Pharmacotherapy

Decision-Making
PD 612
Learning Objectives:

At the end of the lecture the students will be able to:

 Define the different aspects of pharmacotherapy
decision making
 Explain the process of decision making in pharmacy
practice.
 Pharmacotherapy decision making involves more than evidence;
pharmacists should understand the evidence and individualize
decision making according to individual patients’ needs.
 Its is a formal process that defines the way a practitioner arrives at a
decision from the information at hand.
 Decision-making in pharmacy practice can be conceptualized as a
series of cognitive processes and skills that allow pharmacists to make
patient-centered, therapeutic decisions.
 Clinical decision-making skills are recognized as a central component
of professional competency.
 Decision making has been described as a 7-step process

(1) identifying the need for a decision,

(2) gathering information,
(3) identifying alternatives,
(4) weighing the evidence,
(5) choosing among alternatives,
(6) take action and
(7) reviewing the decision.
A general model for the clinical decision-
making process in pharmacy. The dashed line around
the decision component indicates that this is the final
step in process and will be enacted with the patient.
 Information gathering.
 Information gathering is a multifaceted stage and will include a diverse
range of tasks including, but not limited to;

 identifying the need for a decision,

 an assessment of laboratory results,
 the identification of drug-related problems,
 the initial description of treatment and patient-centered goals,
 patient assessment (physical and psycho-social),
 a review of relevant literature related to therapeutic entities,
 and a consideration of patient factors that may impact drug therapies
(e.g. risk of adverse effects).
 This might occur while conducting medicines review
services, during a patient consultation, while
monitoring the outcomes of a previous decision, or
from an external source, e.g. a referral.
 In some cases, the signal that initiates the decision-
making process may be driven by the patient, and in
other cases, may occur in the absence of direct patient
contact. The types of signals that initiate the decision-
making process are diverse, and will inevitably extend
beyond ‘drug-related problems’ as defined
in pharmaceutical care.
 The information gathering stage does not necessarily
need to be contextualized to an individual patient.
 A pharmacist could, for example, research and answer a
drug information query without access to detailed
patient information.
 Likewise, a clinical check of a prescription that requires
clarification with the prescriber (as may occur if an
inappropriate dose is identified) may only superficially
extend beyond information gathering in the absence of
patient level data.
 Clinical Reasoning
 Clinical reasoning (predicated on health information i.e. a function of
patient related factors and evidence based practice), requires the
pharmacist to appraise the information gathered and to contextualize this
specifically to the goals of the patient.
 The aim of this stage is to curate the information gathered and synthesize a
viable set of options in the context of the patient's goals.
 Clinical reasoning is much more than the collation of options from the
evidence-base or from published treatment guidelines.
 It requires the pharmacist to use critical thinking skills to appraise the
information gathered and to ensure that the information is robust so it will
suit the needs of the patient.
 The clinical reasoning step will provide the basic components to enable
clinical judgment.
 Questions to Develop Clinical
Reasoning (examples)
1. What clinical data from the patient’s chart is relevant and must be recognized as
significant?
2. Which priority will guide the plan of care?
3. What is the desired patient outcome?
4. What interventions will be initiated based on this priority and desired outcome?
5. How will the effectiveness of the pharmacist interventions be evaluated?
6. What assessment(s) will be focused on based on the patient’s primary problem or
pharmacy care priority?
7.What recently collected clinical assessment data are relevant and must be
recognized as significant?
8. What relevant clinical assessment data need to be closely watched to detect a
possible change in status?
9. What is the worst possible/most likely complication(s) to anticipate today with this
patient?
10. What assessments need to be initiated to identify if this complication develops?
Clinical Judgment.

