Use of the Ottawa Decision Support Framework

OBJECTIVE To investigate family physicians’ views on factors that make health care decisions diffi cult for patients, interventions family physicians use to support patients making decisions, and interventions proposed by the Ottawa Decision Support Framework (ODSF). DESIGN Thirteen group discussions. SETTING Five family practice units. PARTICIPANTS One hundred twenty family physicians. INTERVENTIONS The multifaceted implementation intervention consisted of feedback from participants, a reminder at point of care, and an interactive workshop. During the workshop, family physicians were asked about their views on 2 videos both showing the concluding phase of a simulated clinical encounter with a woman facing a decision about hormone therapy. One video showed usual care; the other showed use of the ODSF process and related tools. Content was analyzed using observations by non-participants, fi eld notes, material collected from participants during workshops, evaluation forms completed at the end of workshops, and comments written on exit questionnaires from the implementation trial. MAIN OUTCOME MEASURES Family physicians’ views on the types of diffi cult decisions their patients face, the factors that make decisions diffi cult for patients, the interventions family physicians use to support patients’ decisions, and the interventions proposed by the ODSF. RESULTS The 2 most frequently cited factors making decisions diffi cult for patients were experiencing uncertainty and fears about adverse outcomes. Before being introduced to the ODSF, participants had used mostly information-related strategies to provide decision support. After learning about the ODSF, participants overwhelmingly identifi ed assessing patients’ values as a priority. At the end of the workshop, the 5 changes in practice participants most frequently intended to make were, in order of importance, to assess patients’ values, to ask about patients’ preferred role in decision making, to screen for decisional confl ict, to assess support or undue pressure on patients, and to increase patients’ involvement in decision making. CONCLUSION The ODSF process and related tools have the potential to broaden family physicians’ views on supporting patients facing diffi cult decisions. EDITOR’S KEY POINTS • Empirical data indicate that physicians are uncomfortable with actively engaging patients in decision making and that they have not yet adopted shared decision making. • The Ottawa Decision Support Framework was developed to guide interventions aimed at preparing patients and health care providers for shared decision making. • This study investigated family physicians’ views on the types of diffi cult decisions their patients face, the factors that make decisions diffi cult for patients, the interventions family physicians use to support patients’ decisions, and the interventions proposed by the Ottawa framework. • The 5 changes physicians most frequently intended to make in practice were to assess patients’ values, to ask for patients’ preferred role in decision making, to screen for and identify decisional conflict, to assess support or undue pressure from others, and to increase patients’ involvement in decision making. Research Abstracts Print short, Web long This article has been peer reviewed. Full text available in English at www.cfpc.ca/cfp Can Fam Physician 2006;52:476-477. Research Supporting patients facing difficult health care decisions Recent years have seen the emergence of shared decision making, a process whereby decisions are shared by patients and doctors, informed by the best evidence available, and weighted in light of patients’ individual characteristics and values.1 In accordance with a patient-centred approach,2,3 shared decision making aims to enable patients “to take an active role in deciding about and planning their health care.”4,5 A systematic review of shared decision-making programs indicates that, compared with usual care or simple information leaflets, these programs performed better in terms of disseminating more information, encouraging patients to have more realistic expectations, lowering decisional conflict, increasing the proportion of people active in decision making, reducing the proportion of people remaining undecided, and fostering greater agreement between values and choice of therapy.6 The National Population Health Survey carried out in 1996-1997 revealed that 81% of Canadians visited a primary care physician at least once that year.7 In population studies dealing with the question of health decision making, Canadians indicated their desire to participate actively in the decision-making process.8 They indicated also that counseling by a physician continues to be the way they prefer to receive information before they make health decisions.9 When faced with health-related decisions, Canadians expect their physicians to have the necessary skills to ensure adequate decision support or, at least, that their physicians can direct them to trustworthy resources. Empirical data indicate, however, that physicians are uncomfortable with actively engaging patients in decision making10-13 and that they have not yet adopted the concept of shared decision making.9,11-15 It is in this context that new conceptual frameworks for shared decision making have emerged.1,16 The Ottawa Decision Support Framework (ODSF) was devised to guide development of interventions aimed at preparing patients and providers for shared decision making.16,17 The ODSF helps patients and providers make their way through a structured process of shared decision making. One of the ODSF’s important contributions is to identify decisional conflict as one of the key elements in decision making. Decisional conflict can be expressed as a state of uncertainty about which course of action to take when the choice among competing actions involves risk, loss, regret, or a challenge to personal life values.18 Identification of decisional conflict is one of the key skills taught to health care providers learning about shared decision making.1,19 Conflict can be assessed using the Decisional Conflict Scale (DCS).20 This paper reports on data collected during a large trial of implementing the ODSF in primary care. We investigated family physicians’ views on the types of difficult decisions their patients face, the factors that make decisions difficult for patients, the interventions physicians use to support patients making difficult decisions, and the interventions proposed by the ODSF.