Shared decision-making urged for clinicians, patients with advanced HF

Patients with advanced HF should have ongoing conversations with their health care providers to make informed decisions about treatment options that match their personal values, goals and preferences, according to recommendations from a scientific statement issued by the American Heart Association.

Shared decision-making extends beyond informed consent, requiring that health care providers and patients consider information together and work toward consensus. This process should focus on outcomes that are most important to patients with advanced HF, such as survival, symptoms burden, quality of life, living at home and caregiver expectations. Decision-making for advanced HF is becoming increasingly important but also increasingly challenging because patients are living longer with their heart disease and treatment options continue to expand, the authors wrote.

“For patients with advanced HF, the decision-making process should be proactive, anticipatory and patient-centered. This involves talking about goals of care, expectations for the future and the full-range treatment options, including palliative care,” Larry A. Allen, MD, MHS, assistant professor of medicine at the University of Colorado Anschutz Medical Center, said in a press release.

Larry A. Allen

Recommendations to improve shared decision-making

Health care professionals may have trouble finding time to discuss preferences, prognoses and medical options with patients. The authors recommend an annual review, a concept based on annual wellness visits, to open dialogue between clinicians, patients and families. The annual review can be used to discuss prognosis, reasonable therapies and the patient’s values, goals and preferences. This review should be held in addition to, not as a replacement for, additional discussions triggered by events such as hospitalizations and other changes in the patient’s health, according to the statement.

“The process of checking in with patients on a regular basis is extremely important because HF and general health change over time,” Allen said in the release.

Important “milestones,” such as first implantable cardioverter defibrillator shock, rehospitalization and development of cardiorenal limitation to continuation of ACE inhibitors, should be addressed as they occur and should trigger a focused version of the HF review, which would include reassessment of prognosis, treatment options and patient preferences.

“To communicate effectively, clinicians must both determine and then readdress over time patients’ understanding of their HF and their goals and treatment preferences and then determine how to have these conversations within the scope of clinical care,” the statement said.

To begin the conversation, physicians can use the Ask-Tell-Ask technique. Physicians ask patients and families what they want to know; tell patients in a simple language the answers to their questions; and then ask them to repeat the information to assess their understanding. Clinicians should repeat patients’ desired goals to ensure the goals were heard correctly.

Decision aids, including booklets, pamphlets, videos and Web-based systems, may also be used to complement a clinical encounter by providing information about options and outcomes and by assisting patients in clarifying their personal values.

Other recommendations for improving shared decision-making include:

• Initiating the development of a comprehensive plan for end-of-life care that is consistent with the patient’s values, preferences and goals.
• Assessment and integration of the emotional readiness of the patient and family.
• Changes in organizational and reimbursement structures to promote high-quality decision-making and delivery of patient-centered health care.

A call to action

“Our statement is a ‘call to action,’ not only to clinicians within our community directly responsible for facilitating shared decision-making but also to those on a national level who would reform and restructure the health care medical system to truly support patient-centered care,” the authors wrote.

For more information:

• Allen LA. Circulation. 2012;doi:10.1161/CIR.0b013e31824f2173.

Disclosure: The writing group and reviewers report several relevant financial disclosures. See the statement for a full list.

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