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
