According to a 2014 article, “Research on the support for decision making in cancer treatment has emphasized the concept of shared decision making (SDM), where patients participate in the process of making a decision with healthcare professionals."
Patients who use SDM are more often satisfied with their outcomes, even when met with unexpected or unfavorable side effects. Oncology nurses at any practice level can actively participate in the SDM process; if you haven’t been involved in SDM before, here’s what you need to know to get started.
What Is Shared Decision Making?
ONS member Frank dela Rama, RN, MS, AOCNS®, AGN-BC, prostate cancer nurse navigator and clinical nurse specialist at the Palo Alto Medical Foundation in California, says he sees the aim of SDM as “helping one person make the best choice, given a complex problem or dilemma where many viable choices are available. Rather than telling that person what to do directly, SDM involves collaborating with all vested parties to help that person learn the pros and cons of each choice.
“In my daily practice working with patients newly diagnosed with prostate cancer, there are almost always at least two or three viable treatment choices, with no true frontrunner even once we look beyond just efficacy and into quality of life issues and other ‘what ifs’,” dela Rama continues. “Our goal in prostate cancer SDM is for the patient himself to pick the best option, after a thorough review of all aspects, including clinical effectiveness, possible side effects (prioritizing side effects, such as which potential side effects do you think you could deal with or not?), as well as potential effects on family, significant others, or friends.”
ONS member Debbie J. Tuttle, DNP, FNP-BC, AOCNS®, CBCN®, is an oncology nurse practitioner specializing in breast cancer at California Oncology of the Central Valley in Fresno. She defines shared decision making as “the patient’s well-informed choice of a plan of care from an appropriate and reasonable set of options that fit the patient’s goals and priorities.
“I work in a medical oncology community practice which specializes in brast cancer,” Tuttle continues. “A number of treatment decisions are clear cut for patients, in that they make the determination that the toxicities and potential adverse effects of a well-established treatment are worth the reduction in risk of recurrence. However, the management of breast cancer often presents several options that are equivalent in efficacy, such as breast conservation surgery combined with radiation versus mastectomy and neoadjuvant versus adjuvant chemotherapy. Additionally, patients have other treatment decisions, such as electing adjuvant systemic chemotherapy for a small margin of benefit in reducing the risk of recurrence, where the patient’s personal preferences are key to the final decision. A highly functioning multidisciplinary team allows the patient the opportunity to hear detailed information on the risks and benefits of all of the options from a variety of providers.”
How Shared Decision Making Benefits Patients
Patients involved in SDM report higher levels of satisfaction with their treatment and outcomes, dela Rama says. “They feel like they made the right decision at the time, given the available information. Past patients with prostate cancer who did not have a formal SDM intervention were more likely to regret or be less satisfied with their decision, especially when adverse side effects occur.”
Tuttle concurs, and she shares a particularly poignant story of how patient experiences with SDM can be positive, even in the face of negative outcomes. “I recall a young patient who chose not to treat with what would have been standard for her diagnosis after all of the appropriate information was presented. The medical outcome was poor as a result of this, but she never seemed to regret her decision. It was the right one for her in her mind and ultimately, saving ‘a body’ versus supporting ‘independent control of what was done to her body’ was most important to this patient. This was a difficult pill for us to swallow, but we continued as a team to support her decision and, more importantly, support her in what was ultimately the right decision for her.”
Barriers to Making Effective Shared Decisions
Dela Rama identified two barriers to SDM. The first is physicians and providers not being familiar with SDM and the role of the nurse navigator: providers may feel as if a navigator is taking away their patients. However, the true role of the navigator is to ensure that patients have the information they need to make a personal decision based on their values and beliefs; then, patients are handed back to the treating physicians to administer the treatment plan. A second barrier is time. “I average at least 45 minutes for a first visit with a man newly diagnosed with prostate cancer. There are many aspects to review, as well as plenty of questions to answer,” dela Rama says.
“All I know is that the men who carefully—but not compulsively—considered all aspects of their prostate cancer treatment seem to be the most satisfied and comfortable with their decision, even years out, no matter what the outcome.”
The Oncology Nurse’s Role
Time is a factor in SDM, but almost every oncology nurse may take an active role in the process, especially through patient education. “Nurse navigators can be one of the first healthcare providers to sit and spend time with patients after their diagnosis,” Tuttle says. “This time can be a key opportunity to begin exploring patients’ preferences in decision making while providing the foundational education from which well-informed decisions should stem.”
As the experts in the management of these disease states, healthcare providers such as oncology nurses live and breathe these details. “I believe that the process of informing patients, in detail, regarding their pathology reports and breast cancer diagnosis allows patients the freedom to concentrate on choosing from available options with a level of confidence that may not be obtained from a presentation of ‘this is what I have decided for you’,” Tuttle says. “I commonly tell new patients that their diagnosis is a 12-credit crash course in breast cancer. They need repetition, review, and clarification on many details of their diagnosis and treatment from all members of the healthcare team. In our practice, it is a heartfelt belief that no single one of us is the key to the patient’s success. It is a necessity that each of us educates and reinforces in our respective interactions.”
All nurses, no matter their role, can contribute to SDM, ensuring that their patients make well-informed treatment options that are in line with their values and preferences.