Off Script: Sharing, Caring, and Daring to Dream
A flash debate and clinical equipoise spark some contemplation of the challenges of shared decision-making.
SAN DIEGO, CA—I was at a “flash debate” this morning in the Main Arena at TCT 2018 when a complex multivessel case was presented, prompting a lively discussion about the appropriate care of the patient: PCI or CABG?
It is a testament to our hard-won progress in interventional cardiology that we can claim to have reached clinical equipoise for the patient with diabetes and multivessel disease. Multiple tools were employed in the decision-making process, including anatomical-, functional-, and patient-centered risk scores for PCI versus CABG, but it was clear that despite the sophistication of all our efforts thus far, there were characteristics of the case that were beyond the reach of our modeling.
Herein lies the central challenge for us as practicing clinicians. In an effort to seek certainty, or at the very least the reassurance of “doing the right thing,” we traditionally relied on our intuition, labeling medicine an “art,” the basis of which we have issued decrees from the mountain. We consult our colleagues, hoping a trial by jury of peers will increase clarity. We turn to our colleagues who have alternative skill sets and tools, hoping the village council will provide a clearer solution.
It is reassuring to see we are now moving back towards the original object of affection, the center of the circle, and are codifying the need to share the decision with the patient. This need has always been there but not consistently acknowledged or built into medicine in our paternalistic patterns of practice. We also have to remember that our patient is not an island, that she or he has family, has ties to loved ones in the giant web of human interconnectivity, and our decisions ripple in all directions.
All this sounds idealistically sound, but can we realistically include our patients in highly complicated decisions that even we cannot agree upon? True, complete informed consent can be argued to be illusory, and that we and our patients are merely reaching a balanced truce between blind trust in our duty of care, common goals, and a basic, watered-down version of anticipated events. It is likely impossible to ever reach the ideal of a fully informed patient given we cannot fully achieve this state of bliss ourselves.
Still, we must not give up. We must aspire to educate and include as much as is pragmatic and reasonable.
How Will We Achieve This?
For one, we have to recognize that a hastily scrawled, witnessed signature on a piece of wordy legalese, one worthy of the terms of conditions from the App store, does not constitute informed consent. I am not advocating for long, protracted, excruciatingly detailed counseling sessions. Many patients are not interested in much of the details and should be allowed to choose their desired level of understanding. We need to have personal tablet interfaces, appropriate to education, cultural, reading, and (dis)ability levels, that include videos and simple diagrams covering all aspects of the proposed procedure.
Beyond the basics of the procedure, I also think we should show where our decisions fall within the guidelines and appropriate use criteria. The consequences of their choices, such as the need for good, prolonged medication compliance, should be covered. The economic consequences of their choices must be clearer.
The next is a stretch, and likely an idea worth a lot of push-back, but I’ll share it as a challenge: what about a program that allows patients to enter their details, which would then match them to any trial ever performed related to their specific scenario? Were they included? Excluded? Not represented at all? How well did the trial work? We have spent years producing evidence. Let’s make applying it pragmatic.
Ridiculous? Maybe. But I thought I’d share a dream.