Shared decision-making resources for older people living with frailty considering surgery

Internationally, one of the best known SDM models is the Three Talk model.¹ It describes:

• team talk
• option talk
• decision talk.

The Three Talk model was developed using a multi-stage consultation process and has been implemented in a wide range of clinical settings and healthcare decisions.^2,3 However, older patients living with frailty often have multiple comorbidities and other complex needs requiring an adjustment to the usual processes.^2,4

A Dutch group of researchers undertook a Delphi study to adapt the Three Talk model by expert and patient consensus for use with older patients living with frailty who have multimorbidity. The final model they arrived at includes six types of dialogue:^2,3

• preparation talk
• goal talk
• choice talk
• option talk
• decision talk
• evaluation talk.

Over the past decade there has been a growing acknowledgement that frailty is a strong predictor of poorer surgical outcomes.^5,6,7,8,10 Patients living with frailty have:⁵

• a higher post-surgery complication rate
• a greater chance of re-admission
• an increased mortality rate over the following 12 months.

This has been found to be consistent across a range of surgical procedures, including vascular, abdominal, orthopaedic, oncological and cardio-respiratory.^5,6,7,8,11

Decision-making about surgery with older patients living with frailty may involve uncertainty, limited evidence and a situation of equal balance between the available options. Given that there may be limited potential benefit and substantial harms in many cases, the patient’s values, goals and preferences need to be explicitly sought. Lengthy hospital stays and financial costs may also be a factor to weigh up with the patient and their family.

Taking a holistic view of older people living with frailty and integrating their personal preferences into surgical decisions has also been advocated by qualitative research.¹² This research recommends SDM could be facilitated by greater involvement of the patient’s GP and through engaging in the SDM process over several consultations.¹²

The use of SDM in valvular surgery decisions with older patients living with frailty has also been evaluated through the use of patient-reported outcome measures (PROMs). It showed that SDM was associated with improved quality of life.^{11, 12, 13, 14} Similarly, a study of 172 institutionalised elderly patients with proximal fractures of the femur were exposed to SDM and over half chose non-operative management.¹⁵ Quality of life was similar in both the operative and non-operative patients and adverse events were much less frequent in the non-operative group. While patients managed with non-operative methods were more likely to die within 30 days, caregivers rated their quality of death experience as much better than of those in the operative group.¹⁵

The identification of frailty pre-operatively may provide an opportunity for some patients to undergo pre-habilitation as an option. Patients living with frailty should be referred to a geriatrician or the patient’s GP to:

• review polypharmacy
• discuss goals of care
• refer to a dietitian and/or physiotherapist for progressive resistance training.

Several scales for assessing frailty exist, and some are more comprehensive than others. The RACGP Aged Care Clinical Guide (Silver Book) recommends that GPs consider an annual frailty assessment for their older patients.¹⁶

The Australian-developed FRAIL scale is a brief, validated tool that has demonstrated feasibility in a range of clinical settings, including primary and residential aged care.^17,18,19 Other commonly used frailty assessment tools include:

• Physical frailty Phenotype
• Frailty Index
• Clinical Frailty Scale
• Edmonton Frail Scale
• Timed Up and Go Test.

All these scales are linked from the RACGP Aged Care Clinical Guide (Silver Book).¹⁶

Advance care planning (ACP) is an important adjunct to SDM conversations with older patients living with frailty and their families.^{15, 20} ACP is also associated with the appointment of a proxy decision-maker and the completion of advanced directives that may be relevant for surgical decisions. Existing ACPs could be identified in the preparation talk and the topic of end of life be raised within the goal talk as:

• Do you ever think about the end-of life?
• Can you tell me more about that?

Should a more detailed discussion about ACP be required, resources are available at Advance Care Planning Australia.

There is an important inter-connection between SDM and health literacy. Improving SDM skills in patients can improve health literacy²¹ and health literacy skills are also important to enable SDM.²² The tools in this package therefore have integrated health literacy strategies, such as teach back in the healthcare professional directed resource and an accessible reading age for the patient and family resource (Grade 8 reading level).²³ Teach back involves checking understanding throughout the conversation via questions such as:

• What do you know about your current problem?
• Let me summarise what we have discussed so far and check that we haven’t missed anything.
• Do you need more time or information?
• Can you tell me in your own words what we have discussed and decided, to make sure I haven’t forgotten anything?

While it is important not to stereotype patients by their ethnic background, cultural factors can affect conversations about treatment decisions for elderly patients.²⁴ For example, East Asian cultures can be influenced by the concept of filial piety emanating from Confucianism, Buddhism and Taoism. Therefore, family members and doctors may dominate the discussions in some families.²⁵ It has been suggested that appealing to a collectivist mindset might be one way to overcome this.²⁵

Despite the diversity of cultural backgrounds and religious beliefs, resources available to assist discussions are limited.²⁶ Cultural factors may be highlighted through questions in these guides such as:

• What’s important to you? (your culture, traditions and spiritual beliefs)
• Is there someone who you would like to help support you in making the decision? If so, who would that be?

SDM is now an integral part of the National Standards for Quality and Safety in Australia.^{27, 28} It “involves discussion and collaboration between the consumer and their healthcare provider. It is about bringing together the consumer’s values, goals and preferences with the best available evidence about benefits, risks and uncertainty of treatment, in order to reach the most appropriate healthcare decisions for that person”.²⁸

The use of SDM tools, such as question prompt lists and patient decision aids, improves a patient’s understanding of the benefits and risks of treatment options and result in more informed decisions aligning with their personal preferences.^{29, 30}

Several studies have shown that when patients are encouraged to ask questions about their options, there is an increase in the discussion of evidence. Their preferences are also more likely to be considered and there is greater satisfaction with the decision made.^{31, 32 ,33 ,34} There is also evidence that improving SDM skills improves health literacy.^{21, 22} Importantly also, we know that when patients are given options in a balanced way through SDM, they are less likely to choose invasive elective surgery and more likely to opt for conservative options.²⁹

Multiple comorbidities are a common feature of frailty in the elderly and treatment can come with a substantial burden. The concept of minimally disruptive medicine (MDM) “explicitly acknowledges that guidelines and protocols may need to be adjusted to take into account patients’ preference, context and circumstances when the burden of treatment is assessed”.³⁵

An Australian survey of 2,500 people aged over 50 years found that people with five or more chronic illnesses spent an average of 2.5 to 3.5 hours per day on healthcare-related activities.³⁶ Thus MDM is now a concept embedded within the RACGP Aged Care Clinical Guide (Silver Book).¹⁶ It is important to consider that the outcomes of surgery for some older people living with frailty may lessen or increase this burden. Therefore, we have included several MDM questions in the resources to integrate this concept. These are:

• Are there things your healthcare team have asked you to do, that you find helpful?
• Do they improve your health and wellbeing?
• What are they? (For example, medicines, tests, diet, exercises, wound care, other).
• Are there things your healthcare team have asked you to do that you find unhelpful?
• Do they cause you trouble or stress?
• What are they? (For example, medicines, tests, diet, exercises, wound care, other).
• What are your days like when you are not at healthcare visits?
• Where do you find the most joy or happiness in your life?^{4, 16}

If a more detailed MDM assessment is required, the I-CAN tool could be used.