 Clinical judgment can be understood as the process of

weighing-up the options available, and prioritizing
them on the basis of their impact.
 The impact of a decision will extend beyond the
treatment outcomes for the patient's health and may
also include financial considerations, social
implications, effects on the patient's family, or how
the patient interacts with other health services.
 In all cases, judgment involves a benefit-risk
assessment.
Decision

 Making a decision is the final stage in the process and it

is made in partnership with the patient.
 In the judgment step, the practitioner will assign a
weighing to each reasoned option.
 Importantly, this is the transition from a set of
weighted options to a patient-centered decision.
 In this way, the decision step concludes a judgment with
an action such that the patient is part of the
interpretation of the judgment.
 The decision stage has at least two embedded tasks:
(i) a patient-centered consideration of the pertinent judgments through
an open and supportive communication framework and
(ii) the enactment of the decision. In the enactment of the decision, the
consultative recipient may either be the patient or another health
professional.
Decisions are based on many factors including;

 those relating to the history and goals of the patient

and family,
 the current evidence base for medicine effectiveness,
 the pharmacological and pharmaceutical implications of
the drug and product,
 social expectations and constraints, and the ability of
the practitioner to arrive at,
 communicate and negotiate the decision.
 ROLE OF PHARMACIST IN
DECISION MAKING:
 The role of pharmacists naturally align with
 Beneficent (to do good) and
 Non-maleficent (to avoid harm) activities.
 Primary beneficence refers to a decision of a practitioner that was
self-initiated, i.e. the practitioner initiated the decision making
process.
 A primary beneficent service is one in which the pharmacist is the
initiator of a treatment or intervention that has not previously been
considered by another healthcare professional.
 A pharmacist providing primary beneficent services will identify the
need for a decision and continue through the process to enact a
decision in an independent and autonomous manner.
 A typical example might be a prescribing pharmacist or medical
practitioner diagnosing and initiating treatment of a condition.
 A primary beneficent service could include a pharmacist vaccinating a
patient.
 Secondary beneficence refers to a decision of a second practitioner
that is intended to influence the decision of the initiating (primary
beneficent) practitioner.
 A secondary beneficent service is one where a pharmacist provides
support to another (primary beneficent) practitioner. To this end, the
pharmacist (the secondary beneficent practitioner) is involved in the
overall decision-making process up to and acting to influence the
reasoning, judgments, or decisions that were initiated by a primary
beneficent practitioner to improve patient outcomes.
 An example of a secondary beneficent service is a pharmacist may
contact a prescriber about a clinical concern and provide advice
intended to improve health outcomes in the patient.
 A co-beneficent service requires the pharmacist to work collaboratively
with another healthcare practitioner and to share the responsibility for a
decision that is made and enacted together.
 Providing a co-beneficent service may involve asynchronous completion of
the decision-making cycle by the two practitioners in order to complete
different aspects of the process.
 In practice, a co-beneficent service might involve shared prescribing
roles between a pharmacist and a medical practitioner in a primary care
setting.
 In this setting the physician may assign the diagnostic label and identify
the overall therapeutic approach that aligns with their prognostic
reasoning and the pharmacist may identify and endorse the particular
therapeutic intervention. Separation of the roles of diagnostician and
prescriber has potential significant advantages.
Collaborative Decision Making
Pharmacists as the non-maleficent
practitioner

 Non-maleficent pharmacy service may be primarily drug-

focused and could occur in a setting with limited access to
patient information.
 An example would be providing a clinical check for drug
interactions at the time of dispensing. In this case, the
pharmacist is identifying a signal of a potential harm, is
acting on this via the decision process, and will follow up
with the practitioner or patient.
 In this example, the pharmacist did not instigate the care
process (i.e. the diagnosis and prescription) but rather
provides support to the process.
 Non-maleficent services could also be a primary component
of a patient-centered clinical role for the purposes of
reducing iatrogenic burden, e.g. identifying medicines
that carry risk with limited anticipated benefit in a de-
prescribing service.
A model for the clinical decision-making cycle for non-maleficent
pharmacy practice. The ‘decision’ component associated with the non-
maleficent cycle concerns the interaction with the primary beneficent
practitioner.
 The professional activities of a pharmacist may have
both non-maleficent and beneficent components, either
within the same role or in different roles that they may
perform.
 For instance, the clinical checking of prescriptions (in
the absence of information about diagnosis and medical
goals) will require predominately a non-maleficent
approach where the pharmacist may primarily see their
role to reduce harm.
The “What,” “Why,” and “When”
of
Decision Making

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Definition

 Shared decision making occurs when a health care

provider and a patient work together to make a health
care decision that is best for the patient.
 The optimal decision takes into account evidence-
based information about available options, the
provider’s knowledge and experience, and the
patient’s values and preferences.
 Patient perspectives, beliefs, expectations, and goals
for their health and life, including the process that
patients go through in weighing the potential benefits,
harms, costs, and burdens associated with different
treatment or disease management.

