Presented in: Pre-Conference Workshop on Communication Skills in Management of Cancer Patients, World Cancer Day Conference & Expo 2015 by National Cancer Society of Malaysia

1. Shared decision-making
Dr Tan Chai Eng
MMed (Family Medicine)
Department of Family Medicine
WORLD CANCER DAY CONFERENCE AND EXPO 2015
PRE-CONFERENCE WORKSHOP 7 FEBRUARY 2015
Filepic http://www.thestar.com.my/Lifestyle/Health/2014/06/08/Cochrane-comes-to-Malaysia/

2. What would you choose if you had
cancer?
• Why do doctors die differently? Ken Murray, 2011
(http://www.zocalopublicsquare.org/2011/11/30/how-
doctors-die/ideas/nexus/)
Gallo, 2003

3. Should patients be given a choice?
A 35 year old woman is
newly diagnosed with Stage
1 breast cancer. What are
her options for treatment?
A 35 year old woman is
diagnosed with sepsis due
to a gangrenous diabetic
foot. What are her options
for treatment?
A 35 year old woman is
newly diagnosed with Stage
4 breast cancer with bone
and lung metastases. What
are her options for
treatment?
A 35 year old woman is
diagnosed with
fibroadenoma. What are
her options for treatment?

4. Decision-making process
Patient and
family’s goals and
preferences
Clinical
evidence and
expertise
Biological,
psychological and
sociological
context
SDM
http://www.cincinnatichildrens.org/

5. Shared decision-making
“an approach where clinicians and patients
share the best available evidence when faced
with the task of making decisions, and where
patients are supported to consider options, to
achieve informed preferences.”
Elwyn et al. 2010

6. Why shared decision-making?
• Decreased patient anxiety and decisional
conflict
• Improved knowledge of patients
• More confidence in decisions
• More active patient involvement
• Decisions made based on accurate
expectations and consistent with personal
preferences
O’Connor 2009, Coulter 2005

7. SDM in Malaysia
• Patients desired quality information but were
not given enough information to make a
choice. (Ng, 2013)
• Lack of low health literacy impedes patient
involvement in SDM (Ng, 2013)
• Levels of patient-centredness varied amongst
medical specialities. (Chan, 2012)
• Communication of health information to
patients needs to be improved (Tan, 2012)

8. How can SDM be practised in cancer
care? (Politi, 2012)
Determine the situations in which SDM is critical
Acknowledge the decision to the patient
Describe options, including risks, benefits and uncertainty
associated with options
Elicit patient preferences and values
Agree on a plan for next steps in the decision-making
process

9. Determine the situations in which
SDM is critical
• Not all cancer decisions are preference sensitive
• Examples of situations where SDM is required:
– Cancer screening decisions e.g. PSA screening,
mammography
– Participation in experimental clinical trials for new
cancer drugs
– Treatment options – benefits vs risks, patient
preferences and social circumstances
– Advanced directives / end-of-life decisions

10. Acknowledge the decision to the
patient
• Inform the patient that a decision is required.
• Choice talk (Elwyn, 2012)
– Making sure that patients know that reasonable
options are available

11. Choice talk
• Step back
– Now that we have identified the problem, it’s time to think
what to do next.
• Offer choice
– There is good information about how these treatments
differ that I’d like to discuss with you.
• Justify choice:
– personalising preferences : Treatments have different
consequences, some will matter more to you than to other
people;
– role of uncertainty: Treatments are not always effective
and the chances of experiencing side effects vary

12. Choice talk (cont)
• Check reaction
– Shall we go on? Shall I tell you about the options?
• Defer closure (if patients react by asking you
to tell him what to do)
– I’m happy to share my views and help you get to a
good decision. But before I do so, may I describe
the options in more detail so that you understand
what is at stake?

13. • List options and describe the benefits and
drawbacks in a BALANCED way
• Language that is easily understood, preferably
one that the patient understands
• Frame statistics using easily understood
frequencies
– “Our best estimate is that n of 100 people like you will
have a recurrence without having this treatment,
compared with n of 100 people who will have a
recurrence after having this treatment”
Describe options, including risks, benefits and
uncertainty associated with options

14. Use of graphics to convey risks
http://www.iconarray.com/ by University of Michigan
• Helps patients with limited literacy to understand
risks better

15. Patient decision aids
• Tools developed to help patients be involved in
making decisions
(http://decisionaid.ohri.ca/AZinvent.php)
• 56 different tools to help facilitate patients to
make decisions regarding cancer screening /
treatment
• Local:
– MAKING DECISIONS ABOUT YOUR BREAST CANCER
TREATMENT: A decision aid for woman with early
breast cancer – Ng CJ, Universiti Malaya

16. SCOPED (Belkora)
http://www.scoped.org/
Decision-making checklist
• Situation: clarifying known facts about my condition
• Choices: clarifying which options are available
• Objectives: clarifying my goals and priorities
• People: clarifying roles and responsibilities
• Evaluation: clarifying how my choices affect my
objectives
• Decisions: clarifying which choice is best and next
steps

17. • Patient’s preference do not always correlate
with age, gender, ethnicity
• Important to explore the patient’s values
“From your point of view, what matters most to you?”
• What are the patient’s ICE: Ideas, Concerns
and Expectations?
• Reflective listening
• Preference clarification exercises within PDAs
Elicit patient preferences and values

18. “Are you ready to decide?”
“Are there more things we should discuss?”
“Do you want more time?”
• Patients should be informed that decisions
may be reviewed e.g. after a few cycles of
chemotherapy
• Plan for managing possible side effects
Agree on a plan for next steps in the
decision-making process

19. How can SDM be practised in cancer
care? (Politi, 2012)
Determine the situations in which SDM is critical
Acknowledge the decision to the patient
Describe options, including risks, benefits and uncertainty
associated with options
Elicit patient preferences and values
Agree on a plan for next steps in the decision-making
process

20. References
• Gallo J, Straton J, Klag M, et al. Life-Sustaining Treatments: What Do Physicians Want and Do They
Express Their Wishes to Others?. Journal of the American Geriatrics Society, 2013, Vol 51: 961-9.
• Elwyn G, Frosch D, Thomson R, et al. Shared decision-making: a model for clinical practice. J Gen
Intern Med 27(10):1361-7
• O’Connor A, Bennett C, Stacey D, et al. Decision aids for people facing health treatment or
screening decisions. Cochrane Database of Systematic Reviews. 2009, Citation: (3):CD001431.
• Coulter A, Jenkinson C: European patients’ views on the responsiveness of health systems and
healthcare providers. Eur J Public Health 2005 Vol 15:355-360
• Ng CJ, Lee PY, Lee YK, et al. The overview of patient involvement in healthcare decision-making: a
situational analysis of the Malaysian context. BMC Health Services Research. 2013 Vol 13:408
• Chan CM, Ahmad WA. Differences in physician attitudes towards patient-centredness: across four
medical specialties. Int J Clin Pract 2012, 66:16-20
• Tan CE, Yaakup H, Shah SA, Jaffar A, Omar K. Preferences of Malaysian cancer patients in
communication of bad news. Asian Pac J Cancer Prev 2012 Vol 13:2749-52
• Politi M, Studts J, Hayslip J. Shared decision-making in oncology practice: what do oncologists need
to know? The Oncologist. 2012 Vol 12:91-100
• Belkora J, Katapodi M, Moore D et al. Evaluation of a visit preparation intervention implemented in
two rural, underserved counties of Northern California. Patient Education and Counselling 2006 Vol
64:350-9

21. Thank you
• Role-play to try it out…