Priority Aligned Decision Making: Anchoring in What Matters Most

Transcript

• 00:22By the end of our time together today,
• 00:24I'm hoping that you'll be able
• 00:27to discuss the challenges and
• 00:29decision making for older adults
• 00:31with multiple chronic conditions.
• 00:33Reflect on what matters is the cornerstone
• 00:36M of the Age Friendly Health System
• 00:39Initiative and introduce tools to
• 00:42identify what matters most to your
• 00:44patients and align decision making
• 00:47with individual patient priorities.
• 00:49But first, I'm going to start with a story.
• 00:52I want to introduce you to a patient who I
• 00:55met in my fellowship in geriatric medicine,
• 00:57Misses B.
• 00:58It was a usual primary care afternoon and
• 01:01one of my patients was coming in for a
• 01:04follow up after a recent hospitalization.
• 01:07And unfortunately,
• 01:07it it actually had been one in a
• 01:10string of hospitalizations for
• 01:13varying symptoms and conditions,
• 01:15including shortness of breath and fatigue.
• 01:18She had volume overload in the context
• 01:21of heart failure and some respiratory
• 01:23symptoms in this in the setting of COPD.
• 01:26So I prepped for clinic in the usual way.
• 01:29I made a list of check boxes of
• 01:30things I wanted to discuss with her,
• 01:32one of those things including a
• 01:34CAT scan in the hospital that had
• 01:36picked up a long nodule.
• 01:38I wondered how she was ambulating
• 01:40if she was still needing oxygen,
• 01:42and so I prepped for our
• 01:44clinic visit together.
• 01:45Now,
• 01:46a little bit about Misses B.
• 01:48She was a fiercely independent older
• 01:50woman who lived in senior housing with
• 01:53only intermittent help from her family.
• 01:56And unfortunately,
• 01:57with the string of hospitalizations,
• 02:00she had become more dependent on her
• 02:02family to do things like make meals
• 02:05and get medications from the store.
• 02:08And she was coming to the visit with her
• 02:11daughter on the day that I was seeing her.
• 02:13So we we started out the visit by catching
• 02:15up and seeing how she was feeling.
• 02:17I asked if she recalled the CAT
• 02:19scan with the the long nodule and
• 02:21if she was planning on seeing her
• 02:23cardiologist the following week.
• 02:25And she sort of took a moment and
• 02:29sighed and she said to me, you know,
• 02:31it's just all so much I can't
• 02:34keep track of it.
• 02:35Honestly,
• 02:36I'm not always taking that water pill.
• 02:39I'm not sure if it helps me.
• 02:41I can't do things for myself.
• 02:43I'm confused about the recommendations.
• 02:46One doctor told me to drink more and
• 02:48then one told me I was drinking too much.
• 02:50I just feel exhausted.
• 02:52So this case really for me in that
• 02:55moment as a geriatric medicine fellow
• 02:58highlighted a lot of the challenges that
• 03:00we face in the care of older adults,
• 03:02particularly those who have
• 03:04multiple medical problems.
• 03:06And we know that this
• 03:08population is growing actually.
• 03:09So we've seen an increase in the
• 03:11number of persons that have two
• 03:14or more medical conditions and
• 03:16those medical conditions are what
• 03:18we call multi morbidity.
• 03:19I think that for those of you
• 03:21listening in today,
• 03:22many of you have run into the
• 03:24challenges that we'll talk about next.
• 03:26So we're going to talk a little bit
• 03:29about some of the the challenges
• 03:30that exist in the care of persons
• 03:33with multiple chronic conditions.
• 03:35So the first is that
• 03:37there's uncertain benefits.
• 03:39There's the potential for unintentional harm.
• 03:42Care can be quite burdensome.
• 03:45Trade-offs in this population are more
• 03:48common and what matters most to patients.
• 03:50The cornerstone of our talk today varies
• 03:53in the context of these trade-offs,
• 03:54which is an important thing to remember.
• 03:57Additionally, as we've gotten more
• 03:59specialized in the healthcare field,
• 04:02healthcare delivery has become
• 04:03a bit more siloed,
• 04:04which can result in fragmented care
• 04:07and conflicting recommendations,
• 04:08as I pointed out with my patient earlier.
