Shared Decisions in Healthcare

In this interactive from the School of Health, Wellbeing and Social Careat The Open University, you'll explore the myriad factors that influencedecision making in healthcare, and see how patients and their families are brought in to achieve a shared decision.

Click on the green icon to see your first patient...

Welcome to your waiting room.

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Nicotine is as addictive as heroin! Nicotine Replacement Therapy makes quitting much more likely.

This patient will need to make supported lifestyle changes before treatment can go ahead...

The complex relationship between social factors, lifestyle choices and mental health contribute to health inequality and impact upon patients' options and outcomes...

Did You Know:

This patient has smoked tobacco for many years and is being treated for clinical depression. She is obese and has a Body Mass Index of 41.

Mental Health and Lifestyle Factors

For each individual, a surgeon will make a decision about whether a total knee replacement is appropriate based on several factors, such as the level of pain or disability and anaesthetic risk. In the case of Mrs Jones, the surgeon agrees that her symptoms are sufficiently serious to warrant surgery but wants to give Mrs Jones an opportunity to quit or cut down tobacco smoking and reduce her weight first. Obesity can make surgery more complicated and the recovery after surgery can be slower. Quitting smoking before surgery reduces the patient's risk of a range of complications

Click on the green icon to learn where they might be...

Hmm, it looks like your next patient isn't here.

For example NHS England have identified that some groups of people need specific support to help them to get to Out Patient appointments.

Some people, often those with the poorest health, face challenges that make it difficult for them to attend medical appointments.

• People with poorer Health literacy and Digital literacy
• People with financial difficulties
• People who require carers to be brought to their appointment
• Children and young people
• People with mental health conditions
• People who are neurodiverse
• People who are vulnerable because of their experiences
• People with a disability

Did You Know:

In our hospital, Mr Faulkes ‘did not attend’ his Outpatient appointment because he could not get the time off work. He tried to cancel it but could not get through by phone. The clinic has yet to introduce a text message appointment system that sends reminders and enables patients to cancel appointments.

Patients that persistently miss appointments may be removed from waiting lists.

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We all miss things occasionally, but there is often more to it that simply being forgetful...

DNAs are reported to cost the NHS £1 billion per year. 1 out of 20 appointments are 'DNAs'

DNA - Did Not Attend

There's a family with a child in the waiting room. Click on the green icon to see them next...

Did You Know:

It is important at this stage that Aisha, even though she is young, is involved in the discussions with her parents. The consultant will explain the treatment options available, making it clear that, whatever the agreed pathway, it will be a shared decision and that none of the options are risk free.

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This family needs time to discuss how they all feel about their options, and the potential consequences. Click below to go back to the waiting room ...

There will be a lot of verbal and written information given to Aisha and her family to help them with their decision making.

The NHS facilitated nearly 4,600 transplants in 2022/23

Research has shown that a kidney from a living donor lasts longer, and a kidney from either parent, if they are a match, is preferred to using an anonymous altruistic donor.

Difficult Choices

The options are;1: Do nothing until Aisha needs dialysis 2: Start planning for the transplant surgery using Aisha’s father's kidney. 3: Put Aisha on the transplant list to receive a kidney from an altruistic or deceased donor.

Your last patient is still waiting. Click on the green icon to see the man's history...

Cardiac CT (computed tomography) scan

Blood tests

Cardiac MRI (magnetic resonance imaging)

Next

'Stress' test (exercise tolerance test or ETT)

Mr Sharma will need to have some tests. The results will help the doctors decide on the best treatment options to recommend. Click on the blue icons below to learn more about each test:

Electrocardiogram (ECG)

Chest X-Ray

Assessments and Investigations

Echocardiogram (Echo)

Radiologist

Cardiac Nurse Specialist

Interventional cardiologist

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Mr Sharma could be a suitable candidate for planned coronary angioplasty with stenting; click next to find out his options...

Next

This meeting brings different healthcare professionals together to look at results, share ideas about treatments and make recommendations to help the patient decide on the treatment that is right for them. Mr Sharma was asked if he wanted to be present when they discussed his test results but declined.

Who attends Mr Sharma's Meeting?

Click on the portraits below to learn more about the staff who are involved in clinical decisions at an MDT meeting:

Multi-Disciplinary Team meeting (MDT)

Intervention

Maintenance

Option 2

The cardiologist asks Mr Sharma what his thoughtsare about the different treatments and actively listens to Mr Sharma’s views to understand what matters to him.

Option 1

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Meeting with Patient in Clinic

Understanding this information will help Mr Sharma to make a decision that is right for him. By having this two-way discussion, Mr Sharma’s preferences and priorities can be understood. Mr Sharma has his son with him so he can be involved too. His cardiologist gives him some information leaflets to help the family in their discussions.

For each option, the cardiologist explains the risks and benefits to the patient, and what might happen in each scenario...

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Back to Start

Summary: Sharing the Whole Journey

Shared decision-making puts patients at the centre of their care, something all healthcare organisations aim for. Every day, health professionals make clinical decisions and assess who should be prioritised for treatment, using their experience and knowledge, clinical assessments, and diagnostic test results to recommend treatments. When there is more than one ‘planned’ treatment option, health professionals help the patient to understand the choices to be made, compare their options, and make decisions. When shared decision-making works well, two types of expertise join up; the clinical expertise of the health professional, and the patient as an expert in their own health. Both are ‘experts’, but in different ways.

