Hi, Thanks for having me join this webinar today. I am tasked with providing a general introduc>on to Shared Decision Making and will be introducing the basic concept and some of its aBributes. My colleagues will be following up with more specific informa>on about our roles as consumers in the Shared Decision Making process. Let’s begin.
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Shared Decision Making is a cyclical process through which interested par>es collaborate in learning and communica>ng to achieve forward movement. In general health care, shared decision making is described as the collabora>on between pa>ents and caregivers to come to an agreement about a healthcare decision. It is especially useful when there is no clear "best" treatment op>on. The caregiver offers the pa>ent informa>on that will help him or her: • Understand the likely outcomes of various op>ons • Think about what is personally important about the risks and benefits of each op>on • Par>cipate in decisions about medical care In her paper, SHARED DECISION-‐MAKING IN THE MEDICAL ENCOUNTER: WHAT DOES IT MEAN? (OR IT TAKES AT LEAST TWO TO TANGO), Cathy Charles proposes four key characteris>cs of shared decision making… (1) that at least two par>cipants-‐-‐physician and pa>ent be involved; (2) that both par>es share informa>on; (3) that both par>es take steps to build a consensus about the preferred treatment; and (4) That an agreement is reached on the treatment to implement. Decision making may be a very quick and easy process to decide between op>ons or it may be very difficult and require much delibera>on. The difference between pa>ent educa>on and shared decision making is that pa>ent educa>on typically focuses on informing about a specific op>on and the risks and benefits of that op>on. Tools used in shared decision making strive to present balanced evidence-‐based informa>on about all reasonable op>ons and incorporate values clarifica>on into the decision making process. Consumers are encouraged to become ac*ve par*cipants in the process of choosing between the op>ons. It is the emphasis on values clarifica>on and ac>va>on
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Shared Decision Making is not “business as usual’. Not only does it differ from tradi>onal pa>ent educa>on models, it also differs from the Informed Consent Process. Informed consent is a legal procedure to ensure that a client knows all of the risks and costs involved in a specific treatment. The elements of informed consents include informing the client of the nature of the treatment, possible alterna>ve treatments, and the poten>al risks and benefits of the treatment. In order for informed consent to be considered valid, the client must be competent and the consent should be given voluntarily. Shared Decision Making is a much more fluid process. It relies on the exchange of informa>on and assumes an equal and balanced standing between the consumer and the professional. Both are seen as being experts in their ‘fields’. The consumer being an expert in their life, values, and experiences… and the professional possessing clinical exper>se. Shared Decision Making is not a legal agreement, rather it is an ongoing, evolving process – especially when being used in a mental health segng. Shared decision making is not a one >me event, but is revisited and incorporated into the ever evolving therapeu>c rela>onship. Achieving consensus – even just agreeing to disagree – is a hallmark of shared decision making. This is because each shared decision creates a founda>on for the next shared decision. But, perhaps, the most important aBribute to shared decision making is the inclusion of, the explora>on of one’s personal values as part of the decision making process. My values and principles ul>mately impact my ac>va>on in the decision making process and my ability to be mo>vated to carry out the shared decision.
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Some people feel that there is too much overlap between shared decision making and what is termed pa>ent-‐centered care. I would propose that all recovery oriented prac>ces should shared common aBributes and that this indicates a strength, rather than a weakness in the models. Shared decision making is one way, or one tool, for achieving pa>ent-‐centered care. It is important that people feel empowered to par>cipate – to lead – in their treatment and decision making processes. This can only happen if people feel heard and responded to. Some of the push back for adop>ng a shared decision making model has come from those who feel they already do shared decision making in an “informal” process, but frequently it looks like this…
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A more formalized adop>on of shared decision making processes can open the door for true collabora>on. Collabora>on does not require either party to relinquish or turn over their power or exper>se. In fact, it elevates both par>es and celebrates their exper>se. One task of shared decision making is to deminish the “us” and “them” nature of the mental health rela>onship and establish a more consumer driven approach to the treatment team. The invita>on to collaborate can be extended by either party. Collabora>on implies an act of working together. This means that both par>es have work to do towards an agreed upon goal or outcome. Collabora>on isn’t easy. The invita>on to collaborate is just the beginning of a process, not the end. In fact, many books and ar>cles have been wriBen about just the act of collabora>on alone. Many >mes collabora>on means that there will be a need to resolve conflict and achieve synergy – the interac>on of two forces so that their combined effect is greater than the sum of their individual efforts.
