Patient and Cardiologist Perspectives on Shared Decision Making in the Treatment of Older Adults Hospitalized for Acute Myocardial Infarction

Abstract

Background. Medical and interventional therapies for older adults with acute myocardial infarction (AMI) reduce mortality and improve outcomes in selected patients, but there are also risks associated with treatments. Shared decision making (SDM) may be useful in the management of such patients, but to date, patients’ and cardiologists’ perspectives on SDM in the setting of AMI remain poorly understood. Accordingly, we performed a qualitative study eliciting patients’ and cardiologists’ perceptions of SDM in this scenario. Methods. We conducted 20 in-depth, semistructured interviews with older patients (age ≥70) post-AMI and 20 interviews with cardiologists. The interviews were transcribed and analyzed using ATLAS.ti. Two investigators independently coded transcripts using the constant comparative method, and an integrative, team-based process was used to identify themes. Results. Six major themes emerged: 1) patients felt their only choice was to undergo an invasive procedure; 2) patients placed a high level of trust and gratitude toward physicians; 3) patients wanted to be more informed about the procedures they underwent; 4) for cardiologists, patients’ age was not a major contraindication to intervention, while cognitive impairment and functional limitation were; 5) while cardiologists intuitively understood the concept of SDM, interpretations varied; and 6) cardiologists considered SDM to be useful in the setting of non-ST elevated myocardial infarction (NSTEMI) but not ST-elevated myocardial infarction (STEMI). Conclusions. Patients viewed intervention as “the only choice,” whereas cardiologists saw a need for balancing risks and benefits in treating older adults post-NSTEMI. This discrepancy implies there is room to improve communication of risks and benefits to older patients. A decision aid informed by the needs of older adults could help to better convey patient-specific risk and increase choice awareness.

Barriers and facilitators to shared decision-making in hospitals from policy to practice: a systematic review

“…Included articles used qualitative study designs, with the majority using interviews [ 44 , 46 – 48 , 50 – 52 , 55 – 57 ], followed by focus groups [ 44 , 46 , 51 , 54 ], observation [ 49 , 53 ], and conference breakout session [ 45 ].…”

“…Of the included articles, the majority focused on emergency department settings [ 45 , 47 , 48 , 55 , 56 ] and acute mental health settings [ 50 , 51 , 54 ], with other settings including cardiology [ 52 , 57 ], oncology [ 53 ], stroke rehabilitation [ 44 ], and acute monitoring [ 49 ]. There were 11 authors for 14 articles, with four separate articles by Schoenfeld included [ 47 , 48 , 55 , 56 ].…”

“…Knowledge (An awareness of the existence of something) Barriers - Not knowing what SDM is [ 57 ] - Incorrect definition of SDM [ 46 , 52 , 55 , 57 ] - Assumes patient understands information shared [ 53 ] - Does not know true risk of options [ 56 ] - Limited or no knowledge of disease or options [ 46 , 47 , 50 , 54 ] - Limited understanding of risk [ 44 , 45 , 50 , 52 , 53 , 56 ] - Not provided adequate information for decision [ 53 , 55 ] - Provided biased information [ 50 , 55 ] - Not understanding jargon used by clinicians [ 51 , 53 ] - Not knowing own patient history (i.e. previous drug treatment) [ 54 ] - Not having knowledge of language to describe their experience of illness [ 51 ] - Lack of guidelines that include SDM [ 46 ] Facilitators - Understanding of SDM and what it entails [ 47 , 49 ] - Understanding of risks and benefits for treatment options [ 47 – 49 ] - Well informed about the disease and treatment options prior to the SDM conversation [ 45 , 47 , 50 , 52 – 54 , 57 ] - Patient is able to understand consequences and risks of alternatives [ 45 , 47 , 50 – 53...…”

“…which drugs they had been treated with previously) [ 54 ] - Use posters/reminders to create awareness of SDM implementation programme [ 44 , 49 ] - Tailored information services for patients [ 46 ] - Support cross-site learning through regular meetings [ 44 , 46 ] - Pool information from separate SDM initiatives to speed knowledge translation [ 46 ] - Promote awareness of the benefits of SDM through research [ 55 ] - Promote patient awareness of SDM through national campaign [ 46 ] 2. Skills (An ability or proficiency acquired through practice) Barriers - Lack of training in SDM [ 44 , 48 – 51 , 55 , 56 ] - Lack of communication skills [ 51 , 55 ] - Lack of skills to train junior doctors in SDM [ 48 , 56 ] - Overreliance on clinical algorithms for determining treatment decisions [ 48 , 56 ] - Decision is left to the patient [ 53 ] - Informational capacity to make informed decisions (barrier and facilitator) [ 45 , 47 , 50 , 52 , 54 , 56 ] - Senior clinicians are expected to teach junior doctors how to do SDM without having training themselves [ 48 , 56 ] - Lack of training to do SDM [ 46 , 48 , 50 , 51 , 56 ] Facilitators - Communication skills, i.e. ability to explain risks and benefits of treatment option [ 45 – 48 , …”

“…Skills (An ability or proficiency acquired through practice) Barriers - Lack of training in SDM [ 44 , 48 – 51 , 55 , 56 ] - Lack of communication skills [ 51 , 55 ] - Lack of skills to train junior doctors in SDM [ 48 , 56 ] - Overreliance on clinical algorithms for determining treatment decisions [ 48 , 56 ] - Decision is left to the patient [ 53 ] - Informational capacity to make informed decisions (barrier and facilitator) [ 45 , 47 , 50 , 52 , 54 , 56 ] - Senior clinicians are expected to teach junior doctors how to do SDM without having training themselves [ 48 , 56 ] - Lack of training to do SDM [ 46 , 48 , 50 , 51 , 56 ] Facilitators - Communication skills, i.e. ability to explain risks and benefits of treatment option [ 45 – 48 , 50 – 53 , 56 , 57 ] - Formal training in SDM [ 44 , 48 – 51 , 55 , 56 ] - Trust in one’s own clinical skills and ability [ 47 , 55 – 57 ] - Awareness of one’s own limitations as a clinician [ 55 , 57 ] - Has been given education in communication with patients [ 48 , ...…”