AN AUDIT OF SHARED DECISION MAKING IN THE LOW CLEARANCE CLINIC –
A PROBLEM OF PRACTICE OR DOCUMENTATION?
Introduction:
The most significant choice faced by people with deteriorating chronic kidney disease (CKD)
concerns which treatment path to follow as their kidneys stop working, namely dialysis
(haemodialysis or peritoneal), transplantation, or conservative management. For some patients,
strong evidence of superiority of one therapy over the others is lacking, but the choice made will
have profound effects on lifestyle and routine; the decision should therefore be made cooperatively between patient and clinician. Benefits of sharing the decision include greater
adherence and satisfaction for patients (DH 2011, Ouwens 2005), improved clinical outcomes
and safety and reduced service use (Ouwens 2005, Mosen et al 2007), and reduced practice
variation (Glover 1938).
Aim:
This audit aimed to measure the degree to which the choice of advanced CKD therapy was
shared between patients and clinicians in a low clearance clinic.
Method:
Evidence that decision making had been shared was extracted from the ‘Low Clearance
Education’ page of the unit’s electronic database. The following questions were asked:
· Has the patient been given information about all appropriate therapy options?
· Has the clinician advised the patient which option(s) is medically superior?
· Has the patient provided information regarding their beliefs, values, and lifestyle?
· Has a decision been reached?
Non-completion or negative responses to any of these components would indicate that the
decision-making process had not been fully shared. All patients whose modality was ‘Low
Clearance’ on May 2015 were included in the audit. Excluding factors were an eGFR over
15ml/min (at this level there is less clinical need to have reached a decision) and less than 90
days in low clearance care (which could be inadequate time for all the stages of shared decision
making to have been completed for a non-urgent decision).
Results:
There were 303 patients included, 82.5% of whom had reached a decision. However, only 18%
had documented evidence of a fully shared decision. 62% of patients had had their values
recorded. Only 58% had been given information about all appropriate therapy options, and very
few – 9% - had documentation of the clinician’s recommendation. 5% had no elements of
shared decision making documented at all.
Discussion:
Almost all patients experienced at least one element of shared decision making but only 18%
had completed all the steps necessary for the decision to be fully shared. This was despite the
active promotion of shared decision making amongst the clinicians of the low clearance clinic
and its involvement in shared decision making initiatives and projects. This low figure is likely
to be due at least in part to inadequate documentation. In order to be practicable the audit
reviewed just one summary page of the database, and thus may have missed evidence of shared
decision processes. For example, complex discussions with patients are often recorded across a
series of clinical letters. It is also possible that some qualitative comments are not recorded at
all. Thus the degree to which decisions are shared may well be significantly higher than shown
in this audit. As the commissioners of low clearance services (NHS England) ask for audited
evidence of shared decision making as a marker of quality care, this problem of how to record
and measure the sharing of decisions needs resolution. Certainly steps should be taken to
improve and standardize clinician documentation. Asking patients themselves how involved
they were in the decision may also provide a useful measure.