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Tools to Promote Shared Decision Making in Serious Illness A Systematic Review

C. Adrian Austin, MD1; Dinushika Mohottige, MD2; Rebecca L. Sudore, MD3,4; Alexander K. Smith, MD3,4; Laura C. Hanson, MD, MPH1,5
[+] Author Affiliations
1Center for Aging and Health, Division of Geriatrics, University of North Carolina, Chapel Hill
2Department of Medicine, Duke University, Durham, North Carolina
3Division of Geriatrics, Department of Medicine, University of California, San Francisco
4San Francisco Veterans Affairs Medical Center, San Francisco, California
5Palliative Care Program, University of North Carolina, Chapel Hill
JAMA Intern Med. 2015;175(7):1213-1221. doi:10.1001/jamainternmed.2015.1679.
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Importance  Serious illness impairs function and threatens survival. Patients facing serious illness value shared decision making, yet few decision aids address the needs of this population.

Objective  To perform a systematic review of evidence about decision aids and other exportable tools that promote shared decision making in serious illness, thereby (1) identifying tools relevant to the treatment decisions of seriously ill patients and their caregivers, (2) evaluating the quality of evidence for these tools, and (3) summarizing their effect on outcomes and accessibility for clinicians.

Evidence Review  We searched PubMed, CINAHL, and PsychInfo from January 1, 1995, through October 31, 2014, and identified additional studies from reference lists and other systematic reviews. Clinical trials with random or nonrandom controls were included if they tested print, video, or web-based tools for advance care planning (ACP) or decision aids for serious illness. We extracted data on the study population, design, results, and risk for bias using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Each tool was evaluated for its effect on patient outcomes and accessibility.

Findings  Seventeen randomized clinical trials tested decision tools in serious illness. Nearly all the trials were of moderate or high quality and showed that decision tools improve patient knowledge and awareness of treatment choices. The available tools address ACP, palliative care and goals of care communication, feeding options in dementia, lung transplant in cystic fibrosis, and truth telling in terminal cancer. Five randomized clinical trials provided further evidence that decision tools improve ACP documentation, clinical decisions, and treatment received.

Conclusions and Relevance  Clinicians can access and use evidence-based tools to engage seriously ill patients in shared decision making. This field of research is in an early stage; future research is needed to develop novel decision aids for other serious diagnoses and key decisions. Health care delivery organizations should prioritize the use of currently available tools that are evidence based and effective.

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