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"Getting old is like climbing a mountain; you get a little out of breath, but the view is much better!" - Ingrid Bergman

The final part of the three-talk model is ‘Decision Talk’. This section of the resource speaks about how we achieve a decision through the shared decision-making process. This is a decision that includes the preferences of older people and their supporters, guided by experience and expertise of the health and social care professionals. This is not the end point but one point on the older person’s journey where the integration of health and social care is central to sustaining and supporting decision making.

What is Decision Talk?

Decision Talk makes sure a decision is made that is right for each person (1)Shared decision making NICE guideline [Internet]. 2021. Available from: www.nice.org.uk/guidance/ng197

How do we make decisions TOGETHER?

  • Focus on preferences: Guide the person to form preferences. Suggested phrases: “What, from your point of view, matters most to you?” (3)Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared decision making: A model for clinical practice. Vol. 27, Journal of General Internal Medicine. 2012. p. 1361–7. .
  • Elicit a preference: Be ready with a back-up plan by offering more time or being willing to guide the person if they indicate that this is their wish (3)Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared decision making: A model for clinical practice. Vol. 27, Journal of General Internal Medicine. 2012. p. 1361–7. .
  • Moving to a decision: Try checking for the need to either defer a decision or make a decision. Suggested phrases: “Are you ready to decide?” or “Do you want more time? Do you have more questions?” “Are there more things we should discuss?” (3)Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared decision making: A model for clinical practice. Vol. 27, Journal of General Internal Medicine. 2012. p. 1361–7. Do you feel your values and wishes have been considered?
  • Offer review: Reminding the person where feasible, that decisions may be reviewed is a good way to arrive at closure (3)Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared decision making: A model for clinical practice. Vol. 27, Journal of General Internal Medicine. 2012. p. 1361–7. .
  • Maintain a collaborative process: Consider what compromises have been made by the older person; by the carer; by the health and social care professional. Maintain a collaborative process throughout that actively incorporates the patient and family in the discharge process, empowering older people and their families to become part of the care team, results in more inclusive and equitable care for older people (4)Williams A, Kesten KS. Engaging Older Adults and Families Using the IDEAL Discharge Protocol: A Quality Improvement Initiative to Improve Outcomes and Reduce Readmissions. J Gerontol Nurs. 2023 Oct 1;49(10):13–9..

Explore preferences & make decisions

Including families in the discharge process improves the likelihood of compliance with the discharge plan and helps older people avoid readmission (4)Williams A, Kesten KS. Engaging Older Adults and Families Using the IDEAL Discharge Protocol: A Quality Improvement Initiative to Improve Outcomes and Reduce Readmissions. J Gerontol Nurs. 2023 Oct 1;49(10):13–9..

A decision can be to accept the current condition or defer action until another time.

Protected time and a quiet area for conversations helps older people and families / carers to feel respected and appreciated which enables them to reflect upon and carefully consider shared decision-making conversations, during the process of making a decision.

There will be times when an older person may lack the ability to decide. At such times the older person’s ability to make that decision needs to be considered. In the following video Steph Kerr shares her expertise on the legislation, principles and best interest decision making relating to assessing mental capacity.

Q&A

How can tools to support decision-making be of benefit to me?

When carers and older people are provided with tools and opportunities to engage more actively in care and discharge planning (for example, use of notepads and tape recorders), this encourages participation and enhances communication, leading to better information retention, less frustration and a greater sense of involvement. Carers experience reduced frustration, and older people report increased satisfaction with their care and discharge process.

Why is it important that carers are supported by staff?

When carers are provided with support and guidance this enables them to assist older people in articulating their values and preferences. As a result, older people are more likely to actively participate in decision-making.

Why is shared decision-making so critical overall?

Providing hospital driven discharge planning processes in collaboration and follow-up with primary care teams together with older people and their carers, can strengthen staff engagement. It can also enhance older people’s confidence and ownership about returning home safely and sustainably. It can encourage older people’s desire and motivation to exchange information and express preferences for care with clinicians. Ultimately, this leads to improved hospital discharge shared decision-making through provision of a superior, more inclusive, structured, person-centred collaboration among providers, older people, and families/carers.

Examples of shared decision-making

Reflection

  • Older person: What matters most to me and have my preferences and wishes been considered during discussions to help inform my decision?
    Is there a certain family member/carer who might be better placed to be involved in discussions between myself and hospital staff?
  • Supporter or Carer: What tools might help me retain information about available options in order to help support shared decision-making, for example, pen and paper?
    Who is the point of contact to help me understand that the right decision is being made?
    Has careful deliberation occurred before reaching a decision?
  • Staff: Have I enabled the older person and their family/carer to be involved in conversations where a decision needs to be made? Is there a way I could have done this better?
    Have I supported the older person and their family/carer, through active listening, to articulate their values and preferences?

Life after hospital