Supporting Shared Decision Making and Client Consent

We’ve all had them: consultations in which you know which treatment is best for the patient but the client won’t agree to it. Why do these situations happen, and what can we do about them?

Let’s look at this opening scenario in more detail. You know which treatment is best for a mythical “standard” patient with a certain condition. However, the patient has its own idiosyncrasies, does not come to see the veterinary team unaccompanied, and lacks its own finances to reward you for your efforts.

I think we need to stop seeing clients as barriers to treatment and instead bring them along on the decision-making journey with us. That’s what we are going to look at in this article, which is being published at an opportune moment in veterinary practice.

Interest is undoubtedly growing in providing what is termed “contextualized care” in the United Kingdom¹ or “spectrum of care” in the United States.² The cost of living is spiralling upward, and owners are finding it increasingly difficult to fund their animals’ health care.

However, the renewed interest in what could also be badged as “shared decision making” shows that many have arrived late to the party. Even before the current crisis (regarding confidence in the veterinary profession in the United Kingdom illustrated by the Competition and Markets Authority’s investigation into suspected lack of competition in the veterinary sector³), this approach to the veterinarian–client–patient relationship could usefully have formed the basis for the relationship.

Using shared decision making as the basis for communication with clients provides several advantages, such as automatic achievement of client consent to the chosen treatment pathway and greater client satisfaction.⁴

How Do We Communicate From a Shared Decision-Making Platform?

A common model of shared decision making includes 3 stages: choice talk, options talk, and decision talk (FIGURE 1).⁵ At each stage, clients are encouraged to offer their input, which forms the basis for supported decision making.

Choice Talk

At this stage, let clients know that they have choices and that the veterinary healthcare team will support them in making the best decision for themselves and their animals. Even if there is realistically only a single option for treatment, there are usually options of euthanasia or relinquishment, which may need to be offered to ensure that the client has a choice. When deciding what counts as a choice, remember that choices must improve the animal’s current situation.

This part of the conversation may be started with a phrase such as, “You do have options,” or “There are several ways to treat this condition.” Emphasize that clients won’t be left to make the decision on their own. Enhance both of these statements with “ … and I am/we are here to talk you through them and to help you to decide which choice is best for you and [animal’s name].” We can (and should) involve other members of the veterinary team. For example, if you would like a veterinary nurse to help with explanations, you can say “We are here to talk you through the choices, and our veterinary nurse will help you to explore each option …” Having a veterinary nurse in the room leads to increased use of shared decision-making techniques during consultations in practice.⁶ By inviting client involvement in this way, we are acknowledging and encouraging client autonomy, which relies on there being more than a single genuine option. It is difficult to envisage a scenario in which there are no options (except, perhaps, some emergency situations).

Next, introduce the options, presented in a neutral way, so clients feel that they have a real choice. According to a study in palliative pediatric medicine, the order in which options are presented does not seem to influence decision making⁷; however, the way in which they are framed does have an effect.⁸ For example, if the patient has a lump that has suddenly appeared, you could say, “These are the options: we can wait and see; we can analyze the tissue today to see what is going on; or we can surgically remove it and then see what it is, but that would probably need to wait until next week.” Introducing the opportunity to have treatment started today may influence the client’s choice. It would be better to leave time frames out of the initial choice talk and simply say, “These are the options. We can wait and see; we can analyze the tissue to see what is going on; or we can surgically remove it then see what it is.” The client now knows that they have 3 options.

Options Talk

The options stage may be introduced by asking a question that encourages the client’s involvement, such as, “How do these sound to you?” If we have been listening to the client from the start of the consultation, we will have picked up on their stated values and concerns. If not, we could ask appropriate questions:

“What were you hoping that we could do today?”

“What is most important to you regarding how we go about dealing with this lump?”

We can use the client’s responses to help work out which option they are likely to prefer, but we must now indicate to the client that we will go through each option to explain the benefits, risks, and financial costs to help them make the best decision for them and for their animal. Pause frequently to check in with the client for understanding (e.g., “What do you think about this option?”) and to provide space for questions. Use language that is suitable for each particular client, depending on their previous experiences. For an example of explaining the “wait and see” or “do nothing” option to the client whose dog has a lump, see BOX 1.

Of course, the actual costs of each option should be included as well. This aspect can be introduced by saying, “Would you like me to go through how much each of these options would cost?” Another aspect of the options talk is appreciating the patient’s preferences and characteristics, in which the obvious “expert in the room” is the client. Asking and listening carefully to their opinion with regard to such factors will be crucial for supporting them in making a decision that is right for the patient.

Decision Talk

At this stage, support the client to help them to make the best decision for them and their animal. If we have listened well to the client throughout, we should be in a position to say, “From what you have told me, it sounds like you are considering [option] as the way forward—have I got that right?”

We know that many veterinary clients prefer to be involved in decision making⁹; however, we also know that, as in human medicine, some prefer that their healthcare professional decide for them,¹⁰ particularly in emergency situations,¹¹ and we must bear that in mind when encouraging client involvement.

Consider situations in which a client asks, “What would you do?” or asks you to make the decision for them, or consider what happens in an emergency situation when there is no time to go through options. To honor client autonomy, we must respond positively and tell them what our preferred option would be but with the caveat that we are not in their shoes. We need to acknowledge that we do not know the intricacies of their relationship with their animal, and, most importantly, we still need to tell them about the risks, costs, and benefits of our preferred option to fulfill the requirements of consent.

How Far Apart Should the Stages of Shared Decision Making Be Spaced?

The 3 stages of shared decision making can take place during a single consultation or they can be extended over multiple consultations. For example, if we have just broken some bad news to a client, it may be best to pause after the choice-talk stage and book a follow-up consultation to go through the options in detail. Similarly, if a client is overwhelmed with the information received during the option-talk stage, we can provide written, visual, or auditory information about each option and ask them to come back after they have accessed the information. This visit would be a follow-up consultation during which they can ask any questions they may have and discuss the decision. Supporting clients who are considering options available for treatment and presenting these options in a way that encourages their participation facilitates the best treatment for the animal in those circumstances while acknowledging client autonomy with regard to accepting or declining any particular treatment option.

Summary

Using a contextualized care/spectrum of care ethos and shared decision making in consultations should leave clients satisfied with the encounter; the veterinary team confident that they have obtained client consent for treatment; and you, the veterinarian, less stressed by situations in which you strongly prefer a particular treatment that the client will not agree to.