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The SHARE Approach

 The SHARE Approach is a five-step process for shared

decision making that includes exploring and comparing
the benefits, harms, and risks of each health care
option through meaningful dialogue about what matters
most to the patient.

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The SHARE Approach

 Step 1: Seek your patient’s participation

 Step 2: Help your patient explore and compare
treatment options
 Step 3: Assess your patient’s values and preferences
 Step 4: Reach a decision with your patient
 Step 5: Evaluate your patient’s decision

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Nine essential elements

1. Define/explain problem.
2. Present options.
3. Discuss benefits/risks/costs.
4. Clarify patient’s values/preferences.
5. Discuss patient ability/self-efficacy.
6. Discuss doctor knowledge/recommendations.
7. Check/clarify patient’s understanding.
8. Make or defer a decision.
9. Arrange follow-up.

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Why shared decision making is important?

 In many cases there are several treatment options

available.
 Evidence-based assessments of treatments and
interventions often fail to identify one treatment as
clearly superior to another.
 Shared decision making (guided by providers) can help
patients understand the benefits and harms of the
options and clarify their own values and preferences.

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 Benefits for your patients
 Shared decision making can:

 Improve the patient’s experience of care

 Improve patient adherence to treatment

recommendations - emerging evidence that
it can help improve health outcomes

Benefits for your organization

 Shared decision making can:
 Improve the quality of care delivered
 Increase patient satisfaction

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When to engage in shared decision making?

 Engage when your patient has a health problem that

needs a treatment decision.
 Not every patient encounter requires shared decision
making.
 Some patients may not want to or be ready to
participate in shared decision making.

 A patient choosing not to

participate in the decision-making
process is still making
a decision.
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The “Who” and “How” of
Decision Making

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Who is involved in shared decision
making in the clinical setting?

 The entire medical team should be familiar with and involved in shared
decision making.

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Collaborative roles in shared decision making – Key Roles

 Patient
 Actively participates and is the center of shared
decision making
 Physician, Pharmacist, physician assistant,
or nurse practitioner
 Lets their patient know there is a choice and invites
patient to be involved in the decision
 Presents options and describes the risks and harms
 Explores patient’s values and preference

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Collaborative roles in shared decision
making
 Family members and caregivers
 Offer support in clarifying the patient’s values and
preferences
 Serve as legal proxy for children, elderly, or
seriously ill patients

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Collaborative roles in shared decision
making
 Medical treatment specialists
 Offer input when treatment options require input from specialists

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Supportive materials

Decision support
resources are an
important part of
the “how” of
shared decision
making.

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Using evidence-based decision aids
to support shared decision making

 Rely on materials that have reliable, unbiased

summaries of evidence-based research.

 Reputed International Organizations have

many evidence-based treatment option resources.

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Benefits of using decision aids
in shared decision making
 Improves patient’s knowledge of options

 Results in patient having more accurate

expectations of possible benefits and risks

 Leads to patient making decisions that are more

consistent with his/her values

 Increases patient’s participation in decision making

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The SHARE Approach
Step by Step

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Key takeaways

 Shared decision making is a two-way street

 Occurs when a health care provider

and a patient work together to make a
health care decision that is best for
the patient.
 The optimal decision takes into
account evidence-based information
about available options, the provider’s
knowledge and experience, and the
patient’s values and preferences.

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Key takeaways

 The SHARE Approach is a five-step process for shared

decision making that includes exploring and comparing
the benefits, harms, and risks of each health care
option through meaningful dialogue about what matters
most to the patient.
 Conversation starters can help you engage patients as
you present each of the SHARE Approach Model’s five
steps.

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Key takeaways

 Using evidence-based decision aids in shared decision making can:

 Improve patient’s knowledge of options
 Result in patient having more accurate expectations of possible benefits
and risks
 Lead to patient making decisions that are more consistent with their
values
 Increase patient’s participation in decision making

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Any Questions