Enable. Empower. Enrich.

“Shared decision making… particularly if people are ill, should have the underpinning goal of restoring autonomy” (1)Elwyn G. Shared decision making: What is the work? Patient Educ Couns. 2021 Jul 1;104(7):1591–5..

This part of the three-talk model, ‘Option Talk’ is about revisiting the conversation with the older person and their supporters to consider the range of options including risks, benefits and consequences within the decision-making process.

Communication tailored to the individual and supported through use of well-structured decision-making tools remains key, especially where there is uncertainty and when choices involve compromise between benefits and risks (1)Elwyn G. Shared decision making: What is the work? Patient Educ Couns. 2021 Jul 1;104(7):1591–5. (2)Shared decision making NICE guideline [Internet]. 2021. Available from: www.nice.org.uk/guidance/ng197.

What is Option Talk?

'Option talk', is discussion of the alternatives to address the risks, benefits and consequences of each option (2)Shared decision making NICE guideline [Internet]. 2021. Available from: www.nice.org.uk/guidance/ng197.

How to present options

  • Check knowledge: Even when people are well-informed they may only be partially aware of options and the associated harms and benefits. (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. .
  • List options (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. .
  • Describe options: Try giving information in ‘chunks’ (chunking and checking) (4)Kurtz SM SJD. The Calgary-Cambridge Referenced Observational Guides: an aid to defining the curriculum and organizing the teaching in communication training programmes. Med Educ. 1996 Mar;30(2):83–9..
  • Provide decision support: Tools make options visible and may save time (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. .
  • Summarise: List the options again and assess understanding. This is a good check for misconception (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. .
  • Include family / supporters: The older person involved in the decision may not be able to be fully involved due to their condition so it is important to ensure there are supporters / family members who can be present when options are discussed.
  • Encourage Collaboration: Enable patient and family engagement through professional / patient collaboration to ensure that all involved have opportunity to talk, listen and engage with each other to arrive at a decision (5)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. (6)Grimmer KA, Dryden LR, Puntumetakul R, Young AF, Guerin M, Deenadayalan Y, et al. ISSN 1540-580X The Internet Journal of Allied Health Sciences and Practice [Internet]. Vol. 4. 2006. Available from: http://.

Communication is key

A negotiated approach to decision making has been described as a “delicate web”. (7)Dubler NL. Improving the discharge planning process: Distinguishing between coercian and choice. Gerontologist. 1988;28:76–81. Discharge planning can be spread out over time and revisited as and when required. Health and social care professionals can enhance older people’s readiness (8)Preen DB, Bailey BES, Wright A, Kendall P, Phillips M, Hung J, et al. Effects of a multidisciplinary, post-discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: a randomized controlled trial. Vol. 17, Source: International Journal for Quality in Health Care. 2005. (9)Ulin K, Olsson LE, Wolf A, Ekman I. Person-centred care - An approach that improves the discharge process. European Journal of Cardiovascular Nursing. 2016 Apr 1;15(3):e19–26. and can support older people and carers to understand the risks, benefits, and consequences of available options.

This joint process empowers people to make decisions about the care that is right for them at that time (with the options of choosing to have no treatment or not changing what they are currently doing always included) (2)Shared decision making NICE guideline [Internet]. 2021. Available from: www.nice.org.uk/guidance/ng197. Early, open and honest conversations are critical for building trust within the shared decision-making process.

When carers are invited and supported to participate in shared decision-making, they feel more informed and involved, which reduces their uncertainty and anxiety leading to increased motivation, reassurance, and hope in their caregiving role.

Eileen's Story

We invite you to listen to Eileen relate her experience of shared decision making in the care of her mother and the differing realities that need to be considered.

What are the barriers and solutions to shared decision-making?

Older person

Older people can sometimes find it difficult to engage with interventions such as booklets if they sense that staff are burdened. Clarity about supporting roles can help staff deliver interventions more successfully (11)Baxter R, Murray J, Cockayne S, Baird K, Mandefield L, Mills T, et al. Improving the safety and experience of transitions from hospital to home: a cluster randomised controlled feasibility trial of the “Your Care Needs You” intervention versus usual care. Pilot Feasibility Stud. 2022 Dec 1;8(1)..

Community / family

Short duration of hospital stays, and fluctuating health can create barriers for older people especially those without family or friends from being fully involved in the decision-making process. As their health improves, they can become more involved. Interventions such as discharge planning checklists can assist older people and carers to identify needs for follow-up care (6)Grimmer KA, Dryden LR, Puntumetakul R, Young AF, Guerin M, Deenadayalan Y, et al. ISSN 1540-580X The Internet Journal of Allied Health Sciences and Practice [Internet]. Vol. 4. 2006. Available from: http://.