• 04:11So let's unpack these a little bit more.
• 04:14First, care can be of uncertain benefits.
• 04:17So you might wonder what I
• 04:18what I mean by that.
• 04:19To start with,
• 04:20we know that older adults are not
• 04:23often included in the clinical trials
• 04:25that are used to form guidelines
• 04:28for different medical conditions.
• 04:30We don't know if the results of the clinical
• 04:33trials do or don't apply because of this.
• 04:36Secondly,
• 04:36older adults with multiple medical
• 04:38problems may have less benefit than
• 04:41is suggested by the trials because
• 04:43their other conditions affect their
• 04:45health and the response to treatments.
• 04:48What's good for misses BS.
• 04:49Heart failure, for example,
• 04:51may not be good for other
• 04:52medical problems that she has.
• 04:54And importantly,
• 04:55we have to think about what defines
• 04:59benefit in this population.
• 05:02What's what one person values is not going to
• 05:04be the same as what another person values.
• 05:07And so you have to figure out
• 05:09how you're defining benefit.
• 05:11I said there's the potential
• 05:13for unintentional harm and
• 05:15iatrogenic complications.
• 05:16So we know that as people accumulate
• 05:19chronic medical conditions,
• 05:21they often also accumulate medications.
• 05:24Polypharmacy is defined as
• 05:26five or more medications,
• 05:27and that's associated with
• 05:29a number of adverse events.
• 05:31Additionally,
• 05:31studies have shown that one in three
• 05:35older adults with multiple chronic
• 05:38conditions receive at least one
• 05:41guideline recommended intervention
• 05:43that harms A coexisting condition.
• 05:46Care can be quite burdensome for people.
• 05:49And you know,
• 05:50some of these statistics I
• 05:52remember learning about were were
• 05:54quite impressive and staggering.
• 05:55So older adults spend an average of
• 05:58two hours per day on healthcare tasks.
• 06:00That's like the length of a of
• 06:03a movie for for us,
• 06:04up to 1/2 a day per each
• 06:07healthcare encounter.
• 06:08So think about someone who has three
• 06:11or four health professionals that
• 06:13they see regularly with accompanying
• 06:15laboratory testing and diagnostic testing.
• 06:18And then think about how 1/2 a day
• 06:21for each of those encounters comes
• 06:23out of your patient's life and time.
• 06:25And we don't know if that's time
• 06:28that they would rather be spending
• 06:30doing something else.
• 06:31trade-offs are more common.
• 06:32So what do I mean by this?
• 06:34We know that in healthcare there
• 06:37are trade-offs.
• 06:37We know personal life that there
• 06:39are trade-offs.
• 06:40I want to run a marathon someday,
• 06:42but I'm not in the shape I need to be
• 06:44to run a marathon today.
• 06:45So I'd have to weigh the trade off
• 06:47of training for 1:00 to be able to
• 06:50achieve that goal in clinical care.
• 06:51Think it back to my patient misses B.
• 06:54She was short of breath and given a diuretic.
• 06:57The trade off of that medication is
• 06:59that she had frequency of urination.
• 07:01Was she willing to accept the burden if
• 07:04it helped her achieve what she wanted to?
• 07:06Better symptom control?
• 07:08To guide these trade off conversations,
• 07:11we need to understand what
• 07:13matters most to our patients,
• 07:14including what they want to achieve,
• 07:16what they're willing and able
• 07:18to do or not willing and able
• 07:20to do to achieve those goals.
• 07:22Fortunately,
• 07:23studies show that patients understand
• 07:26this concept of trade-offs,
• 07:28and in fact, as I suggested,
• 07:31they people vary in what they
• 07:33most want to achieve.
• 07:34Which is not surprising when older
• 07:36adults were asked in broad categories
• 07:39whether they prefer to maintain function,
• 07:43even if that means a less life
• 07:46expectancy or preserve symptoms,
• 07:48or if they want to live as long as possible,
• 07:51even if that results in a decline
• 07:53cognitively or physically.
• 07:54You can see the statistics here on the
• 07:57slide that 42% value maintaining function,
• 08:0032% value maintaining
• 08:02symptoms or symptom relief,
• 08:04and 27% want longevity is the
• 08:07thing that they most value.
