This article was published by PLoS Journals on 13 March 2018:
Typically, shared decision making, with or without a decision aid, involves patients in discussions about the options for treatment, the benefits and harms of each therapy, and the patient’s preferences, and a collaborative decision about how to proceed is made. For single conditions, that requires some motivation and teachable skills. But an additional challenge in providing healthcare for older people is the likelihood of multimorbidity: approximately half of older adults have 3 or more chronic conditions . The patterns of comorbidity are largely determined by common conditions in older people, such as coronary heart disease, diabetes, hypertension, chronic obstructive pulmonary disease (COPD), heart failure, depression, arthritis, and cancer. Multiple conditions complicate shared decision making, as management is not the simple sum of the parts. Should a patient with late-stage cancer continue statins? When is an implantable defibrillator appropriate in a patient with dementia? Are beta blockers mandatory in a patient who is depressed after a myocardial infarction? Multimorbidity is a problem itself but also creates interactions that can generate additional problems—of particular concern are polypharmacy and burden of treatment.
The authors conclude that shared decision making in older adults with multimorbidity needs a stepwise and individualised approach. The sharing first needs to occur in a discussion that considers what the patient’s priority problems and goals are so that any care provided aligns with these. For the decisions about how to achieve the prioritised goals, the more typical ‘sharing of the decision’ about the preferred option can then occur, although existing decision aids should be used with caution as they are unlikely to account for the increased risk of harm in older people or potential drug–drug or drug–condition interactions, and personalisation of this information is ideally needed. In juggling the competing priorities and conditions (and clinicians), our aim should be to help patients achieve their goals as much as possible while disrupting their lives as little as possible.
Hoffmann T, Jansen J, Glasziou P (2018)
The importance and challenges of shared decision making in older people with multimorbidity.
PLoS Med 15(3): e1002530. https://doi.org/10.1371/journal.pmed.1002530
Read the full article here: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002530