SDM during Covid-19Shared decision making

Shared decision making and COVID-19

Authors: Nami Nelson, Professor Dawn Stacey, Associate Professor Sophie Hill

In this time of uncertainty, and in emergency situations, how important is it to maintain a focus on patient and family engagement in health decision making? Quick decisions may need to be made, but the rapidly changing context may have shifted the pros and cons of treatment options, leaving everyone confused about what is the right choice.

A quick recap on Shared Decision Making (SDM)

SDM is a process of where the patient (+family) and the clinician make a decision using the best available evidence (if available), and the patient’s informed preferences. This means the patient needs to know a decision has to be made, know the treatment options, the pros and cons of each option and be able to work through what matters most to them with each option (for more information go to ‘What is Shared Decision Making’).Under normal (non-crisis) circumstances, getting ready for SDM meant clinical staff had to know how to start an SDM conversation, have the right information ready, and then involve the patient.But in a COVID-19 pandemic, does SDM go out the window? Well no, because SDM provides a great pathway through these new and complex situations. Take, for example, people who are immune suppressed. Many will need to revisit their existing treatment plans because they might expose themselves to COVID-19. Oncologist, Dr Ranjana Srivastava, wrote in The Guardian in March 2020 about the importance of a supportive, shared decision making process for cancer patients faced with changes to their treatment as a result of the COVID-19 crisis. As Dr Srivastava explains ‘now we have an even greater responsibility to ensure that the decision to continue chemotherapy has been made deliberately’ (Srivastava, March 2020).Certainly, some may reconsider treatment options including having a pause for a period of time. Others may consider new locations for care. SDM, then, is very useful, because it is a clear, orderly, and transparent way of setting out the options and helping patients consider what matters most to them (see Hoffman et al., 2014). In fact, with the outbreaks of COVID-19 in nursing homes in Canada, decision aids were created to help patients and their families who were considering whether or not to temporarily take them to live with family.Consider the example of discharging an elderly patient following a stroke. Before, this patient may have been able to stay in a bed longer or may have been able to go to a rehabilitation service but now may choose to minimise risk of COVID-19 and receive rehabilitation at home. When patients and family are involved with weighing the harms and benefits to reach a preference, they are likely to be influenced by fears about COVID-19, the possible need for self-isolation, and possibly with options of longer care at the hospital no longer available.A feature of this pandemic is that we are inundated with new information and updates on movement and/or option restrictions. The SDM process can help patients and their families think through their options, weigh harms and benefits, and reach preferences informed by the best available facts. As a result, this can reduce some of the stress and decisional conflict they may be experiencing, in what is already a stressful time.To help streamline the SDM process during periods of crisis, we have created a 3 step quick prompt tool that guides health professionals through three basic steps:

  • Step 1: Preparation for SDM
  • Step 2: Consultation with patient (and/or family)
  • Step 3: Documentation of the decision and key considerations for the choice in the patient record

Questions to consider:

  • What approach is being taken at your health service to support patients and/or their families faced with new decisions about care or changing harms/benefits during the COVID-19 pandemic?
  • What can we put in place now to make SDM a natural and easy process to follow when patients and their families are facing these tough health decisions?

References

Tammy Hoffmann et al., 2014. Shared decision making: what do clinicians need to know and why should they bother? Medical Journal of Australia. Access here: https://onlinelibrary.wiley.com/doi/abs/10.5694/mja14.00002Ranjana Srivastava, 2020. Which cancer patients should be continuing chemotherapy during the coronavirus? The Guardian, Australian edition, 24 March. Access here: www.theguardian.com/commentisfree/2020/mar/24/which-cancer-patients-should-be-continuing-chemotherapy-during-the-coronavirus

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