National Healthcare Decisions Day—Enhancing Shared Decision Making

Jean S. Kutner, MD, MSPH, Chief Medical Officer, University of Colorado Hospital, Professor of Medicine, Associate Dean for Clinical Affairs, University of Colorado School of Medicine

Editor’s Note: April 16 is National Healthcare Decisions Day. Jean S. Kutner, MD, is the Chief Medical Officer for the University of Colorado Hospital and a Professor of Medicine at the University of Colorado School of Medicine. In this blog post, she shares why NHDD serves as a visible reminder of the relevance and importance of shared decision making, particularly in the setting of serious illness.

As described on the organization’s website, National Healthcare Decisions Day (NHDD) “exists to inspire, educate, and empower the public and providers about the importance of advance care planning” (www.nhdd.org). With its focus on advance care planning, NHDD serves as a visible reminder of the relevance and importance of shared decision making, particularly in the setting of serious illness.

Shared decision making entails fully informing patients (or surrogates) about treatment options, including the trade-offs between risks and benefits, incorporating patient values and preferences into treatment decisions, and engaging patients or their surrogates in making and implementing a decision.1,2 A shared approach is especially important for situations where outcomes are uncertain, there is no clearly superior choice, and the patient’s values or preferences are a key element of making the “best choice”.3,4 Shared decision making has been demonstrated to improve patient knowledge about treatment and management plans and to improve satisfaction with care.5

National Healthcare Decisions Day connects people with resources to help them make, discuss, and document future healthcare wishes and decisions, particularly choosing a healthcare power of attorney and documenting the kinds of medical treatments wanted near the end of life.

While not as dramatic as decisions about life support, decisions about continuing or discontinuing chronic medications in the setting of a life-limiting illness warrant similar attention and are prime for shared decision making.

We recently published findings from a randomized clinical trial of continuing vs. discontinuing statins among people with limited life expectancy.6 The study found that stopping statin medications in this population is safe and may be associated with benefit, including improved quality of life, use of fewer non-statin medications, and a corresponding reduction in medication costs. Given the uncertain benefit, and possible harm, of continuing statins among people with life-limiting illness, shared decision making between the patient and provider regarding continuing or discontinuing these medications is warranted. In the context of uncertain benefit—and potential harms—incorporating patient preferences into decision making becomes paramount.

This study’s secondary endpoints provide critical information to help answer the question, “How can we make a decision together about the management of your statin medication based upon your personal wishes, circumstances, and the evidence?”

  • For the patient worried about pill burden, discontinuing statins reduces polypharmacy beyond the simple reduction in medications due to stopping the drug.
  • When symptoms and quality of life are the concern, study data show that people whose statins were discontinued had trends toward improvement in these outcomes, while continuing the medications shows trends toward worsening (although these trends were not statistically significant).
  • For the patient who does not want to discontinue the statin, perhaps because he is not ready to acknowledge true prognosis or is most comfortable taking a long-term medicine that has always been in his pill cup, the data suggest that continuing the medicine shouldn’t be harmful.

As NHDD enhances awareness of advance care planning, we should think not just about planning for medical decisions in the future, but also about current treatments—and engage in shared decision making that takes into account potential risks and benefits, as well as patient values.

  1. Katz SJ, Hawley S (2013). The value of sharing treatment decision making with patients: Expecting too much? JAMA, 310(15): 1559–1560.
  2. Charles C, Gafni A, Whelan T (1997). Shared decision-making in the medical encounter: What does it mean? (Or it takes at least two to tango). Social Science and Medicine, 44(5): 681–692.
  3. Hoffman RM, McNaughton-Collins M (2014). The superiority of patient engagement and shared decision-making in noninferiority trials. Journal of General Internal Medicine, 29(1): 16–17.
  4. Bakitas M, Kryworuchko J, Matlock DD, Volandes AE (2011). Palliative medicine and decision science: The critical need for a shared agenda to foster informed patient choice in serious illness. Journal of Palliative Medicine, 14(10): 1109–1116.
  5. Oshima Lee E, Emanuel EJ (2013). Shared decision making to improve care and reduce costs. New England Journal of Medicine, 368(1): 6–8.
  6. Kutner JS, et al. (2015). Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: A randomized clinical trial. JAMA Internal Medicine. Published online March 23, 2015. DOI:10.1001/jamainternmed.2015.0289. Accessed April 15, 2015.