Learn about the research taking place in the Faculty of Wellbeing, Education and Language Studies Learn about how we aim to improve shared decision-making for people with heart conditions

Continue Learning...

Having Treatment

Once a shared decision has been reached between Mr Sharma and his medical team, his treatment can go ahead. Mr Sharma will have been given advice about what to expect during his recovery, and will attend follow-up appointments to check his progress.

Cardiac Nurse Specialists can work in a hospital or in a community setting. They provide support, advice and information to people about how best to self-manage their heart health.

Cardiac Nurse Specialists

After being placed on the transplant list, the wait for a kidney from an altruistic donor or deceased person can be 2-3 years, on average.

Intervention

called a ‘lifestyle’ treatment because it does not ‘fix’ the problem but usually relieves angina symptoms.

Consider coronary angiogram (with or without a coronary stent) as well as heart medications and healthy lifestyle. Coronary stenting is

A Cardiac MRI provides information on the structure and function of the heart, as well as the type and severity of heart disease.

Cardiac MRI (magnetic resonance imaging)

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58 years old, South Asian Male, Non-smoker, Healthy BMI

Mr Sharma may be a suitable candidate for aminimally invasive procedure; move on to find out about Mr Sharma's options...

RELEVANT HISTORY: For the last 3 years, Mr Sharma hasexperienced a dull ache in his chest (angina) when walking uphill. Tests show narrowing in the blood vessels supplying his heart muscle. His cardiologist prescribed medicine and recommended healthy lifestyle changes.

CURRENT SYMPTOMS: Mr Sharma feels the dull ache in his chest more often and for longer. Sometimes the ache spreads down his left arm.

GP NOTES: Because the symptoms are worsening, Mr Sharmawas referred to his cardiologist, who ordered more tests.

Mr Sharma

Aisha and her parents have undergone a variety of tests, which have shown that Aisha’s father is a good match to donate a kidney, and that Aisha is suitable to undergo a kidney transplant.

Aisha and her parents have attendedmany hospital appointments over the last 6 months, following the decision by Aisha’s parents to offer one of their kidneys for donation.

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HISTORY:

GP NOTES:

8 years old, Female, severe irreversible kidney damage, will soon require dialysis and/or a kidney transplant.

Aisha (Paediatric)

A chest X-ray looks at the lungs, heart, major blood vessels, and other structures in the chest.

Chest X-Ray

Clinical radiologists are specialist doctors trained to read and interpret medical images, using a wide range of imaging techniques including X-ray, ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET) and molecular imaging. Radiologists also run patient clinics, take biopsy samples and prepare patients for surgery.

Radiologist

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After

Before

Click to view before and after

A coronary angioplasty is done under local anaesthetic. A thin tube, or catheter, is inserted through an artery in either the groin, or wrist, and guided up to the heart vessels (coronary arteries) using X ray video. A contrast dye, injected through the catheter, will show up the heart vessels. A tiny balloon at the tip of the catheter can be inflated to widen any narrowings in the coronary artery. Usually a stent, which acts as a scaffolding to hold the vessel open, will be used.

A stress test looks at how well the heart works during physical exertion. The stress may be physical exercise, such as walking on a treadmill, or it may be caused by a medicine that can be given to get the same effect.

Stress Test (exercise tolerance test or ETT)

See this patient

REASON FOR VISIT: to see a surgeon to talk about a total knee replacement (arthroplasty).

CURRENT SYMPTOMS: Lately the painand stiffness has worsened. She is finding it hard to sleep and cannot walk far to get shopping or visit her family. Because she lives alone, she is starting to feel very isolated and lonely.

GP NOTES: Patient has been living with a painful swollen knee for over 2 years.

65 years old, Female, Smoker,Obese, Clinical Depression

Mrs Jones

An Interventional Cardiologist uses catheters to treat heart disease. Catheters are very small tubes through which minimally invasive procedures on the heart or blood vessels are carried out. This means there is no need to make a large incision.

Interventional Cardiologist

Blood tests check for certain diseases and conditions. A full blood count (FBC) checks the bloods haemoglobin and platelet levels. Blood chemistry tests check how well the liver and kidneys are working. Other tests may check the blood’s ability to clot.

Blood Tests

An electrocardiogram (ECG) can spot an abnormal heart beat and show when the blood supply to the heart muscle is blocked.

Electrocardiogram (ECG)

When a person donates a kidney, there are several practical issues that need to be considered. The donor will need to take time off work for the tests, surgery and recovery. Aisha's father and family must understand that there is the possibility that the kidney may not function once transplanted.

An echocardiogram is a type of ultrasound scan, that looks at the structure of the heart and surrounding blood vessels, and analyses how blood flows through the heart.

Echocardiogram (Echo)

A cardiac CT scan looks for narrowing of the heart’s blood vessels and problems with the heart, larger blood vessels and heart valves.

Cardiac CT (computed tomography) scan

Dialysis treatmentdominates and restricts every aspect of a person’s life, but it is necessary to keep a person alive.

Stopping smoking at least 8 weeks before surgery reduces your risk of a range of complications. If you smoke, you have a 1 in 3 risk of postoperative breathing problems. This can be reduced to 1 in 10 if you stop 8 weeks before your operation.

Continue with heart medications and healthy lifestyle changes, as before.

Maintenance