Enable. Empower. Enrich.

This part of the resource builds an understanding of the importance of Shared Decision Making for older people, their carers and the care team. It highlights how each contribution is important and plays a vital role in leading to the right decision being reached.

What is Team Talk?

“introduces the fact that there are options, and that the right option will depend on what matters to each person” (4)NICE. Shared decision making National Institute for health and care excellence2021

Older people often rely on personal networks and speaking directly to health and social care personnel to receive information (5)Walker J, Crotty BH, O’Brien J, Dierks MM, Lipsitz L, Safran C. Addressing the challenges of aging: how elders and their care partners seek information. The Gerontologist. 2017;57(5):955–62.. They may face unique difficulties in having their voices heard and wishes recorded on documentation related to discharge planning (6)Rhynas SJ, Garrido AG, Burton JK, Logan G, Macarthur J. New care home admission following hospitalisation: How do older people, families and professionals make decisions about discharge destination? A case study narrative analysis. International Journal of Older People Nursing. 2018;13(3):e12192.. Their priorities and abilities to make decisions may differ from other populations due to both health histories and understanding (7)Lilleheie I, Debesay J, Bye A, Bergland A. Experiences of elderly patients regarding participation in their hospital discharge: a qualitative metasummary. BMJ Open. 2019;9(11):e025789.. An explicit invitation to participate in SDM is important to older adults. To enable this health and social care staff need a supporting organisational context and good communication skills to devise indivdualised approaches to shared decision making (8)Pel-Littel RE, Snaterse M, Teppich NM, Buurman BM, Van Etten-Jamaludin FS, Van Weert JCM, et al. Barriers and facilitators for shared decision making in older patients with multiple chronic conditions: a systematic review. BMC Geriatrics. 2021;21(1)..

Q&A

What is shared decision making?

Shared decision making is a collaborative process that involves a person and their healthcare professional working together to reach a joint decision about care. It could be care the person needs straightaway or care in the future. It involves choosing tests and treatments based both on evidence and on the person's individual preferences, beliefs and values. It means making sure the person understands the risks, benefits and possible consequences of different options through discussion and information sharing (4)NICE. Shared decision making National Institute for health and care excellence2021

Why is Shared Decision Making (SDM) important for older adults?

Shared decision making is important across all health and social care contexts. Done well it has been shown to improve trust between older people and health care professionals (9)Ommen O, Thuem S, Pfaff H, Janssen C. The relationship between social support, shared decision-making and patient’s trust in doctors: a cross-sectional survey of 2,197 inpatients using the Cologne Patient Questionnaire. International journal of public health. 2011;56(3):319–27.. Shared decision making has the potential to provide numerous benefits for older people, clinicians, and the health care system, including increased knowledge, less anxiety over the care process, improved health outcomes, reductions in unwarranted variation in care and costs, and greater alignment of care with a person’s values (10)Oshima Lee E, Emanuel EJ. Shared decision making to improve care and reduce costs. New England Journal of Medicine. 2013;368(1):6–8.. Shared decision making has been shown to be of particular benefit to disadvantaged communities (11)Durand M-A, 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;9(4):e94670..

What are the benefits of SDM particularly related to discharge planning?

Hospital discharge is a critical step in an older person’s care (7)Lilleheie I, Debesay J, Bye A, Bergland A. Experiences of elderly patients regarding participation in their hospital discharge: a qualitative metasummary. BMJ Open. 2019;9(11):e025789.. A personalised approach to the planning of discharge has been shown to shorten hospital stays, slightly reduce readmission and may increase older people’s satisfaction (12)Gonçalves-Bradley DC, Lannin NA, Clemson L, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database of Systematic Reviews. 2022;2022(2)..

How do we do it?

Essential elements of shared decision making include recognising and acknowledging that a decision is required; knowing and understanding the best available evidence on risks and benefits; and incorporating the older person’s values and preferences into the decision (13)Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared decision making: a model for clinical practice. Journal of general internal medicine. 2012;27(10):1361–7..

The importance of placing decisions within the context of the person and their life is emphasised, enabled by developing a trusted relationship and goal setting that incorporates the person’s views and values.

‘There is no right way to achieve shared decision making. Each interaction will bring different decisions, contexts and prior relationships into the mix’. (14)Elwyn G. Shared decision making: what is the work? Patient Education and Counseling. 2021;104(7):1591–5.

Whether we live alone or with family or friends, how we interact and respond to our environment is different for each person as we are unique and what we bring to our decisions is also unique. Understanding this helps us to give and receive support in making decisions. This is no different for older people and how the older person sees their world should be the starting point for early conversations (2)Clayman ML, Gulbrandsen P, Morris MA. A patient in the clinic; a person in the world. Why shared decision making needs to center on the person rather than the medical encounter. Patient education and counseling. 2017;100(3):600–4., which helps us to really listen.

Spheres of Influence in Decision Making

The role of the multi-disciplinary team

In this recording the benefits to the older person and the wider team of having the nurse as ‘the constant’ in sustaining continuity of care is suggested. While each role is different their interdependence is core to realising person-centred goals.

Myths relating to shared decision making

While people generally accept that shared decision making as a principle is a good idea there remains a reluctance to truly integrate it into everyday practice. Myths identified in 2014 (18)Légaré F, Thompson-Leduc P. Twelve myths about shared decision making. Patient education and counseling. 2014;96(3):281–6. remain as reported in current literature.

