Strategies For Making Patient Priorities Aligned Decisions
Strategy: Align decision-making among clinicians when there are different perspectives or recommendations.
Conflicting recommendations usually occur when clinicians use different information in decision-making.
Discuss health interventions (medications, diagnostics, treatments, surgeries, specialty care) around each patient’s health priorities, rather than disease-based tradeoffs
“The patient’s preferences and priorities do not support (medication, intervention). I think we should consider not doing, deprescribing, etc.”
“Given this patient’s problems, health trajectory, uncertain applicability of disease guidelines, and her (his) health priorities which are (fill in), please consider the following suggestions for (change in medication, appropriateness of test, appropriateness of procedure)”
See also Discuss health interventions under the first strategy Click Here
Primary Care Clinician to Cardiologist communication
“Mrs. X, one of our shared patient’s main concerns is her fatigue which is keeping her from doing activities that matter to her. While there are several possible explanations, as a first step, I think we should stop her Metoprolol. Its main benefit is survival which is not her main priority. What are your thoughts?”
One clinician may feel disease-specific guidelines (e.g. for hypertension, glucose control, statin therapy in older adults, heart failure management) don’t apply; another clinician may feel benefits of following guidelines outweigh harms.
Consider if you and other clinician are focusing on different outcomes, not on achieving patient’s health outcome goals. If so, agree that patient’ goals should drive everyone’s decisions.
Consider if the other clinician is concerned about other issues that resulted in conflicting recommendation.
The Cardiologist does not agree that the metoprolol is causing a patient’s fatigue; she thinks it’s the patient’s heart failure and the metoprolol is a key part of guideline-based treatment.
Clinicians may differ on whether statin therapy for primary (or secondary) prevention is aligned with a patient’s stated health priorities.
The primary clinician stopped Metoprolol because the patient felt it caused fatigue that interfered with their desired activities, including volunteering and caring for her grandchildren. The cardiologist thinks the metoprolol is necessary given her heart failure. Brainstormed an alternative:
Cardiologist: “I’m concerned about stopping the metoprolol. It took me several months to titrate up to that dose. Her heart failure is severe and beta blockers are one of the best ways to prevent progression.”
Primary clinician: “Well, I wouldn’t say I was completely comfortable with it, but she was confident that she felt better without the medication.”
Cardiologist: “Did you explain that this decision may shorten her life?”
Primary Clinician: “I did. She said she’d just rather feel better today.”
Cardiologist: “It sounds like she was pretty clear about her goals. I wonder if she would agree to restart a low dose. If she continues to feel poorly on it, we can stop it altogether.”
Primary Clinician: “That sounds like a good compromise.”
The clinicians may differ on whether statin therapy is likely to help the patient achieve her goals of volunteering, and caring for her grandchildren.
Clinician 1 notes that patient’s muscle soreness is making it harder for her to do her desired activities; the patient thinks it is the statin and Clinician 1 agrees.
Clinician 2 is worried patient may have a heart attack if she does not remain on the statin therapy and that could keep her from doing her activities too.
The clinicians agree that desired outcome is patient being able to do her desired activities for as long as possible. After acknowledging the legitimacy of each clinician’s concerns, they agree that the best possible benefit of the statin is only a modest absolute reduction in yearly risk of a stroke or MI and her other conditions are as likely to contribute to any future loss of function or to death. Therefore, given the potential adverse current effect that precludes her doing her desired activities, a several months trial off the statin is warranted to see if she is able to do more. (other possibility would be to try a lower dose or different statin)