Browsing by Subject "Shared decision making"

Now showing 1 - 7 of 7
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    Current Emergency Department Disposition of Patients With Acute Heart Failure: An Opportunity for Improvement
    (Elsevier, 2022) Sax, Dana R.; Mark, Dustin G.; Rana, Jamal S.; Reed, Mary E.; Lindenfeld, Joann; Stevenson, Lynne W.; Storrow, Alan B.; Butler, Javed; Pang, Peter S.; Collins, Sean P.; Emergency Medicine, School of Medicine
    Emergency department (ED) providers play a critical role in the stabilization and diagnostic evaluation of patients presenting with acute heart failure (AHF), and EDs are key areas for establishing current best practices and future considerations for the disposition of and decision making for patients with AHF. These elements include accurate risk assessment; response to initial treatment and shared decision making concerning optimal venue of care; reframing of physicians' risk perceptions for patients presenting with AHF; exploration of alternative venues of care beyond hospitalization; population-level changes in demographics, management and outcomes of HF patients; development and testing of data-driven pathways to assist with disposition decisions in the ED; and suggested outcomes for measuring success.
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    Evaluating Shared Decision Making in Trial of Labor After Cesarean Counseling Using Objective Structured Clinical Examinations
    (Association of American Medical Colleges, 2020) Tucker Edmonds, Brownsyne; Hoffman, Shelley M.; Laitano, Tatiana; McKenzie, Fatima; Panoch, Janet; Litwiller, Abigail; Di Corcia, Mark J.; Obstetrics and Gynecology, School of Medicine
    Introduction Although shared decision making (SDM) is optimal for trial of labor after cesarean (TOLAC) counseling, resources to assess residents' clinical competency and communication skills are lacking. We addressed this gap by developing and testing an objective structured clinical examination (OSCE) to evaluate whether learners were able to use SDM in TOLAC counseling. Methods We created three simulation scenarios with increasing complexity to assess the skills of residents in their first, second, or third postgraduate year in using SDM in TOLAC counseling. All cases involved a standardized patient requesting a TOLAC consultation. Residents were provided with a medical history and instructed to counsel and develop a care plan. A 10-item scoring rubric was used, and each item was rated 0 (absent), 1 (partial), or 2 (complete). Three coders independently rated the encounters; discrepancies were resolved by consensus. Results Over 3 years, 39 residents participated in 60 OSCE encounters. The majority provided complete discussions of the clinical issue (93%), chances of success (72%), and maternal and fetal risks (100% and 85%, respectively) but obtained partial assessments of understanding (78%). Discussions of benefits were typically absent, with the exception of the maternal benefits (47%). More than 40% of residents did not discuss the patient's goals, 53% lacked discussion of uncertainties related to TOLAC, and half failed to explore the patient's preference, with most deferring a decision to a future encounter. Discussion Residents consistently discussed diagnosis, prognosis, and maternal risks yet infrequently addressed goals and preferences—two critical elements of SDM.
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    Is It Time for Precision Dialysis?
    (American Society of Nephrology, 2021) Gupta, Nupur; Wish, Jay B.; Medicine, School of Medicine
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    Perceptions of Options for Mode of Delivery in Periviable Decision-Making
    (2019-07) Bode, Leah; Tucker Edmonds, Brownsyne
    This study sought to qualitatively evaluate women’s perspectives on shared decision-making for mode of delivery (MOD) in the setting of periviable delivery (22-25 weeks), including their understanding of alternatives, risks/benefits, and provider recommendations. Interviews were conducted with women hospitalized for a threatened periviable delivery. We explored decision-making prompts related to MOD. Participants were also prompted to discuss their understanding of MOD risks/benefits and provider recommendations. Interviews were coded and analyzed using NVivo 12. Two-thirds of participants explicitly acknowledged having the option of cesarean section (CS) or vaginal delivery (VD). Maternal comorbidities limited some to one option. Many expressed a particular MOD preference, but most ultimately wanted “whatever’s best for baby.” Conceptually, MOD preference and decision-making were distinct, but typically aligned. However, occasionally, women recognized a MOD choice, but did not perceive the decision to be theirs, and vice versa. Likewise, consent was a separate concept, as some gave consent but did not feel they made a/the MOD decision. Understanding of MOD risks was mostly limited to bleeding, infection or fetal harm. Nine participants did not discuss any risks/benefits. Most women did not describe classical cesarean or risk to future pregnancies as risks. Patients felt that physicians recommended CS for fetal distress and to avoid risk of VD, though both CS and VD were equally recommended overall. Findings revealed a need for providers to clarify options and decision-making roles; review risks more comprehensively; refine recommendations; and create shared MOD plans in periviable counseling to aid women in informed, shared MOD decision-making.
