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Christine Clark BSc, MSc, PhD,
A recent article in the Journal of Participative Medicine (Millenson M, 2011) describes the slow but steady rise of patient power in healthcare. This has important implications for all healthcare workers, including pharmacists.
The original Code of Ethics of the American Medical Association contained the statement, “the obedience of a patient to the prescriptions of his physician should
be prompt and implicit. [The patient] should never permit his own crude opinions as to their fitness to influence his attention to them.”
We have come a long way since those days. We have moved from profoundly paternalistic systems, in which ‘the doctor knows best’, to systems that are increasingly able to accommodate patients’ views and preferences on the types of treatment that they would like.
In the UK, there is a growing movement to understand better what patients want from healthcare and much talk of ‘shared decision-making’. The phrase, ‘no decision about me without me’ captures the spirit of shared decision making. This phrase was prominent in the coalition government’s vision for the health service, articulated in the white paper, ‘Equity and Excellence: Liberating the NHS’, published in July 2010. It is probably fair to say that some of this has been driven by the large amounts of healthcare information on the Internet. The words are good and the thinking behind them is honourable, but the practicalities of implementation are myriad.
There is no generally-accepted definition of shared decision-making – indeed it means different things in different circumstances and for different patients. It is patient-driven but needs to be adjusted to each situation individually – the objective is not to push the entire burden of decision-making on to patients but to enable them to share in the process in an informed way. The goal of shared decision-making is to make decisions in a manner consistent with the patient’s wishes. This could include decisions about whether or not to have an operation and which drug treatment to choose when there are several options.
These are big decisions; people need time to think about them and information to guide them. There is already evidence from some specialities that shared decision-making is successful. In the USA, shared decision-making within care planning has been shown to improve the experience of care, quality of outcomes and costs. In the UK, the use of a shared decision-making aid by patients who were technically suitable for knee replacement surgery resulted in fewer patients opting for surgery. Significantly, those who did undergo surgery got better outcomes and both groups had high levels of satisfaction.
How can these positive results be extended across the full spectrum of care? Three things will help to move this forward: the wider development and use of shared decision-making aids, the implementation of patient-reported outcome measures and the adoption of healthcare standards that explicitly include the patient perspective. Indeed, in the UK in June 2011 a guide to the use of PROMs in hip and knee replacements, groin hernia and varicose vein surgery was published. Hospital pharmacists need to be engaged with all these developments – both at policy level and in the care of individual patients – to ensure that they continue to play their part in ensuring that medicines are used effectively.