Shared decision making between older people with multimorbidity and GPs: a qualitative study

Abstract

Background: Shared decision-making, utilising the expertise of both patient and clinician, is a key feature of good-quality patient care. Multimorbidity can complicate shared decision-making, yet few studies have explored this dynamic for older patients with multimorbidity in general practice. Aim: To explore factors influencing shared decision-making from the perspectives of older patients with multimorbidity and GPs, to inform improvements in personalised care. Design & setting: Qualitative study. General practices (rural and urban) in Devon, England. Method: Four focus groups, two with patients (aged 65+ with multimorbidity) and two with GPs. Data were coded inductively by two researchers applying thematic analysis. Results: Patient acknowledgement of clinician medicolegal vulnerability in the context of multimorbidity, and their recognition of this as a barrier to shared decision-making, is a new finding. Medicolegal vulnerability was a unifying theme for other reported barriers to shared decision-making. These included expectations for GPs to follow clinical guidelines, challenges encountered in applying guidelines and in communicating clinical uncertainty, and limited clinician self-efficacy for shared decision-making. Increasing consultation duration and improving continuity were viewed as facilitators. Conclusion: Clinician perceptions of medicolegal vulnerability are recognised by both patients and GPs as a barrier to shared decision-making and should be addressed to optimise delivery of personalised care. Greater awareness of multimorbidity guidelines is needed. Educating clinicians in the communication of uncertainty should be a core component of shared decision-making training. The incorrect perception that most clinicians already effectively facilitate shared decision-making should be addressed to improve the uptake of personalised care interventions.

Integrating shared decision-making, expressing preferences and active participation of older adults in primary care nursing: a systematic review of qualitative studies and qualitative meta-synthesis

“…This desire to participate was also considered a willingness to be fully informed and that this information should be based on evidence. In this way, older people declared that being fully informed is being prepared to face any process 45 49…”

“…The personality of the healthcare professionals played an essential role in bringing the older person closer to a real moment of shared decision-making, who highlighted honesty, kindness, understanding and respect as critical qualities 45 49. In short, older people positively valued those professionals who treated them not as someone who depended on their clinical judgement but as ‘equals’: ‘I feel more as an equal than I ever used to, and that helps me to have a sensible, constructive conversation with him.…”

“…The overload of work resulted in healthcare professionals always being in a hurry. In addition, there was a lack of longitudinal care; therefore, older people did not feel a continuous personalised approach because, once and again, they were attended to by different professionals each time they used the health system 45 49 50. This excessive workload brought significant problems with time available to be optimally attended.…”

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“…However, these treatments are invasive and may lead to complications. Shared decision-making is thus mandatory for managing older patients [ 16 ]. Although the pathophysiology of vasculitis is complicated, physicians must explain the effectiveness and complications of treatment to their patients and decide on management plans.…”

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“…People from these communities are more likely to report not being offered structured education, 16 and that health care advice lacks cultural relevance 17 . ‘ There is good evidence that people get much greater clinical benefit if education is culturally tailored,’ said Dr Goff 18 …”