• aortic valve stenosis
• quality of health care
• delivery of health care

Shared decision-making (SDM) is accepted as an important element in improving the quality of patient care and treatment. Although healthcare professionals believe that they incorporate SDM in their daily clinical practice, the evidence proves otherwise. In evaluating cardiac treatment options, physicians generally focus on treatment complications and survival as the main outcomes.

Currently, healthcare professionals are still insufficiently trained in SDM, healthcare guidelines do not provide any indications for SDM, disease-specific guidelines often lack decision-making aids, and SDM outcomes are not systematically incorporated in an evaluation to improve the quality of healthcare.

SDM is defined as ‘a collaborative process that allows patients, relatives and clinicians to make healthcare decisions together, considering the best scientific evidence available, as well as the patient’s values, goals, and preferences’.

SDM is grounded on the ethical principles of individual self-determination and respect for autonomy. In addition to an ethical motive, SDM is also associated with benefits such as increased knowledge, more accurate risk perception, increased satisfaction with the decision and improved long-term health-related quality of life.1 Although its importance has been largely supported, the application of SDM in routine cardiac care is still limited. In addition, current SDM models for clinical practice and decision-making aids that encourage patient participation in decision-making lack focus on older patients.1 2

SDM is particularly appropriate in preferential decision-making, such as in-treatment decision-making for older patients with cardiovascular disease, for whom alternatives for major surgery are available, for example, non-surgical invasive therapy (such as transcatheter aortic valve replacement) or conservative therapy. Cardiac disease is the second leading cause of morbidity and mortality worldwide. Due to the ageing population and increasing heterogeneity and concomitant multimorbidity, the (surgical) evaluations of these patients have become more complex. Treatment considerations should balance survival, risk of short-term complications and long-term adverse outcomes, such as delirium and functional decline, that may imperil the quality of life of older patients. In addition to the evidence on benefits and harms, treatment considerations should depend on the patients’ preferences regarding quality or quantity of life. Therefore, patients should be involved in the decision-making process to improve the quality of care delivered. In 2017, Elwyn et al 3 proposed a new practice three-talk model of SDM, based on ‘team talk’, ‘option talk’ and ‘decision talk’ (table 1).

Patient-centred care encourages active collaboration and SDM between patients, their caregivers and healthcare professionals to design and manage a customised and comprehensive care plan. In the context of personalised medicine, the concept of goal setting is very important. Shared goal-setting is defined as ‘a process by which healthcare professionals and patients agree on a health-related goal’.4 Personalised care should be adapted to a patient’s goals, values and resources.5 We distinguish a three-goal model in clinical practice, namely, disease-specific or symptom-specific goals, functional goals and fundamental goals. Fundamental goals are goals that specify the patients’ priorities in life related to their values and core relationships. All three types of goals are interrelated, and explicit awareness of a patient’s goals at all three levels is needed to provide a guide for SDM in clinical practice. Otherwise, the risk of a potential mismatch between medical standards and individual patient preferences and needs increases unnecessarily.

Professional guidelines for the treatment of symptomatic patients with severe aortic stenosis (AS) recommend SDM for the integration of the involved patients’ preferences and values. The implementation of SDM in daily practice is influenced by various barriers and facilitators. Additional insight into the professionals’ and patients’ perceptions of and experiences with SDM in the treatment of AS will provide more clues to the successful implementation of SDM in cardiac care.

Van Beek-Peeters et al 6 address this important knowledge gap. These authors studied professionals’ perceptions of and experiences with SDM in the treatment of symptomatic patients with severe AS by interviewing 21 healthcare professionals from 9 out of 16 heart centres in the Netherlands. The healthcare professionals (n=21: eight cardiothoracic surgeons, seven interventional cardiologists, five nurse practitioners and one physician assistant) were all involved in the SDM process for the treatment of severe AS and were included in the study after an invitation by email requested participation.

