Prioritizing what patients care about
In recent years, clinicians and patients have embraced shared decision making as a critical element of a trusting clinician-patient relationship. The goal of shared decision making is to involve patients and caregivers in treatment decisions, so that decisions are based on patients’ goals and priorities, rather than what the clinician assumes the patient wants.
Shared decision making is especially important for older patients with multiple chronic conditions, because guidelines may suggest certain treatments based on targets (such as A1C or blood pressure), without taking into account how these treatments will affect patients’ quality of life or treatment burden.
In a recent study in JAMA Internal Medicine, Dr. Mary Tinetti at the Yale School of Medicine and colleagues measured the effects of patient priorities care (PCC) on patient-reported outcomes and treatment burden for patients with multiple chronic conditions. Patient priorities care is “an approach to decision-making that includes patients’ identifying their health priorities (ie, specific health outcome goals and health care preferences) and clinicians aligning their decision-making to achieve these health priorities.” They found that patients who received PPC were twice as likely to have medications stopped, less likely to have diagnostic tests ordered, and reported decreased treatment burden, compared to patients who received usual care.
While shared decision making models like PCC have shown the potential to improve patient outcomes and reduce treatment burden, they have proved difficult to implement on a larger scale. Studies of clinician-patient conversations show that few clinicians elicit patient concerns before making treatment decisions, and clinicians who do ask patients about their goals often interrupt patients within a matter of seconds. Even though guidelines may require shared decision making before doing tests like cancer screenings, clinicians regularly fail to point out the harms and benefits of testing.
In an accompanying commentary, Dr. Ian Hargraves and Dr. Victor Montori from the Mayo Clinic discuss ways in which clinicians can better align treatment decisions with patients’ priorities. They posit that many shared decision making efforts have failed because clinicians have been trained to document patients’ preferences and values to check off boxes, rather than have a real conversation with patients. They write:
“In our experience with developing shared decision-making interventions, we have found that patients often struggle with questions about their preferences or about what matters to them, and clinicians often seem unable to act on their answers. The commonsensical “What matters to you?” may be the wrong question. This inadequacy may lie in that values, preferences, goals, and what matters most to us are not relatively set traits of a person available for extraction. Rather, the values, preferences, and goals arise in living life and are discovered in understanding how life is lived.”
With PCC, the patient and non-physician clinician have a conversation about the patient’s life, relationships, and activities to help the patient identify their health goals. Focusing on how patients live their lives and want to live their lives may help identify which health care treatments are helping or preventing patients from reaching their goals.