• 08:10Additionally,
• 08:10people vary in the things that
• 08:12they are or are not willing to
• 08:15do to achieve those goals or the
• 08:17things that matter most to them.
• 08:18And so we have to consider,
• 08:21you know,
• 08:21what matters to our patients when
• 08:23we think about the recommendations
• 08:24that we're going to make to them.
• 08:26And lastly, I'll say healthcare has become,
• 08:29as I mentioned a little bit more
• 08:31siloed in the current iteration.
• 08:34And so multiple specialists across
• 08:37healthcare systems sometimes can result
• 08:40in a compilation of recommendations
• 08:42and increased burden on our patients.
• 08:46And it can be quite frustrating to
• 08:49hear conflicting recommendations and
• 08:51and to have to coordinate care between
• 08:54multiple healthcare professionals.
• 08:56This these challenges that we've
• 08:58gone through can result in feeling
• 09:01frustrated can be hard for us.
• 09:03This uncertainty that I mentioned
• 09:05means that there's not one right
• 09:07or best answer which is challenging
• 09:09I think for many of us who grew up
• 09:11in a multiple choice test society.
• 09:13So choosing one right or best
• 09:16thing is not always possible.
• 09:19It can also be hard to attribute the
• 09:22symptoms to just one thing misses BS.
• 09:24Fatigue and shortness of breath
• 09:26could be due to multiple of her
• 09:28medical problems and other things.
• 09:30Conflicting recommendations from colleagues,
• 09:32as I mentioned,
• 09:33can put us in a difficult
• 09:35position to not know where to go.
• 09:37We might think that our patient
• 09:39is not adherent,
• 09:40but the patient may think
• 09:41this isn't helping me,
• 09:43it's not helping me achieve
• 09:44what I want to do.
• 09:45And so there's a mismatch
• 09:47in the communication.
• 09:49To guide us a little bit,
• 09:51there is,
• 09:51I want to talk a little bit about
• 09:53a concept called Age Friendly Care.
• 09:55So the Johnny Hartford Foundation
• 09:58and the Institute for Healthcare
• 10:00Improvement joined forces to to
• 10:03create something called the Age
• 10:05Friendly Health System Initiative.
• 10:06These two organizations sought to
• 10:09outline the particular areas where
• 10:11geriatric medicine adds value to the
• 10:13care of older adults with a specific
• 10:16goal to outline processes that improve
• 10:19care and reduce healthcare costs.
• 10:21This initiative took into the
• 10:23account perspectives of patients,
• 10:25caregivers, clinicians,
• 10:26healthcare systems and payers and
• 10:28is known as the forums framework.
• 10:31This provides us an approach to guide
• 10:34the the delivery of of clinical care,
• 10:37the development of education
• 10:39initiatives and interventions and
• 10:41I'd say is has been really pivotal
• 10:44to the field of geriatric medicine.
• 10:46I'll just take a moment to reflect
• 10:49here though that while all of the Ms.
• 10:51are certainly critical in the care
• 10:54of of our older adult population,
• 10:56that the what matters M is really
• 11:00the bedrock.
• 11:00How can you make decisions about which
• 11:04medications make sense for a for a patient?
• 11:06How can you know what interventions
• 11:08most make sense to optimize mobility
• 11:11without knowing what a patient
• 11:13wants to achieve and what they're
• 11:15willing to do to achieve that?
• 11:17So to me,
• 11:18the matters most and really
• 11:19is like the North Star.
• 11:20It's a guiding force in our decision making.
• 11:24And we're in a fortunate position that
• 11:27leaders in the field of geriatric medicine,
• 11:29including Mary Tonetti here at Yale,
• 11:32among others,
• 11:33developed a framework called the
• 11:35Patient Priorities Care Initiative.
• 11:38This is a a shift in chronic disease
• 11:42management to focus on not individual
• 11:47individual medical problems by themselves,
• 11:51but to contextualize them within
• 11:53what matters most to your patients.
• 11:56And so this provides us with
• 11:58tools and resources because even
• 12:00when you know what matters most,
• 12:02decision making can sometimes be hard.
• 12:05So what is patient priorities?
• 12:07Care.
• 12:07It moves decision making and the
• 12:11conversation with with our patients.