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    A Pilot Study of Neonatologists' Decision-Making Roles in Delivery Room Resuscitation Counseling for Periviable Births
    (Taylor and Francis, 2016-07) Tucker Edmonds, Brownsyne; McKenzie, Fatima; Panoch, Janet E.; White, Douglas B.; Barnato, Amber E.; Obstetrics and Gynecology, School of Medicine
    BACKGROUND: Relatively little is known about neonatologists' roles in helping families navigate the difficult decision to attempt or withhold resuscitation for a neonate delivering at the threshold of viability. Therefore, we aimed to describe the "decision-making role" of neonatologists in simulated periviable counseling sessions. METHODS: We conducted a qualitative content analysis of audio-recorded simulation encounters and post-encounter debriefing interviews collected as part of a single-center simulation study of neonatologists' resuscitation counseling practices in the face of ruptured membranes at 23 weeks gestation. We trained standardized patients to request a recommendation if the physician presented multiple treatment options. We coded each encounter for communication behaviors, applying an adapted, previously developed coding scheme to classify physicians into four decision-making roles (informative, facilitative, collaborative, or directive). We also coded post-simulation debriefing interviews for responses to the open-ended prompt: "During this encounter, what did you feel was your role in the management decision-making process?" RESULTS: Fifteen neonatologists (33% of the division) participated in the study; audio-recorded debriefing interviews were available for 13. We observed 9 (60%) take an informative role, providing medical information only; 2 (13%) take a facilitative role, additionally eliciting the patient's values; 3 (20%) take a collaborative role, additionally engaging the patient in deliberation and providing a recommendation; and 1 (7%) take a directive role, making a treatment decision independent of the patient. Almost all (10/13, 77%) of the neonatologists described their intended role as informative. CONCLUSIONS: Neonatologists did not routinely elicit preferences, engage in deliberation, or provide treatment recommendations-even in response to requests for recommendations. These findings suggest there may be a gap between policy recommendations calling for shared decision making and actual clinical practice.
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    Potential Unintended Consequences Of Recent Shared Decision Making Policy Initiatives
    (Project HOPE, 2019-11) Blumenthal-Barby, Jennifer; Opel, Douglas J.; Dickert, Neal W.; Kramer, Daniel B.; Tucker Edmonds, Brownsyne; Ladin, Keren; Peek, Monica E.; Peppercorn, Jeff; Tilburt, Jon; Obstetrics and Gynecology, School of Medicine
    Shared decision making (SDM)-when clinicians and patients make medical decisions together-is moving swiftly from an ethical ideal toward widespread clinical implementation affecting millions of patients through recent policy initiatives. We argue that policy initiatives to promote SDM implementation in clinical practice carry the risk of several unintended negative consequences if limitations in defining and measuring SDM are not addressed. We urge policy makers to include prespecified definitions of desired outcomes, offer guidance on the tools used to measure SDM in the multitude of contexts in which it occurs, evaluate the impact of SDM policy initiatives over time, review that impact at regular intervals, and revise SDM measurement tools as needed.
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    Reducing Frustration and Improving Management of Chronic Pain in Primary Care: Is Shared Decision-making Sufficient?
    (Springer, 2022) Matthias, Marianne S.; Henry, Stephen G.; Medicine, School of Medicine