presenting choices to patients larry allen, md intermacs may 16, 2015

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

https://patientdecisionaid.org

larry.allen@ucdenver.edu