Goal setting is insufficiently recognised as an essential part of shared decision-making in the complex care of older patients: a framework analysis

Abstract

Background Multimorbidity poses a challenge for decision-making processes and requires that more attention is paid to patient goals, preferences and needs; however, goal setting is not yet widely recognised as a core aspect of the shared decision-making (SDM) approach. This study aims to analyse clinician perceptions of the concept of goal setting within the context of SDM with older patients with multimorbidity. Methods Semi-structured interviews with general practitioners (GPs) and clinical geriatricians (CGs) were analysed using a framework analysis. The integrative model of SDM was used to develop a categorisation matrix, including goal setting as an additional component. Results Sixteen of the 33 clinicians mentioned explicit Goal setting as an integrated component of their definition of SDM, which was comparable to the number of clinicians who listed Patient values and preferences ( n = 16), Doctor knowledge and recommendations ( n = 19) and Make or explicitly defer a decision ( n = 19), elements which are commonly considered to be important aspects of SDM. The other 17 clinicians (6 CGs and 11 GPs) did not mention Goal setting as an explicit component of SDM. Our analysis revealed two potential reasons for this observation. Besides the use of other terminology, part of clinicians viewed collaborative goal setting and SDM as separate but related processes. Conclusions Our study on clinician perspectives highlighted goal setting as component of a SDM approach and could therefore be considered supportive of recent theoretical insights that SDM models that lack an explicit goal-setting component appear to be deficient and overlook an important aspect of engaging patients in decision-making, particularly for patients with complex multimorbidities. We therefore call for the further development of a comprehensive SDM approach for older patients with multimorbidity to include explicit and unequivocal goal setting elements to sufficiently meet the expectations and needs of clinicians and their patients. Electronic supplementary material The online version of this article (10.1186/s12875-019-0966-z) contains supplementary material, which is available to authorized users.

Goal-Based Shared Decision-Making: Developing an Integrated Model

“…Proposing goal setting as part of SDM for older patients is not novel ( 35 ). Attention has recently been drawn to goal setting being a prerequisite to decision-making for individuals with multiple long-term conditions ( 19 , 20 , 24 , 25 , 28 , 29 , 31 , 32 ), and the sharing of treatment goals is at the core of the Ariadne principles, which aim to provide orientation in decision-making in situations where people face the challenges of multiple morbidity ( 9 , 36 ). However, we are not aware of previous efforts to embed goal setting into a model of SDM in order to assess neither the impact on decision-making nor efforts to consider the impact of setting goals at these 3 levels.…”

“…The absence of goal setting as an explicit step in SDM models has been criticized by clinicians who provide care for elderly patients with complex health conditions ( 24 – 32 ). Empirical work has led to a proposed 3-level model for goal setting ( 28 ).…”

Multi-Morbidity and Polypharmacy in Older People: Challenges and Opportunities for Clinical Practice

“…It is also clear that the impact of multi-morbidity, frailty, and polypharmacy spans both primary and secondary care. Geriatricians and pharmacists are ideally placed alongside GPs to aid goal setting, implement the principles of comprehensive geriatric assessment (CGA), and provide patient-centred care across this arbitrary primary/secondary care divide [ 65 , 66 , 67 , 68 ].…”

“…These principles can be applied across any health and social care setting and have been shown to be highly effective in the management of older people living with frailty and multi-morbidity. The process is iterative and the key to its success is timely review and coordination so that the care plan generated from a CGA remains responsive to the patient’s needs [ 24 , 46 , 66 , 69 , 70 ].…”

The Challenges and Opportunities for Shared Decision Making Highlighted by COVID-19

“…One patient-centered step that could be taken, which incorporates medical uncertainty, is to include goal setting and dispositional hope as a component of any physician-patient SDM approach, such as “what do you most hope to get out of treating your asthma?” 40 …”