Organisation

Staff shortages, time constraints, lack of clarity about roles for clinical staff, dispersed line management; hindering policies - if risk cannot be shared across system boundaries interventions are unlikely to succeed (11)Baxter R, Murray J, Cockayne S, Baird K, Mandefield L, Mills T, et al. Improving the safety and experience of transitions from hospital to home: a cluster randomised controlled feasibility trial of the “Your Care Needs You” intervention versus usual care. Pilot Feasibility Stud. 2022 Dec 1;8(1).. However, when partnership is in focus from the start, this decreases the possibility for mistakes in planned support as it allows more time for planning and preparing the discharge (9)Ulin K, Olsson LE, Wolf A, Ekman I. Person-centred care - An approach that improves the discharge process. European Journal of Cardiovascular Nursing. 2016 Apr 1;15(3):e19–26..

Issues of culture / tradition in families & communities & impact on options acceptable

There is emerging data to indicate that people with the lowest health literacy benefit most from interventions designed to support shared decision-making (13)Durand MA, Carpenter L, Dolan H, Bravo P, Mann M, Bunn F, et al. Do interventions designed to support shared decision- making reduce health inequalities? A systematic review and meta-analysis. PLoS One. 2014 Apr 15;9(4).. Such support can enable better understanding and foster trust.

The idea of asking questions of healthcare professionals might not be considered acceptable in certain cultures (12)Bull MJ, Hansen HE, Gross CR. A Professional-Patient Partnership Model of Discharge Planning With Elders Hospitalized With Heart Failure. 2000.. Culturally sensitive approaches can help bridge shared decision-making gaps through respectful communication.

Education and other social factors such as migrant status were also likely to adversely impact health status and lead to poorer health outcomes (5)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.. Inclusive policies can help address challenges such as language barriers or lack of familiarity of shared decision-making processes.

When something changes

People should have access to reliable information about the risks and benefits of all reasonable options as they unfold.

Decision Aids

A review of the literature undertaken to inform the development of this resource indicates that well-structured tools can empower those involved (10)Prick JCM, van Schaik SM, Deijle IA, Dahmen R, Brouwers PJAM, Hilkens PHE, et al. Development of a patient decision aid for discharge planning of hospitalized patients with stroke. BMC Neurol. 2022 Dec 1;22(1).. Shared decision-making tools include:

  • Booklets (5)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.
  • Films/videos for older people & carers (11)Baxter R, Murray J, Cockayne S, Baird K, Mandefield L, Mills T, et al. Improving the safety and experience of transitions from hospital to home: a cluster randomised controlled feasibility trial of the “Your Care Needs You” intervention versus usual care. Pilot Feasibility Stud. 2022 Dec 1;8(1).
  • Older people friendly discharge care summaries (5)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.
  • Online information and deliberation tools for older people / carers (10)Prick JCM, van Schaik SM, Deijle IA, Dahmen R, Brouwers PJAM, Hilkens PHE, et al. Development of a patient decision aid for discharge planning of hospitalized patients with stroke. BMC Neurol. 2022 Dec 1;22(1).
  • Discharge planning questionnaires / checklists for older people / carers to identify needs for follow-up care (6)Grimmer KA, Dryden LR, Puntumetakul R, Young AF, Guerin M, Deenadayalan Y, et al. ISSN 1540-580X The Internet Journal of Allied Health Sciences and Practice [Internet]. Vol. 4. 2006. Available from: http://
  • Daily discussions to educate older people about their condition, medications, and the discharge process (5)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.
  • Printed consultation sheets to introduce options for discharge destination (Prick, 2022) (10)Prick JCM, van Schaik SM, Deijle IA, Dahmen R, Brouwers PJAM, Hilkens PHE, et al. Development of a patient decision aid for discharge planning of hospitalized patients with stroke. BMC Neurol. 2022 Dec 1;22(1).
  • Goal setting: agreed upon with the older person / carer (8)Preen DB, Bailey BES, Wright A, Kendall P, Phillips M, Hung J, et al. Effects of a multidisciplinary, post-discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: a randomized controlled trial. Vol. 17, Source: International Journal for Quality in Health Care. 2005.
  • Educational program for nurses and social workers (12)Bull MJ, Hansen HE, Gross CR. A Professional-Patient Partnership Model of Discharge Planning With Elders Hospitalized With Heart Failure. 2000.
  • Hospital driven MDT discharge planning in collaboration with primary healthcare providers & carers / older people: using individually tailored care plan (9)Ulin K, Olsson LE, Wolf A, Ekman I. Person-centred care - An approach that improves the discharge process. European Journal of Cardiovascular Nursing. 2016 Apr 1;15(3):e19–26.
  • Discharge meetings with older people / carers & clinical team - with care navigator, from clinical team following up with the older person’s primary care physician and post discharge with the older person regarding any queries (5)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.

Reflection

  • Older person: What do I feel would better enable me to become involved in shared decision-making?
  • Supporter or Carer: What would make me feel more confident and supported during shared decision-making conversations?
  • Staff: Is there a way I can further strengthen how older people and their carers are enabled to partake in shared decision-making conversations to help ensure their understanding of options available?