• 12:13From something like you need
• 12:16Lasix for your heart failure,
• 12:18to knowing your overall health,
• 12:21your medical conditions and
• 12:23what matters most to you.
• 12:25I think we need to consider this medication.
• 12:28I think the Lasix will help you
• 12:30achieve the thing that you want to
• 12:32achieve of you know walking more,
• 12:34being less short of breath whatever
• 12:36your your patient wants to achieve.
• 12:38We let patients be the expert of
• 12:41themselves and what they want to
• 12:43achieve and we use our specific
• 12:45expertise to help them do that
• 12:48through their healthcare who is a
• 12:50good fit for patient priorities care.
• 12:52I think the the simple answer
• 12:54is probably everyone actually,
• 12:55but the the model was developed
• 12:57for those in the middle bucket on
• 13:00the slide for those of who have a
• 13:03shorter life expectancy and may
• 13:06have increasing number or severity
• 13:08of medical conditions contrasting
• 13:09that to the the bucket on the
• 13:12left and right of the slide.
• 13:13So you can see for for even older
• 13:16older adults it's not age specific.
• 13:18For those people who we think
• 13:20have greater than 10
• 13:21years life expectancy,
• 13:22have few medical conditions
• 13:24and function reasonably well,
• 13:26guideline based therapy is probably
• 13:28most appropriate contrasting to to
• 13:30patients who have a more terminal
• 13:32condition with less life expectancy
• 13:34and a more symptom oriented palliative
• 13:36approach might be appropriate.
• 13:38But for those in the middle
• 13:40bucket on the slide,
• 13:41patient priorities care can provide
• 13:43you a compass to guide decision
• 13:46making in the the context of all
• 13:48of those challenges that we talked
• 13:51about you see here on this slide.
• 13:53This is a a diagram that outlines
• 13:55the main components or steps
• 13:57of patient priorities care.
• 13:59On the left hand slide you can see
• 14:01that you start with identifying what
• 14:03matters most to a patient and then
• 14:06you align care with what matters most.
• 14:08And the arrow shows that this is an
• 14:11iterative process because life changes.
• 14:13So you could have a new medical condition
• 14:15or a life circumstance could change.
• 14:18And so it's an iterative process
• 14:20by which we revisit what matters
• 14:22most to to a patient and then over
• 14:25time through ongoing conversation,
• 14:27align care with what matters most.
• 14:31So the first step I said was identifying
• 14:33what matters most to your patients.
• 14:35This can be done in a couple
• 14:37of different ways actually.
• 14:38Our team has developed a website
• 14:41called My Health priorities.org which
• 14:43provides patients an opportunity to
• 14:45go through in real time in a visit
• 14:49or on their own The the process
• 14:51of identifying what matters most.
• 14:53We also have paper resources on our
• 14:56website that can that can be used by
• 14:59any member of the healthcare team.
• 15:01First,
• 15:02you start with exploring what what
• 15:04matters that these are the values.
• 15:06There are 4 broad domains of values that
• 15:09we found our most relevant to our population.
• 15:13Those include connecting,
• 15:15enjoying life,
• 15:16managing health,
• 15:17and functioning.
• 15:18And it's important to explore each
• 15:21of these domains with your patients
• 15:24because you learn about them,
• 15:26you learn about what matters most,
• 15:28and you get to explore the things that
• 15:30they most want to achieve and that
• 15:32that bring them joy in their lives.
• 15:34Once you explore the values,
• 15:37you then use that to inform the creation
• 15:41of meaningful health outcome goals.
• 15:44And these goals should be
• 15:47specific and realistic.
• 15:49Specific speaks for itself,
• 15:50but you want to include exactly
• 15:53what the patient is going to do.
• 15:55This might change over time,
• 15:57but you might ask your patient what would
• 16:00you be doing more of if you felt less tired?
• 16:03How can we help you feel that connection?
• 16:06How can we help you function for yourself?
• 16:09What exactly would you be doing?
• 16:11And it's important to be specific,
• 16:13to be able to know whether or
• 16:15not that goal is realistic,
• 16:17whether or not it's something that that
• 16:19given your patient's current health,
• 16:21mobility,
• 16:22and function,
• 16:23that they're able to be able to do that goal.
