presenting choices to patients larry allen, md intermacs may 16, 2015
TRANSCRIPT
Presenting Choices to PatientsPresenting Choices to Patients
Larry Allen, MDLarry Allen, MDINTERMACSMay 16, 2015
Types of Medical Decision Making
1. Benefit >> Risk: When scientific evidence for benefit strongly outweighs harm, behavioral support (e.g. smoking cessation counseling, beta-blocker) designed to describe, justify, and recommend may be appropriate and complementary to decision support.
2. Benefits ~ Risks: Shared decision making is most easily applied to preference-sensitive decisions, where both clinicians and patients agree that equipoise exists, and decision support helps patients think through, forecast, and deliberate their options.
Types of Medical Decision Making
1. Benefit >> Risk: When scientific evidence for benefit strongly outweighs harm, behavioral support (e.g. smoking cessation counseling, beta-blocker) designed to describe, justify, and recommend may be appropriate and complementary to decision support.
2. Benefits ~ Risks: Shared decision making is most easily applied to preference-sensitive decisions, where both clinicians and patients agree that equipoise exists, and decision support helps patients think through, forecast, and deliberate their options.
LVAD IS a choice?
• “Survival with LVAD is almost always higher than survival without LVAD.”– Joseph Rogers
LVAD IS a choice
• “Survival with LVAD is almost always higher than survival without LVAD.”– Joseph Rogers
• “Everyone dies. So it’s not about choosing life or death, its choosing how you want to live and how you want to die.”– Larry Allen and others
LVAD IS a choice !
• “Survival with LVAD is almost always higher than survival without LVAD.”– Joseph Rogers
• “Everyone dies. So it’s not about choosing life or death, its choosing how you want to live and how you want to die.”– Larry Allen and others
• “There are worse things than death.”– An inspirational LVAD decliner
Trade offs
McIlvennan, Magid, Ambardekar, Thompson, Matlock, Allen. Circ Heart Fail. In Press.
DecisionDecision
DecisionDecision
DecisionDecision
DecisionDecision
Informed Consent: Necessary but insufficient
We ignore how people think
Prospect Theory: Loss Aversion
Terror Management Theory
REFLECTIVERational
Utilitarian (risk v. benefit)“I thought about it
an awful lot”
AUTOMATICEmotional
Self-preservation (fear)“There was no choice”
Heuristics for Stage D HF / LVAD
McIlvennan et al. Circ Qual Care Outcomes 2014.
Internet, Print, and Multimedia Internet, Print, and Multimedia Information SuboptimalInformation Suboptimal
Decision Aids
Paper / Online Video
Recognize Decision and Emotion
Contrasting Summary of Options
Highlight Uncertainty
Present numbers in a digestible way
Inclusion of Family / Caregivers
Values Clarification
Importance of User Impression
Controlled Patient Testimonials
HeartMatePro.com www.patientdecisionaid.org
Pilot Data on DA Use
• 10 DT LVAD-specific questions
• Baseline and 1 month
– 31% increase in correct answers at 1 mo
Decision Values
Decision Values
Control Preferences
Control Preferences PATIENT
Baseline 1-Month
n=10 n=9
Preferred RoleActive=4Shared=2Passive=4
Active=5Shared=3Passive=1
n=8
Actual Role --Active=4Shared=3Passive=1
Implementation: DECIDE-LVAD Trial
