Serial trials

Strategies For Making Patient Priorities Aligned Decisions

Strategy: Use serial trials to determine optimal interventions (based on patient’s priorities).

Serial trials (trying different interventions over time) helps decision making when there is no one right answer and reassures patients there are many things we can do.

Scripts

“When people have several health problems, we can’t always be sure what will work best. We will work together over time to help you achieve (health outcome goal) or improve (bothersome care) as best as we are able. You can let me know if things we are going to do help you achieve (health outcome goal) or improves (bothersome care). If you find that you are not achieving (health outcome goal), we will try something else.”

“There are often several possibilities. We can’t be sure what is causing your (symptom). A good place to start is (proposed change). We’ll see if it helps you achieve (desired activity).”

Script

Starting with The One Thing simplifies decision-making and improves adherence.

“I see that what you want us to focus on is (The One Thing) so you can (health outcome goal). You think (bothersome symptom, burdensome care) may be contributing to your problem. Is that right?” “Let’s review everything,  (bothersome symptom, burdensome care) so that we can find ways to help you do more of what matters most to you”

Scenario

“You have said your tiredness is preventing you from volunteering.  When people have several health problems, as you do, we can’t always be sure what will work best, but there are several possible places to start. Though we can’t be completely sure what is causing your tiredness, given your preference to take less medication, a good place to start is stopping or reducing the dose of your metoprolol. We’ll see if it helps get back to volunteering more, and if need be we can talk about other options, including stopping some of your other medications if this doesn’t help.” 

“It looks like you have identified that the one thing that matters most to you is being less tired so you can spend more time caring for your grandchildren and you think some of your medications may be making you tired. Is that correct? Let’s review everything including your medications so that we can find ways to help you feel less tired so you can spend more time with your grandchildren”.  

Script

“I think we can help you do/achieve (The One Thing, health outcome goal) by (proposed intervention). I hope that by (proposed intervention) we can reduce (bothersome symptom or burdensome care) to allow you to do/achieve (health outcome goal).”

“What health problem or parts of your healthcare do you think is making it more difficult to (fill in health outcome goal)?”

Scenario

The One Thing:
To be less tired so I can help with my grandchildren and I think some of my medications are making me tired.

“Clinician: I am concerned that you are tired during the day because of your sleep apnea. I know in the past you have not wanted to wear the mask at night, but I think we can work together to try other masks that you might be able to keep on. I hope that treating your sleep apnea will make you less sleepy so that you will be able to care for your grandchildren.”

Script

“There are several options to improve (bothersome symptom) or reduce (burdensome care) to allow you to do/achieve (health outcome goal). We can start with (option 1) or (option 2). What are your thoughts?”

Scenario

The One Thing:
To be less tired so I can help with my grandchildren and I think some of my medications are making me tired.

Script

“You have said your tiredness is preventing you from volunteering.  There are several things we can do for your tiredness.

I am concerned that you are tired because of sleep apnea. You said taking so many medications is most burdensome and are concerned that you are having side effects of them.

We have multiple options of where to start. If you are willing, we can try some different sleep apnea masks. Or, we can also discuss changes to your medications. Metoprolol can sometimes cause tiredness so we could start with decreasing the dose (or stopping it). This medication is prescribed for your heart failure, however, so we will need to talk more about what may happen if we make changes to this medication. We will continue to follow your tiredness closely to see if you are able to volunteer more.

Which option would you like to try first?”

Script

“There are several options to improve (bothersome symptom) or reduce (burdensome care) to allow you to do/achieve (health outcome goal). We can start with (option 1) or (option 2). What are your thoughts?”

Scenario

If trial didn’t help achieve patient’s health outcome goal:
“It looks like the change we made last time did not help (health outcome goal). We can try some other things that will help you do what matters most to you. Today, I would like to try (proposed intervention). At our next visit, we will see how you feel you are able to meet your health outcome goal and make changes if we need to.”

If trial helped achieve patient’s health outcome goal:
“It seems like we have made some progress towards (health outcome goal) but we still have some work to do. I am hoping to make some more changes to your treatment plan today, which I think will help you get even closer to/do more of (health outcome goal). Today, I would like to try (proposed change), and at our next visit, we can review how much you were able to achieve (health outcome goal). If we are still not meeting your health outcome goals, we will look at other options.”

Scripts

“I do not think (medication, intervention) will help you do/achieve (health outcome goal). Let’s stop it, and you can let me know if you start to have symptoms that get in the way of (health outcome goal).”

“I would not recommend (intervention, medication) because the risks of the (intervention, medication) outweigh any potential benefits and won’t help you achieve (health outcome goal). What do you think?”

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Case Example

“I see you’ve been on the omeprazole for over a year and you haven’t had any symptoms of your reflux that are preventing you from being with your grandkids. You feel you’re taking too many medications so I think we should stop it. You can let me know if you have symptoms that come back.”

Script

“The recommendation for this (medication, treatment intervention) is (recommended length). As you will no longer get a benefit from this (medication, intervention) to allow you to do/achieve (health outcome goal), I think we should stop it.

Scenario

“ I see you’ve been on Alendronate for 8 years. You have already received the maximum amount of benefit, so I think we should stop it. This will help meet your preference to take less medications.”

Script

“I think that if we do (proposed intervention, procedure, medication, community resources), we can help you do what matters most to you, including (health outcome goal).”

Scenario

Fatigue with positive depression assessment
“I think that if we trial a course of medication for depression we can help you feel less tired and you’ll be able to spend more of your time doing what matters to you like spending time with your grandchildren, and volunteering.”