Communication is clearly a core part of any physiotherapy interaction, and hopefully all practitioners strive to ensure that decision-making in a care episode is shared between therapist and patient. While we many of us skilfully include our patients in the treatment process, it’s not unusual that comments from some are along the lines of “You know best” or “ Well the surgeon said….” These conversations make me question just how well-informed patients are in healthcare decision-making. Coulter et al (1999) argue that people cannot make informed preferences without access to clear and appropriate information. It is clear that many people lack understanding of treatment options and possible outcomes, and most need more time to process information before making a decision. I would encourage reading of the Coulter and Collins (2011) document “Making Shared decision-making a reality” for a practical discussion on the issues involved in shared decision making.
In trying to improve my practice, I encountered patient decision aids. Patient decision aids are evidence-based guides, intended to give information about all aspects of a condition, including diagnosis, prognosis and treatment options, allowing the patient to consider how various decisions might impact them, in order to help them reach an informed preference (Coulter & Collins, 2011). They are different to traditional “patient information sheets” in that they do not tell people what to do, but set out the facts and encourage the reader to deliberate over various options. It has been eye-opening for me to explore the area of patient decision aids, many of which are freely available and cover a wide breadth of conditions. Of particular interest to the Shoulder Community of Practice is a decision aid designed help patients to decide whether they should have surgery or conservative treatment for their rotator cuff disorder.
This decision aid provides an account of the issues concerning related to rotator cuff tears including a description of the injury, the types of surgery and its risks, the other treatments available and how they work. It then provides rating scales where the patient can rate their feelings about various aspects of their decision. It also includes 4 short personal stories from other patients regarding how they made their decision about surgery. There is even a standardised method for assessing quality of patient decision aids – The International Patient Decision Aid Standards (IPDAS), which rates this decision aid as 10/14 for content, 8/9 for process and 1/2 for effectiveness. Its weaknesses are that it was not designed based on any service-user feedback, and also that it does not provide any quantitative information about the likelihood of different outcomes based on the treatment option chosen. Its strengths are that it is evidence based and has been field-tested with patients who gave positive feedback about its usefulness in helping them make a decision about rotator cuff surgery. Personally I have trialled it with a number of patients, who reported that they felt much more comfortable with their decision to continue with physiotherapy for their shoulder problem, after working through the decision aid. A Cochrane review of the use of decision aids concluded that patients had greater knowledge, a better perception of risk, expressed more comfort in their decisions and also that the use of decision aids led to fewer patients opting for surgery (O’Connor et al 2009). As mainly online tools, decision aids may be not be suitable for all people, but it’s certainly an area I’d encourage physiotherapists to explore. Perhaps we need to become involved in developing our own decision aids for physiotherapy care?
Here are some more links to some interesting decision aids, as well as a searchable database:
Karen McCreesh, Shoulder CoP
O’Connor AM, Bennett CL, Stacey D, Barry M, Col NF, Eden KB, Entwistle VA, Fiset V, Holmes-Rovner M, Khangura S, Llewellyn-Thomas H, Rovner D (2009). ‘Decision aids for people facing health treatment or screening decisions’. Cochrane Database of Systemic Reviews, issue 3, article CD001431