• 16:26So you want to keep your goals
• 16:28specific and realistic.
• 16:29To assess if a goal is realistic,
• 16:31you might ask when was the
• 16:33last time you were
• 16:34able to do that activity?
• 16:36And I'll just take a moment to reflect
• 16:38here that why we say a goal should
• 16:41be specific and realistic is really
• 16:42because the goal is what you're going
• 16:45to use to determine if your change
• 16:47in a healthcare plan was successful.
• 16:50You're not calibrating success to
• 16:53only something like a hemoglobin A1C,
• 16:56but you're using whether or not
• 16:58your patient was able to do the
• 17:00goal that they most want to.
• 17:01So thinking back to my patient and
• 17:04clinic misses B in that moment,
• 17:07after she sighed and and expressed some
• 17:10of the frustration she was feeling,
• 17:12I took a step back and I asked
• 17:14her some of these questions.
• 17:16I said, you know,
• 17:17what would a good day look like for you?
• 17:19What do you wish you could do more
• 17:21of if you didn't feel the shortness
• 17:23of breath or fatigue you have?
• 17:25And I honestly was a little bit
• 17:27surprised by her response, she said.
• 17:29I know I'm not going to get back to dancing.
• 17:33I know I probably can't shop
• 17:35on my own for now,
• 17:37but I hate that I can't do things for myself.
• 17:39I hate that I'm having to rely on
• 17:41my family so much to do everything.
• 17:44I just wish I could get my own mail.
• 17:46That's what she wanted.
• 17:47She wanted to go to the mailbox
• 17:49every day and she couldn't because
• 17:51of the symptoms that she was having.
• 17:53So as as I said the patient's health
• 17:55outcome goal is what they most want
• 17:57to achieve that they hope their
• 17:59healthcare can help them do that.
• 18:01Next you identify what a patient's
• 18:03healthcare preferences are to help
• 18:06guide that what they're willing and
• 18:08able to do to achieve that goal.
• 18:10This is the way we find a a balance
• 18:12in those trade-offs.
• 18:13So you find out what your patient
• 18:15thinks is helpful and what they think
• 18:18is burdensome or interfering with their
• 18:20ability to achieve that healthcare goal.
• 18:22And at the conclusion of this process,
• 18:25you'll get to something we call
• 18:26the one thing or the top priority.
• 18:29And this is the thing that the
• 18:31patient most wants to achieve
• 18:33to to focus their healthcare.
• 18:35It could be a symptom,
• 18:37it could be a health problem
• 18:39or burdensome task.
• 18:40But the important thing here is that
• 18:42you connect the goal with what's
• 18:44getting in the way and it provides
• 18:46you a place to start decision making.
• 18:49For my patient misses B,
• 18:50she wanted to be less short of breath
• 18:52so that she could get her mail for herself.
• 18:56So now we're going to pivot to the
• 18:59the right hand slide of of our diagram
• 19:02to aligning care with individual
• 19:04health priorities. We are here.
• 19:08So first you're going to do
• 19:10something we call the consider step,
• 19:12which is an intentional reflection.
• 19:15It's clinical reasoning.
• 19:16It's become increasingly clear how
• 19:18crucial it is to take a step back
• 19:21after you identify what matters most.
• 19:24And this is the fun part.
• 19:25This is where you get to apply nuance
• 19:27and creativity to the evidence base that
• 19:30you think applies most to your patient.
• 19:32This is where you get to think about
• 19:34their active medical conditions and
• 19:36you also get to think about their
• 19:38social determinants of health,
• 19:39their life context,
• 19:40and figure out a way to help
• 19:42them achieve what they want to.
• 19:44You want to figure out what goals they
• 19:46have and what's getting in the way.
• 19:48So you'll create sort of a a long
• 19:50list of the factors that might be
• 19:52contributing to that bothersome symptom,
• 19:54to that shortness of breath that
• 19:56misses B had what medical conditions
• 19:58are getting in the way,
• 19:59what medications might be helping or not?
• 20:04Is the is the driveway 40 feet long?
• 20:07And that's why she can't get to it?
• 20:09You're going to create a long
• 20:10list of the potential problems.
• 20:12And then once you have that list of options,
• 20:15I'm going to give you some
• 20:16strategies of places to start.
