Physicians sometimes ask patients to make decisions where the answer will depend on the patient’s unique perspective and circumstances. For instance, you may offer a lung cancer screening test to two patients who are both heavy smokers. One may welcome the test as a chance for early intervention, while the other may see the risk of false positives as potentially doing more harm than good.
Patient decision aids (PDAs) can help your patients make decisions in situations where the potential benefits are not clear-cut and where the outcome will be determined largely by patient preferences and values. While general health literacy materials help people understand a particular illness, diagnosis, or treatment, PDAs are verified, evidence-based resources focused on specific decision points.
The tools are aimed at situations where patients need assistance in thinking through benefits, harms, probabilities, and how well a treatment or screening might accord with their values. The tools should always complement, rather than replace, an informed consent discussion.
PDAs encourage shared decision-making
Patient decision aids can be an effective way of encouraging patients to participate in their own care.1 The process of shared decision-making treats the patient as an expert in their own life and circumstances, and makes them active participants in major care and treatment decisions. Shared decision-making features an exchange of information between physician and patient, rather than a one-way stream of information from physician to patient.
PDAs can be effective in facilitating this two-way flow of information and helping the patient make difficult decisions. PDAs increase patients’ knowledge of their health conditions, improve the accuracy of their risk perceptions, and create a better fit between their values and the care decisions they are making. While PDAs may slightly increase appointment times, they can decrease the number of patients unable to make a decision and improve physician-patient communication overall.
Case example: Using a PDA to respond to a patient’s request for bone density testing and medication
During an appointment, a 65-year-old female patient tells you that her aunt had an osteoporotic spine fracture. Your patient does not have a history of fracture after age 40, or other clinical risks for fracture, but shares that she is worried about falling and having a hip fracture. She asks if she should have a bone mineral density (BMD) test and start preventive medication.
You inform her that screening may help reduce the risk of fragility fractures in females over age 65 years. Using a patient decision aid to assess her 10-year risk of having a fragility fracture, you have an informed consent discussion about the potential risks of treatment and minimal benefit of initiating treatment at her current age and lack of clinical risk factors.
After your discussion, the patient decides not to have the BMD test at this time and not to start preventive medication. You agree to reassess her fracture risk and need for a BMD test at age 70 years, and give her a copy of the PDA. You document your discussion and reference the PDA, and any questions that the patient had.
Patient decision aid databases
There are well-recognized and sophisticated databases for PDAs online. The inventory of decision aids created by the Ottawa Hospital Research Institute is searchable by health topic and rates each aid according to a number of quality criteria. The Mayo Clinic Shared Decision Making National Resource Center provides aids related to a number of specific health conditions, such as osteoporosis and rheumatoid arthritis. Note that, if using an aid from an American or international source, you should ensure the aid is relevant within the Canadian context.
Using PDAs to promote safe care
When using PDAs, consider the following to promote safe care and reduce medico-legal risk.
1. Provide the PDA to your patient as part of a continued discussion
Generally speaking, it’s best to provide your patient with a PDA as part of a discussion about a proposed treatment or screening. This gives them time to review and reflect on the material. When you provide the PDA, tell your patient that, at the next appointment, they will have a chance to ask questions and fully discuss the decision in question.
Because PDAs are often provided to patients in advance of an informed consent discussion, consider in individual cases whether it is appropriate to use them with patients who are unlikely to follow-up for further discussion. In such cases, medico-legal difficulties may arise if a patient later claims they did not proceed with a treatment or screening because they did not understand the information set out in the PDA, and because there had been no informed consent discussion. In every case, document the information given to the patient, including the encouragement to return with questions and discuss care options further.
2. Use PDAs only in appropriate circumstances
Before using a PDA, consider whether the patient will understand the information as presented in the particular PDA. For example, aids may not be appropriate where there is a language barrier, cognitive impairment, or any other issue affecting a patient’s ability to understand personal health information.
3. Follow up with your patient
After using a PDA, assess how comfortable patients are with their decision, including how well they understand the information, how clear they are about risks and benefits, and whether they have any unanswered questions.
After patients have made their decision, be sure to review the decision at a later date. This is especially critical if the patient’s risk factors change, or if there have been changes to other factors that have influenced the patient’s decision. A patient’s decision about a screening or treatment is rarely final, but can change as their circumstances change.
4. Document your use of the PDA and archive the aid where necessary
Document in the patient chart any PDAs provided to the patient, the patient’s decision, and the fact that the patient was given an opportunity to ask questions about the treatment before making a decision.
Since PDAs posted online are frequently updated or removed, consider archiving a copy of the specific aid that you used. This is particularly important because a legal action may not arise for years after the appointment, and you may need to point to specific aspects of the aid in question.
The bottom line
Patient decision aids can be a useful way of helping patients make treatment or screening decisions that are right for them. However, consider whether a specific aid is appropriate and helpful in the context of each patient. PDAs are not a substitute for informed consent discussions and should be used only as an adjunct to discussions tailored to the specific needs and circumstances of each patient. If you have general questions about the use of PDAs, contact the CMPA for advice.
Additional reading
Note
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Stacey D et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews, 2024. DOI: 10.1002/14651858.CD001431.pub6.