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So, what we have learned thus far is that shared decision making isn’t about gegng you to agree with me, or visa versa. Rather, it is a process which includes an exchange of ideas, values, and principles. We know that shared decision making requires an invita>on to collaborate, a willingness to explore how to make the whole greater than the sum of its parts. Shared decision making is also about resolving decisional conflict, which we will explore in the next few slides.
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In places where shared decision making is not employed, people who do not use psychiatric medica>ons during the course of their mental health treatment have been seen as resistant, non-‐compliant, unmo>vated or as having a poor prognosis. However, none of the labels help iden>fy or define the issues the person maybe having nor do they help resolve any areas of conflict or concern. They are deficit based references that tend to shut down discussion, rather than invite explora>on.
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In actuality, we know that what is going on for many people is decisional conflict about the use of medicine and the role it may or may not play in their recovery. In her qualita>ve research conducted over several years Dr. Patricia Deegan has iden>fied 11 broad areas of concern or conflict we consumers have iden>fied about the use of psychiatric medica>on. These include: concerns about side effects, meds being unhelpful, health concerns, how meds interact w/ drugs or alcohol use, the need more support, explora>on of alterna>ves to medica>on, logis>cal concerns such as how to manage a co-‐pay and/or how to overcome transporta>on barriers, confusion about how to take or use meds, conflic>ng beliefs about the use of medica>on, fears about the use of medicine, and mo>va>onal conflicts. Each of these areas poten>ally impact which course of ac>on to take when choice among compe>ng ac>ons involves risk, loss, regret or challenge to our personal life values.
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Think about difficult decisions in your personal life. What makes these decisions difficult? Not enough, or too much, informa>on Conflic>ng medical evidence Strong emo>ons aBached to the decision No one “right” answer Different advice from different people including providers, family, friends Pressure from family, friends, provider Shared decision making seeks to resolve these conflicts via the use of the collabora>ve wisdom of the pair, and/or the use of various decision aids that assist one in their own values clarifica>on and resolu>on exercises. To paraphrase from a paper wriBen by Adams, Drake, and Wofford; Shared decision making denotes the process of enabling us to par>cipate ac>vely and meaningfully in our treatment by providing accessible informa>on and choices. There are ethical, clinical, and economic arguments for shared decision making. Self-‐ determina>on over one's body is considered a fundamental principle of medical ethics. We, the consumer, are open best suited to make treatment decisions because only we can value trade-‐offs in efficacy and side effects. Furthermore, we open experience beBer outcomes when given informa>on and choices. Ac>ve par>cipa>on open increases sa>sfac>on, facilitates treatment adherence, and in some cases decreases symptom burden. Although many current mental health interven>ons promote client-‐centered care, client choice, and self-‐directed care, the research is just beginning on shared decision making in mental health for those of us with serious mental illness.
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Some important ques>ons to keep in mind as we con>nue through this webinar are: • Are we willing to meet people or share our own areas of discomfort, conflict, or concern? • Can we move beyond the deficit-‐based concepts of resistance and non-‐ compliance? • Can we support people in shared decision making as an alterna>ve to cohersive or controlling prac>ces? • Can we ensure that services are strengths-‐based, person-‐centered, and recovery oriented? With that, I’ll close and Thank you for your par>cipa>on in this webinar.
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