• 20:17Because you might think,
• 20:18well, if I come up with this
• 20:20really long list of things,
• 20:21how am I going to know where to start?
• 20:24And as I, as I outlined here,
• 20:26you'll go through the,
• 20:27the long list of things that can bother
• 20:30somebody's ability to to attain their goals.
• 20:34So you're going to think
• 20:37about that long list,
• 20:38and you're going to think about which
• 20:40of those potential interventions
• 20:42or current interventions are most
• 20:44likely to help the current problem.
• 20:47This might be a change in medications,
• 20:49either stopping or starting something,
• 20:51adjusting A dose.
• 20:52You might recommend a new test or procedure.
• 20:56You might recommend a new healthcare task
• 20:59or more support services in the home.
• 21:01We're going to apply this step
• 21:03now to my patient, misses B,
• 21:05to give you an example.
• 21:07So for our patient misses,
• 21:09BI felt like there were multiple
• 21:12potential things impacting her
• 21:13ability to not get her mail.
• 21:16She felt short of breath,
• 21:17and I thought maybe her heart
• 21:19failure was contributing and she
• 21:21wasn't taking her her diuretic.
• 21:23You know,
• 21:23I thought potentially her
• 21:25COPD was getting in the way.
• 21:26Should we try pulmonary rehab for her?
• 21:29Maybe we could do more physical
• 21:31therapy in the home.
• 21:33It turned out actually,
• 21:35that she felt like she needed help
• 21:37just getting to the mailbox because of
• 21:39her shortness of breath and fatigue,
• 21:41and so we were actually able to get
• 21:42to a place of getting her an electric
• 21:45scooter to get outside of her house.
• 21:46We readjusted the dose of the
• 21:48Lasix and the timing
• 21:50of it and we were able to get her
• 21:52to a place of getting to her mail.
• 21:54You might reflect here that this is
• 21:56also where you get to individualize
• 21:59your healthcare for your patients.
• 22:01What's right for one patient
• 22:02may not be right for another.
• 22:04In fact, you might have two people
• 22:06with the same exact medical conditions,
• 22:08but they might vary in what
• 22:10they're willing and able to do to
• 22:12achieve a goal that they have.
• 22:14And so this diagram here outlines
• 22:16that that one with with the same
• 22:18value and the same goal of visiting
• 22:20with neighbors to people you you
• 22:22might do different things for,
• 22:24focus on physical therapy for one or make
• 22:27a medication adjustment for another.
• 22:30This is also where you can
• 22:32integrate those other Ms.
• 22:34of the age friendly health system.
• 22:35So I talked about this a few slides
• 22:37ago and thinking about medications,
• 22:40mobility and meditation.
• 22:41And here you get to integrate
• 22:43all of these Ms.
• 22:44into your care plan for your patient,
• 22:47anchoring on what matters most.
• 22:51So once you have identified what
• 22:54matters most and you've considered
• 22:56what interventions you want to
• 22:59potentially try to help your patient
• 23:01achieve what matters most to them,
• 23:02we've come up with a couple of key
• 23:05strategies that are helpful in aligning
• 23:07care once you know what matters,
• 23:09and these are not necessarily the only prior,
• 23:12the only strategies that you could use.
• 23:14They might seem obvious to you,
• 23:16in fact you might do some of
• 23:18them some of the time.
• 23:19But we would suggest that you use them
• 23:23systematically and we've developed
• 23:25tools and decision guides where whereby
• 23:27giving you different communications
• 23:29scripts and tips to be able to to
• 23:33do these strategies in real time.
• 23:35So the strategies are to use patients
• 23:38health priorities as the focus of
• 23:41communication and decision making as
• 23:44a target for serial trials and to
• 23:47align decisions among clinicians.
• 23:50When there are different perspectives
• 23:52or recommendations,
• 23:53we'll talk a little bit about the
• 23:55rationale and then unpack them
• 23:56a little bit more.
• 23:57The rationale for these strategies are
• 24:00that patients feel listened to they they.
• 24:03This could help provide a motivation for
• 24:05patients to adhere to recommendations
• 24:07because you link it to what's
• 24:09most important to them.
