Informed Patient Choice: Patient-Centered Valuing Of Surgical Risks And Benefits

Abstract

ABSTRACT:The risks and benefits of any health care intervention are valued differently by stakeholders. One of the ethical imperatives of patient-centered care is the balanced, evidence-based presentation of risks and benefits by providers to patients. Using the example of musculoskeletal surgery with devices, we advocate the use of shared decision-making tools and processes known to improve knowledge, adjust unrealistic expectations, and elicit values about benefits desired and the degree of acceptable risks for individual patients. We describe feasibility and efficacy within our organization and address ways to foster the further adoption of this approach. [Health Affairs 26, no. 3 (2007): 726-730; 10.1377/hlthaff.26.3.726] W i t h a n y s u r g e r y, consent must be obtained from each patient, and valid consent is based on knowledge of the options, the risks and benefits of each option, and the likelihood that these will occur for the individual patient. The legal doctrine and requirements of informed consent are well known. 1 In theory, informed consent is a process, not a moment in time. In reality, it occurs when a clinician requests a patient's signature to authorize that a specific treatment or procedure take place, and the patient signs. In current practice, there is no requirement that shared decision making occur before the signing of the consent form.Not all surgery decisions lend themselves equally to the elicitation of values and preferences. For treatment recommendations that are based on guidelines or standards of care, where there is strong evidence of a treatment's effectiveness and strong agreement among patients that these are valued interventions (for example, surgery for hip fracture), the patient tends to agree to a recommendation instead of engaging in shared decision making. However, many surgeries are elective and fall under the category of preference-and values-sensitive treatment decisions. Assessing the risk/benefit trade-offs in such decisions is best done using a shared decision-making model. Shared Decision Makingn Essential components. The process of shared decision making is a collaboration between clinician and patient, using a decision aid as an adjunct. 2 The incorporation of shared decision-making tools and the elicitation of patients' values and preferences into the traditional but obsolete surgery consent process is 7 2 6 M a y / J u n e 2 0 0 7 P e r s p e c t i v e

Introducing Decision Aids At Group Health Was Linked To Sharply Lower Hip And Knee Surgery Rates And Costs

“…High-quality shared-decision-making discussions involve eliciting patients' preferences, which is not a common diagnostic skill among most currently practicing providers. 6 Further research is needed to confirm whether the decision aids influence patient-provider interactions in this setting (including satisfaction with care), or whether decision aids influence patients' preferences independent of the patient-provider encounter.…”

“…6 Shared decision-making processes often incorporate decision aids, which are balanced sources of information about treatment options for a particular health condition. 6,7 A recent review of eighty-six randomized trials of decision aids found that these aids consistently increase patients' knowledge; improve treatment expectations; increase active participation in decision making; reduce decisional conflict or uncertainty about the appropriate course of action; decrease the proportion of people remaining undecided about treatment; and help patients reach decisions that are more aligned with their stated values. 8 Seven randomized trials have addressed decision making about elective surgical treatments, although no prior trials included hip and knee replacement procedures.…”

The Placebo Phenomenon: Implications for the Ethics of Shared Decision-Making

“…10 The term SDM is often used inconsistently. 11,12 The following elements characterize our understanding of SDM [13][14][15][16][17][18] : SDM may (and should) be employed in life-threatening disease, where biomedical factors far outweigh placebo effects in determining the outcome. Nevertheless, physicians frequently encounter treatment decisions involving chronic and self-limited illnesses.…”

Healthy subjects’ knowledge of surgical complications: a hospital-based survey

“…According to the law, the patient must be informed about the diagnosis and its uncertainties, the purpose, benefits and risks of the recommended treatment, other treatment choices and their benefits and risks, and potential complications (1,2,(4)(5)(6)(7)(11)(12)(13)(14). With sufficient information, the patient can decide whether or not to go ahead with the surgery, knowing the risks of refusing or accepting the treatment (1,5,13). "Sufficient information" is a critical term here; it is the doctor's responsibility to find out how much a patient wants to and should know about the condition and its treatment options (1).…”