Myth 1. Shared decision making takes too much time

This is often an issue for staff and a reason for limiting shared decisions. Time was seen as a barrier to implementation of SDM (19)Alsulamy N, Lee A, Thokala P, Alessa T. What influences the implementation of shared decision making: an umbrella review. Patient education and counseling. 2020;103(12):2400–7. However, there is no evidence to say shared decision making takes more time or increases costs (20)Bruch JD, Khazen M, Mahmic-Kaknjo M, Legare F, Ellen ME. The effects of shared decision making on health outcomes, health care quality, cost, and consultation time: An umbrella review. Patient Educ Couns. 2024;129:108408..

Myth 2. We’re already doing shared decision making

While there is evidence that shared decision making is considered a core part of person centred care. A review of experiences of older people regarding participation in their hospital discharge showed they were given few opportunities to participate in shared decision making regarding their discharge (7)Lilleheie I, Debesay J, Bye A, Bergland A. Experiences of elderly patients regarding participation in their hospital discharge: a qualitative metasummary. BMJ Open. 2019;9(11):e025789..

Myth 3. Not everyone wants shared decision making

Studies show that people want to be more involved in decisions relating to their health care and this trend has been growing. There is also some evidence to suggest that those with lower health literacy may benefit the most from shared decision making (11)Durand M-A, 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;9(4):e94670. (18)Légaré F, Thompson-Leduc P. Twelve myths about shared decision making. Patient education and counseling. 2014;96(3):281–6.

Myth 4. The health care professional can make the decision alone

Most people seek healthcare from a position of having less technical knowledge, experience, and expertise than their healthcare professional. However, each person is an expert in their own life and condition which means they also bring expertise the health care professional doesn’t have to the shared decision. Shared decision making therefore could be described as the ultimate meeting between experts (14)Elwyn G. Shared decision making: what is the work? Patient Education and Counseling. 2021;104(7):1591–5..

Communication and Collaboration as central to Shared Decision Making.

Our Focus Groups and Co-design Workshops with older people, their carers and health and social care staff highlighted Communication and Collaboration as central to Shared Decision Making.

Communication

This is a central theme recurring throughout our conversations with patients, carers and health and social care staff. Good communication is vital, starting with developing a trusted relationship. The best treatment for the condition might not be the same as the best treatment for the person as a whole. Instead of focusing on the treatment of each individual condition, the conversation should start with exploring an older adult’s priorities regarding preferred health outcomes, thus guiding the discussion of options and decisions about treatment or care. Since both the personal preferences of the older adult and the professional experience of the health professional are needed, this process is called ‘shared decision making (8)Pel-Littel RE, Snaterse M, Teppich NM, Buurman BM, Van Etten-Jamaludin FS, Van Weert JCM, et al. Barriers and facilitators for shared decision making in older patients with multiple chronic conditions: a systematic review. BMC Geriatrics. 2021;21(1).. Shared decision making will not be successful unless we tailor our language and communication to the person involved in the decision (21)Siebinga VY, Driever EM, Stiggelbout AM, Brand PL. Shared decision making, patient-centered communication and patient satisfaction–A cross-sectional analysis. Patient education and counseling. 2022;105(7):2145–50..

Collaboration

People live in environments that shape their needs, their beliefs, attitudes and behaviour. For trusted conversation and real partnership, we should recognise and respect these many different aspects of the person. The importance of collaboration in identifying roles within the multidisciplinary team was highlighted throughout our co-design with both health and social care staff and older people. The insights of each team member help build a better picture to guide person-centred decisions.

Tom’s Story

We invite you to listen to Tom relate his experience of shared decision making

When people are provided with clear information and support to understand and manage their condition, this increases their confidence and sense of control, raising expectations in a positive way resulting in a stronger sense of ownership, a feeling of partnership with healthcare providers, and a greater desire to be actively involved in their care.

In Summary. People in hospital should know they have a choice and a role in decisions related to their care both in hospital and in the community (22)Noordman J, Oosterveld-Vlug M, Rademakers J. Shared Decision Making in Clinical Practice. European Journal of Health Communication. 2022;3(1):31–52.. Exploring, recording and enabling the inclusion of older adults’ views and preferences should begin as soon after admission as their health condition allows (8)Pel-Littel RE, Snaterse M, Teppich NM, Buurman BM, Van Etten-Jamaludin FS, Van Weert JCM, et al. Barriers and facilitators for shared decision making in older patients with multiple chronic conditions: a systematic review. BMC Geriatrics. 2021;21(1).. The most important starting point to inform any decision is that the person understands their diagnosis (22)Noordman J, Oosterveld-Vlug M, Rademakers J. Shared Decision Making in Clinical Practice. European Journal of Health Communication. 2022;3(1):31–52.. These early conversations should be revisited throughout the hospital stay (17)Tobiano G, Manias E, Thalib L, Dornan G, Teasdale T, Wellwood J, et al. Older patient participation in discharge medication communication: an observational study. BMJ open. 2023;13(3):e064750..

When participation is framed as a normal and expected part of care, older people feel more empowered and legitimate in their involvement, which enhances their preparedness by encouraging consideration of the practical aspects of returning home.

Reflection

  • Person in hospital: What is stopping me from expressing my worries and concerns?
  • Supporter or Carer: What helps me to feel part of the caring team?
  • Staff: Do we take the time to listen to worries, hopes for future concerns for the person admitted to hospital, have we created space to share this information?
  • What communication skills are important in this first encounter?
  • How do we fact check what we are seeing, while recognising our values, beliefs and potential prejudices?