• 24:11Each priority gives clinicians
• 24:12an anchor to be able to decide
• 24:15if treatment is as effective,
• 24:18if you're able to achieve what you want.
• 24:20Practically speaking,
• 24:21you also just have an opportunity
• 24:23to get everybody on the same page
• 24:25about what matters most to the
• 24:27patient and what they want to achieve
• 24:29out of their healthcare.
• 24:32So let's start with the first with
• 24:35using patient priorities as the focus
• 24:37of communication and decision making.
• 24:39Here, you know we'll we'll talk about
• 24:42my patient misses B and how there
• 24:44were multiple potential options.
• 24:46Remember, she said she wasn't sure if she
• 24:48wanted to take that diuretic medication,
• 24:50and I worried that without it that she
• 24:52was having symptoms of heart failure.
• 24:55So we were talking about something
• 24:56that could be a potential burden to a
• 24:59patient and we're going to discuss that
• 25:02in the context of their priorities.
• 25:04So for for a patient like misses B,
• 25:06you might say something like,
• 25:08I know you don't like the diuretic,
• 25:10but I'm worried that stopping it
• 25:12all together is worsening your
• 25:14shortness of breath.
• 25:16Are you willing to try it again for two
• 25:18weeks and see if it helps you get your mail?
• 25:21You offer a potential burdensome
• 25:22care within the context of what
• 25:25matters most to our patients.
• 25:26Think about how that might feel different
• 25:29to someone from saying something like you
• 25:31need this Lasix for your heart failure.
• 25:33You know,
• 25:34I think it's important to know that our
• 25:36words and the way we communicate with people,
• 25:38it matters.
• 25:39And so using words that link to a
• 25:41patient's priorities allow them to
• 25:43decide if the trade off is worth it,
• 25:47if that burden is worth that benefit.
• 25:50Next we're going to talk about serial trials.
• 25:53And what I mean by this is you have
• 25:55an opportunity to try one of those
• 25:58interventions you think would be helpful,
• 26:00assess whether or not it helps your
• 26:02patient achieve their goal and then
• 26:04over time you can try new things.
• 26:06Serial trials you get to calibrate
• 26:08the success by if your patient
• 26:11achieve what matters most to them.
• 26:13And this,
• 26:14this step really,
• 26:15I'll say it provides me with a breath of
• 26:17relief when I think about all of those
• 26:20possible options that you could go through.
• 26:23And so you can remind yourself that you know,
• 26:25you have the opportunity to
• 26:27continue an ongoing conversation
• 26:29and try new things in the future.
• 26:31Even if you don't get the outcome
• 26:33that you intend on right away,
• 26:35you might say to your patient,
• 26:37there are several things that might
• 26:39help you be less short of breath,
• 26:41which we think is stopping
• 26:43you from getting your mail.
• 26:44Knowing what matters most to you,
• 26:47I think we should start with either more
• 26:49physical therapy or maybe pulmonary rehab.
• 26:52We have other options for later.
• 26:54What do you think?
• 26:56You can use priorities to align
• 26:59decision making among different health
• 27:01professionals when there are different
• 27:04perspectives or recommendations.
• 27:06And the main point here is that communication
• 27:10among clinicians should also focus
• 27:12on what matters most to the patient.
• 27:15You could say something to the clinician to
• 27:17your to an alternate clinician Misses BS.
• 27:20Main concern right now is fatigue,
• 27:22which is helping,
• 27:23which is keeping her from doing
• 27:24activities that matter most to her.
• 27:26While there are possible explanations,
• 27:28I'm worried that X medication might
• 27:31be contributing to her symptoms.
• 27:33What are your thoughts so you focus
• 27:35again on the the what matters
• 27:37most to the patient and not on an
• 27:41individual health condition alone.
• 27:43Back to Misses B, I've given you
• 27:44some spoilers as we've gone along,
• 27:46but Misses B wanted to get to her mail.
• 27:49She felt too short of breath
• 27:51to be able to do that,
• 27:53so we discussed trade-offs.
• 27:55We discussed that diuretic medication and
• 27:58that we felt it would be helpful to her.
• 28:00We discussed that she was willing to
• 28:03accept some increase in urinary frequency,
• 28:05and we used serial trials to figure out
• 28:08optimal timing of taking that medication.
