The answer seems to be just find the “best” treatment. In theory this sounds easy, but in practice it is difficult. What does best mean? What if one treatment has better outcomes on average but is riskier? What if one treatment is more effective than another but requires injections rather than pills? What if patients have a strong preferences for avoiding side effects compared to efficacy?
The Ottawa Decision Support Framework (ODSF) represents one way of getting to a good treatment decisions. The content below summarizes the ODSF approach.
Clarifying Decisional Needs
First, physicians and other providers needs to determine what information is needed to make a good decision. For instance, if the patient already has their mind set on a treatment, it likely is not worth a lot of time explaining their options. On the other hand, if they are still in the process of searching for a treatment, that is a good time to discuss what factors would play into the treatment decisions. The factors could include:
- Personal/Clinical characteristics: Decision support should be tailored to a person’s physical, emotional and cognitive capacities.
- Decisional conflict. Is the patient expressing clear uncertainty about treatment choice, verbalizing concern about undesired outcomes, or wavers between choices? If so, additional discussion of treatment choices is likely needed.
- Lack of knowledge. If patients are not aware of treatment choices or their attributes, the provider should inform them of these options.
- Unrealistic expectation. The patient may believe that a treatment works better than it does (e.g., 100% cure for everyone), underestimate it’s benefits (e.g., this treatment never works), or misunderstand side effects (e.g., vaccines cause autism). Providers should provide information to set more realistic expectation based on available evidence.
- Unclear values. Treatment decisions depend on the factors that patients value most. If physicians do not know these values or patients themselves are ambivalent, additional discussion is needed to clarify these values.
- Unclear perceptions of others or social pressure. Some people may not opt for a treatment they would prefer in isolation because they fear what others might think. Or patients may ask what other patients often due in tis situation.
In these cases, providers should offer facts and set the probabilities of specific outcomes based on existing scientific information.
Patient Decision Aids.
According to Maine Quality Counts, patient decision aids are tools that translate research evidence by providing information on the options, benefits, risks and associated probabilities; helping patients clarify their values for outcomes; and providing guidance in the process of decision making.
Decision coaches are third parties that facilitate discussions between patients and physicians. For instance, decision coaches can assess patients’ decisional needs, provide decision aids or coaching to address known needs, evaluate the decision quality and screen for factors influencing implementation of the decision. Coaches could play a key role in ensuring that patient preferences are reflected in the treatment decision-making dicussion between patients and providers.