Not all respondents defined SDM as an interaction between patient and professional, in which they discussed the pros and cons of the treatment and decisions made together. Some respondents defined SDM without any patient participation. Approximately one-third of the respondents added that professionals can express the decision during the consultation. Although respondents believed that SDM leads to appropriate care and increases patients’ motivation and treatment acceptance, it was remarkable that nearly all respondents were convinced that professionals, in particular, have expertise about treatment options. Respondents valued the patients’ ideas about treatment options but also expressed concerns about the patients’ lack of sufficient knowledge to make treatment choices and the patients’ inability to consider the decision’s consequences. Respondents only used verbal strategies during the consultation to improve patient knowledge. They emphasised the importance of patients having good communication skills and a positive attitude for their involvement in SDM. Therefore, they mentioned that patients’ characteristics for SDM, such as a low level of education, presence of cognitive impairment or difficulties in communication, complicate SDM. Some respondents noted the lack of attention for their own communication skills in daily practice or interprofessional learning opportunities. Collaboration with other disciplines, especially when a more comprehensive evaluation that tailors treatment options to patient needs is provided, will facilitate SDM in daily practice. The implementation of SDM in daily practice is limited by economic constraints, time and a lack of information regarding the patient’s personal context during cardiac team discussions.

The main advantage of this qualitative study is the results of the professionals’ views on the SDM process and highlighting some indications to improve SDM in daily cardiac care practice.

An unavoidable limitation of this study is a possible selection bias due to personal invitation by email. It could be that only healthcare professionals who already had a positive attitude towards SDM participated in the study. Another limitation of the study is that patients with AS were not involved; therefore, patients’ and informal caregivers views on SDM are insufficient.

Nevertheless, this study highlights the increasing need for further integration of SDM at the patient, professional and organisational levels of healthcare. Although a decade has passed since SDM was first implemented in daily practice, especially in cardiac care, professionals must become more familiar with the SDM concept and process.

We know little about real-time clinical practice in (surgical) decision-making among older patients with cardiovascular disease. Further research is needed to study communication patterns in current (surgical) decision-making processes in relation to theoretical SDM competencies, such as the conceptual model proposed by Elwyn. Moreover, observations of clinical practice consultations will provide insight into patients’ and professionals’ competences and needs for SDM, for example, revealing the need for patient empowerment. It is remarkable that physicians are required to take an annual resuscitation course but not to receive an annual interprofessional evaluation of their professional communication skills during SDM. Specifically, for SDM with older people, key elements of a teaching framework for physicians include creating a knowledge base for all health professionals involved, offering practical communication training, facilitating communication by SDM tools, identifying discussion partners, engaging patients, and collaborating and learning interprofessionally.7

Due to the increasing number of older people with concomitant multimorbidity, treatment decision-making processes are increasingly complex. To appropriately apply SDM to all relevant patient information, including demographics; social system; physical environment; health status; preferences to prevent, diagnose and treat diseases; related symptoms; and functional decline must be gathered. To gather all this general information for an older patient with concomitant conditions and diseases, a comprehensive geriatric assessment is increasingly recommended in disease-specific guidelines.

Currently, to fit complex SDM into interdisciplinary clinical practice, multidisciplinary cardiac team meetings must be reorganised. Before patients’ referral by the cardiologist to the heart centre, all relevant patient information must be present, including treatment goals based on shared goal-setting and SDM, prior to referral. Next, the cardiac team meetings should not be an evaluation of technical possibilities only. The referring cardiologist and the patients’ general practitioner and the patient should join this meeting as well, to optimise the SDM process.

In addition to the measured quality of the SDM construct itself by patient-reported experience and outcome (eg, decision regret), it is also necessary to structurally incorporate SDM process evaluations and outcomes into standards of hospital care.

In conclusion, specifically among older patients due to multimorbidity and heterogeneity, the SDM process is complex but still very important due to personalised healthcare and quality of care. To realise patient-centred care in complex patients, we need (1) to change our organisation by planning interdisciplinary meetings with referring specialists and general practitioners and more patient involvement, (2) to train our physicians in SDM and annually evaluate their SDM skills and (3) to incorporate SDM outcomes in quality of care standards.