• 28:10So she didn't feel like the urinary
• 28:12frequency was then getting in the way of
• 28:14her being able to do what she wanted to.
• 28:16We considered other medication
• 28:18adjustments as well and communicated
• 28:20with our colleagues around the patient's
• 28:22priorities about what she wanted
• 28:25to achieve out of her healthcare.
• 28:26She engaged with physical therapy.
• 28:28She was able eventually to be able to
• 28:31use the role later to get to her mailbox
• 28:33and she was able to meet her goal.
• 28:35Ultimately,
• 28:35you know,
• 28:36I'll say thinking back to that
• 28:38first visit with her,
• 28:40we ended up not pursuing repeat CAT
• 28:42scan for pulmonary nodules or biopsies.
• 28:45She didn't feel like it was going
• 28:47to help her achieve what she
• 28:50wanted to and she wasn't interested
• 28:52in additional imaging studies.
• 28:54However,
• 28:55she was able to do what mattered most to her.
• 28:59We're going to talk a little bit
• 29:01about some of the outcomes of the
• 29:03patient priorities care framework
• 29:05and and tools of decision making.
• 29:08So the the initial studies showed that
• 29:11more clinical decisions were linked
• 29:14to individual patient priorities.
• 29:16When the patient priorities
• 29:18care framework was utilized,
• 29:20you can see 66% linked to to what
• 29:24mattered most and 2% not in usual care.
• 29:27There was an increase in the care
• 29:30that was wanted by patients and a
• 29:32decrease in care that was unwanted.
• 29:35Patients reported improved
• 29:37treatment burden and importantly
• 29:40improved satisfaction as well.
• 29:44A study that took place at the
• 29:46Cleveland Clinic where clinicians
• 29:48were trained in the patient priority
• 29:50care approach to decision making
• 29:52and tools following their training.
• 29:54We had a case based virtual huddles
• 29:57where clinicians were able to
• 29:58reflect on the process of using the
• 30:01patient priorities care approach to
• 30:03decision making and implementation
• 30:05workflow and troubleshooting.
• 30:07And this was a qualitative study
• 30:09that looked at some of the clinician
• 30:12comments after implementation
• 30:13of patient priorities care.
• 30:14We we were able to identify some
• 30:19of the major challenges in the
• 30:21care of older adults which we
• 30:22went over in detail already.
• 30:24We were able to talk through
• 30:26how patient priorities care,
• 30:27directly address those challenges and
• 30:29then barriers enablers to implementation.
• 30:32And I'm going to share with you today
• 30:34a couple of quotes that were from
• 30:36the category of enablers of patient
• 30:38priorities care from the categories of
• 30:41perspective change, decision making,
• 30:43focusing and reduction and burnout.
• 30:46So we'll share some of those quotes.
• 30:47Now the more I am with my patients,
• 30:50the more I myself with my patients,
• 30:52the less burnout I feel,
• 30:54the more I feel my heart is open and
• 30:56the warmth I get from my patients
• 30:57and I get it back and that just
• 30:59helps me come to clinic every day.
• 31:03So an important quote from an actual
• 31:05clinician who's done patient priorities care.
• 31:07We've had the opportunity to do education
• 31:10with many different disciplines and
• 31:12trainees and practicing clinicians.
• 31:14I'm sharing with you here an outcomes
• 31:16table from an intervention with
• 31:19our geriatric medicine fellows.
• 31:21So after a training in patient
• 31:24priorities care,
• 31:25our fellows felt that they were
• 31:27more able to identify what mattered
• 31:29most to their patients,
• 31:30align care with that and communicate
• 31:33decision making with their patients
• 31:36and with other clinicians.
• 31:38Thank you so much for joining me today
• 31:41and for for tuning into this talk
• 31:43and sharing with you some additional
• 31:45tools in for patient priorities.
• 31:48Care there are self-directed American
• 31:50College of Physicians modules that
• 31:52are available for you to go through
• 31:54and get even more details than
• 31:56what we went through today.
• 31:58As I shared the My Health Priorities website,
• 32:01we have an implementation toolkit and
• 32:03as I mentioned that decision decision
• 32:05guide that gives you some example
• 32:08tips and scripts that you can use.
• 32:11Thank you again.