication techniques to ensure understanding, encourage patient satisfaction, and decrease any discrepancy between treatment goals and the patient’s expected outcome. The approach facilitates realistic patient expectations, increases the clarity of patient needs, and aids the clinician in adapting the treatment plan accordingly.

PSDM shows evidence of benefiting patients.¹ A study by Sepucha, Atlas, and Chang, et. al, found that patients who were well informed and ultimately received their preferred treatment had better outcomes and higher satisfaction.²

The Doctors Company closed claim review noted inadequate communication as a significant risk factor for claims. Because PSDM, enhances patient-provider communication, it may also lessen the risk of a malpractice suit.

AHRQ’s SHARE Approach

To help clinicians implement a shared decision-making model, the Agency for Healthcare Research and Quality (AHRQ) developed the SHARE Approach, a model using a five-step process that includes exploring and comparing the benefits, harms, and risks of each treatment option through meaningful dialogue about what matters most to the patient. The process uses a mnemonic of “SHARE”:

Step 1: Seek your patient’s participation. Recognize that each clinician-patient relationship includes two experts: the clinician, with knowledge of evidence-based treatment options, risks, and benefits and the effectiveness of each; and the patient, who understands the personal values, preferences, and individual lifestyle. Communicate that a choice exists, and invite your patient to be involved in decisions.

Step 2: Help your patient explore and compare treatment options. Discuss the benefits and potential harms of each option. Provide educational material and discuss it together.

Step 3: Assess your patient’s values and preferences. After discussing the different options, ask which option fits best with the patient’s lifestyle and preference. Consider what matters most to your patient.

Step 4: Reach a decision with your patient. Guide your patient in expressing what matters the most in deciding the best treatment option. When ready, the patient will decide. Your patient may also choose to delegate the decision to someone else. You and your patient decide on the best option. Additional education may be provided to ensure that the patient can follow the treatment plan.

Step 5: Evaluate your patient’s decision. Support your patient so that the treatment decision has a positive effect on health outcomes. A follow-up visit can be part of the treatment plan to evaluate how well the treatment is working.

Case Study

A 40-year-old female with severe osteoarthritis in the right wrist received a referral from her primary care provider to an orthopedic specialist. The orthopedist asked the patient to explain her condition in her own words before he began the examination. Throughout the visit, the physician tried to understand the patient’s lifestyle demands and how her disease affected her daily functioning.

The orthopedist recommended arthroplasty based on his experience treating similar cases and the patient’s specific needs. He outlined the process of the surgery, including possible hospitalization time and physical therapy, and noted the most common risks. The physician took care to note that other treatment options were available, and he outlined them in detail. He explained that, in similar cases he had treated, arthroplasty yielded the most consistent and satisfactory results.

He asked the patient to describe what satisfactory results would mean to her. She replied that, as an avid tennis player, pain management and high functionality were important to her so she could resume playing. The physician considered her desires and explained why he still recommended arthroplasty but would encourage a different type of physical therapy. He took care not to pressure the patient into choosing his recommended option, and he answered her questions honestly about associated risks.

This case highlights the concepts of the SHARE Approach. The physician incorporated the patient’s values, preferences, and lifestyle in the decision-making process. He discussed different treatment options and the risks, benefits, and possible outcomes of each, and he answered all questions. He specifically sought the patient’s definition of a satisfactory outcome. He had the patient review his practice website for additional information on arthroplasty and then recommended a different rehabilitation option following surgery that supported her expectation of being able to resume playing tennis.

Improving Clinician-Patient Communication

The following strategies can help clinicians improve communication techniques:

• Consider using the AHRQ mnemonic SHARE in your practice.
• Use certified patient decision aids to enhance education.
• Always include possible health outcomes (and impact on functional status) and relative cost of treatment or, where appropriate, palliative care options.
• Determine what barriers are present that may prevent optimal treatment decisions
• Document the discussion:
• When and where it occurred.
• Who participated or was physically present.
• The options, risks, benefits, costs, and possible outcomes addressed.
• All of the patient's or his or her surrogate's questions were answered.
• Remember that effective patient-clinician communication can reduce claims.

For additional information, see our complimentary on-demand CME activity titled Making an Informed Consent an Informed Choice: Training for Healthcare Professionals, or contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.

---