This month’s Editor’s Choice from Palliative Medicine . . .
Inge Henselmans, Department of Medical Psychology, Academic Medical Center, Amsterdam, the Netherlands, explains the background to her longer article selected as ‘Editor’s Choice’ in the July 2017 issue of Palliative Medicine.
Chemotherapy for advanced cancer offers uncertain and sometimes little benefit while the burden can be high. Hence, treatment decisions should incorporate patients’ preferences. I firmly believe none of the medical oncologists in our hospital would disagree. Putting shared decision-making into practice, however, is easier said than done.
Hence, we wanted to learn how oncologists went about it in consultations about palliative chemotherapy. Our hypothesis was that, although skilled and confident in providing information about diagnosis and treatment, they would be more hesitant when it came to talking about patients’ values and preferences. This key step of shared decision-making requires a more receptive and exploring attitude, which is likely to be demanding for medical specialists in busy outpatient clinics. Thirteen oncologists were willing to let us audio-record 60 consultations with 41 patients about the start or continuation of palliative chemotherapy.
Our hypothesis was confirmed. In many consultations, patients did make statements related to their values and preferences. Nevertheless, these mostly brief and one-time windows of opportunity were often initiated by patients and rarely led to further conversation. We noticed that both patients and oncologists tended to jump to treatment preferences, skipping the underlying values, i.e., what mattered most, and how that related to patients’ appraisal of pros and cons of treatment. To ensure that patients’ preferences are informed and well considered, and to prevent that so-called ‘naïve’ preferences 1 guide decision-making, it is essential to address values, appraisals and preferences. We were aware, however, that this conversation between oncologists and patients with incurable disease and a limited life expectancy would be far from easy.
Thus, to support shared decision-making about palliative chemotherapy, we currently evaluate the effect of skills training for oncologists and a preparatory aid for patients in a randomised design. The patient aid consists of, among others, value clarification methods to help patients reflect on what matters most prior to the consultation. The oncologist training incorporates all steps of shared decision-making,2 including the exploration of patients’ values and preferences. We focused on those communication skills that were shown to enhance further exploration in the observational study, e.g. asking open and probe questions and reflecting on the patient’s story.
We tended to adopt an apologetic tone when informing those oncologists allocated to the 10 hours of training. However, many were happy to undergo training, and some were disappointed when allocated to the control condition. Reflection and feedback on communication skills in a group of peers is rare for practising medical specialists, yet is apparently well appreciated. The findings of this trial will tell us whether skills training and patient preparation allow oncologists to really put shared decision-making into practice in consultations about palliative systemic treatment.
- Elwyn G, Frosch D, Thomson R, et al. Shared Decision Making: A Model for Clinical Practice. J Gen Intern Med. 2012; 27: 1361-7.
- Stiggelbout AM, Pieterse AH and De Haes JC. Shared decision making: Concepts, evidence, and practice. Patient Educ Couns. 2015; 98: 1172-9.
Read the full article in Palliative Medicine
This post relates to a longer article, ‘Shared decision making about palliative chemotherapy: a qualitative observation of talk about patients’ preferences’ by Inge Henselmans, Hanneke WM Van Laar Hoven, Jane Van der Vloodt, Hanneke CJM De Haes and Ellen MA Smets, published in Palliative Medicine, Vol 31 (7), 625-633. First published online: 26 October 2016. DOI: 10.1177/0269216316676010.
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Read earlier Editor’s Choice posts on the EAPC Blog.