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Modern vascular surgeons offer state of the art care as they use the latest endovascular and surgical techniques, apply current evidence based guidelines, discuss complex cases in multidisciplinary meetings to decide on the best possible treatment, and finally share their advice with their patients to arrive at an informed consent.
As surgical treatments always carry a risk of complications, clinical decision making can be quite intricate. Elective interventions may cause immediate harm (i.e. peri-operative and post-operative complications), while the desired effects (e.g. prevention of stroke or death by aneurysm rupture) take years to show. Particularly in patients who are elderly or have comorbidities, surgery may be less appealing.
Clinical decision making may be challenging when available guidelines are not applicable to a particular patient and his or her condition, or when several treatment options are available for a vascular condition, each with their own benefits and risks. There are many examples in vascular surgery such as EVAR, open repair, or watchful waiting for an abdominal aortic aneurysm; angioplasty or supervised exercise training for intermittent claudication; bypass surgery, angioplasty, or conservative treatment for critical limb ischaemia; or endarterectomy or stenting for symptomatic carotid artery stenosis.
Weighing different treatment options requires good risk communication by vascular surgeons, but this is not enough. The quality of vascular surgical care can be further improved by including the situation and preferences of the patient when making treatment decisions. Most physicians may be accustomed to advising patients to undergo a certain treatment based on their medical expertise and available evidence as to its effectiveness. This advice, however, may well be flawed until we also recognise the patient's autonomy and explicitly involve the patient's expectations regarding their goals in life and preferences for a certain treatment – even if these turn out not to be our first choice.
Shared decision making
Shared decision making (SDM) encompasses the bidirectional communication between physicians and patients to involve the patient's preference in the eventual treatment choice.
It is an ethical and legal requirement to inform a patient in detail about the expected desired and possible undesired outcomes of any possible intervention before asking for informed consent. It is equally essential to involve the patient's preference when deciding about the treatment option to make sure that the surgeon's advice matches the patient's preference.
This is not always the case, as we know that surgical patients tend to prefer the least invasive, risk averse option when informed about several (surgical) treatment options.
Not only the disease, but also the patient's preference should be diagnosed correctly. If not, this so called ‘preference misdiagnosis’ may lead to an undesired treatment decision the patient will adhere to poorly, while being at risk of the possible harmful effects.
This may be avoided when the surgeon explicitly clarifies and incorporates the patient's preference. This will improve patient satisfaction and compliance with the treatment they have agreed to. Moreover, SDM may prevent overdiagnosis and overtreatment and thereby reduce costs.
Particularly in multidisciplinary meetings, complex decisions are typically made without the patient's view being articulated. As a consequence, surgeons often remain unaware of patient's beliefs and concerns about the disease or treatment plan. A commonly perceived barrier is the idea that SDM is time consuming. However, future time savings may offset this initial investment as patients are likely to require fewer or shorter follow up consultations if actively involved in decision making.
Second, vascular surgeons may consider many patients unfit for SDM, for example because of their condition or age. Even then, the patient's preferences can be appreciated via their proxies. It is therefore wise to invite the patient's partner or relative when a treatment decision is to be made.
Finally, vascular surgeons may feel compelled to follow guidelines. Although these provide valuable evidence based recommendations, they do not give a clue about the patient's situation, goals, and preferences. These may be a reason to justifiably deviate from a guideline. Patient involvement in guideline development can help bridge the gap between recommendations and actual patient care.
Obviously, not all patients will want to decide themselves, but they should at least be invited to express their ideas or concerns about different treatment options. Vascular surgeons will need to change some of their habits to encourage SDM. As it is easier said than done to change one's behaviour, several supportive initiatives have been started to promote SDM. First, communication skills training has been developed for medical students and clinicians to practice SDM with actors or patients. Second, a large number of decision aids have become available. These are online decision making support tools, providing information about the disease, treatment options, and their pros and cons.
Patients who use decision aids are better prepared for the consultation and can focus on the issues most relevant to them. Other interesting aids are option grids or decision cards showing questions patients frequently ask about the treatment options and offering answers for each available treatment option.
Surgeons may use these to elicit the patient's preferences when deciding about treatment options.
In an era of rapid medical developments, surgeons should keep abreast of these developments, but should also be inspired by the current incentives to incorporate the patient's preferences in the decision making process to ensure vascular surgical care that is high quality and appreciated by their patients.
De Haes J.C.
Shared decision making: concepts, evidence, and practice.
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