Breast Cancer

Excerpt from Shared Decision-Making is Contagious, by Joyce Kramer, BA, RN, Allina Health System:

After more than a year of diligent work from committees, patient advisory groups and executive leadership to find a way to navigate cancer patients across the system; a small community hospital & clinic decided to hire a cancer care coordinator, that person was me. This is my story, which is a part of a larger story that continues. Breast cancer care coordination was identified as the first priority. I began to develop a framework for a breast cancer program; or another way to put it, a breast center without walls. The first step was to identify physician champions; which included breast surgeon, primary care provider, medical oncologist, pathologist and breast radiologist. Working in tandem with physician champions; clinic work flows that followed the patient trajectory were developed and adopted as policy. Breast cancer education materials such as surgical discharge instruction booklets were developed. EMR documentation and care coordination education sessions were built into scheduling. Next, presentations about breast care coordination was provided for all staff, provider and executive leadership with the intent to keep the interest level high and gain support top down and bottom up. Our breast center without walls was up and running, with predictable tweaks along the way.

Sometime later, I started hearing about a thing called shared decision making in some of my meetings. Then I received a formal invitation to DO shared decision-making using decision aids for men newly diagnosed with prostate cancer. So again, we enlisted a physician champion, a urologist who was at first reluctant to add more education materials or rework his patient work flow to include shared decision-making. I’ll admit, I was skeptical as well, but once I saw the decision aid and we worked out the details of shared decision-making timing, I was willing to try. I met with his patients after he called them with biopsy results. He informed them that they needed to meet with me before their surgical consult- all patients agreed. Cancer patients are hungry for information about their disease and treatment options so it wasn’t a hard sell.

During our shared decision-making sessions, I reviewed pathology results, in most cases these were men with low- grade, low-risk prostate cancer. I used the decision aid to review treatment options, risk, and benefit and discussed their initial thoughts about a treatment option that would fit with their personal preferences and values. I documented shared decision- making sessions in the EMR and routed it to the urologist and primary provider to close the loop and communicate what treatment option interested them. I assigned them homework before they met with the urologist- review the decision aid before your surgical consult and I will be at available to answer questions or provide additional resources. The urologist told me he asked every patient the same question; “did you find the decision aid and shared decision-making session valuable, a resounding YES from all except one that fell under the radar and was missed. When he met with patients in consultation, they were relaxed and focused; they had excellent questions; patient satisfaction increased, he was saving time and providing better care, the provider satisfaction increased.

A light bulb went on for me when I met with men for shared decision-making and used the decision aid, “this is exactly what I’m doing with breast patients, minus a decision aid!” I intuitively was doing shared decision-making. As a nurse, in addition to clinical functions, this is the bulk of our work, we educate and support patients. I raised the question to the shared decision-making powers that be. “May I have decision aids for breast cancer patients?” Shared decision-making was embedded into breast workflows, prior to surgical consult. In both patient populations, patients presented at consult relaxed and focused; they had excellent questions, patient satisfaction increased. The surgeons were saving time and felt they were providing better care, provider satisfaction increased. The shared decision-making bug is highly contagious. It continues to find its way to patients, providers and work flows where preference sensitive conditions exist and there are willing hosts.

Hip Treatment

(coming soon)

Knee Treatment

(coming coon)

Lower Back Pain

(coming soon)

Prostate Cancer

Excerpt from Weighty Choices, in Patients’ Hands, by Laura Landro Wall Street Journal, August 2009:

Thomas Stormont, a urologist and surgeon at Stillwater Medical Group in Stillwater, Minn., was skeptical at first when the group agreed to use the shared-decision-making aids provided by the Foundation for Informed Medical Decision Making as part of a demonstration project. Although the material is reviewed semi-annually for possible updating, Dr. Stormont felt the video and booklet on prostate cancer were incomplete. They didn’t cover some of the newer treatments, for instance, such as prostate cryoablation, the freezing of the prostate to treat localized cancer. “I thought it would be a waste of time, another barrier between me and the patient, and more literature I wasn’t in control of,” he says. Dr. Stormont agreed to use the programs, but supplements them with his own literature that includes information on newer treatment options. He says he has found that the decision aids help patients and their spouses get better educated about early prostate cancer, so his time with them is “more relaxed, efficient and focused.”

Patients have more realistic expectations about their treatment and side effects and are less likely to seek out second opinions, he says. They also are more comfortable choosing less-invasive treatments after reviewing the decision aids, he says. “On one hand, while I am losing some surgical patients because of this process, on the other, we both are more comfortable that they are choosing the best treatment for them—one that they are more informed about, more comfortable with and less likely to regret later on,” he says.

Don Paulson, 74, a patient of Dr. Stormont, learned last week that he has prostate cancer, which he says came as a shock after years of good health. At an initial counseling session, oncology care coordinator Joyce Kramer went over the diagnosis and treatment options with him and his wife, Phyllis. She reassured the couple that the cancer was not life threatening and sent them home with a prostate-cancer DVD and some printed literature to view prior to a visit with Dr. Stormont over the weekend. “We had a chance to digest it rather than getting it all in one big chunk,” says Mr. Paulson. After watching the video, Mr. Paulson says he felt he understood his options far better. He is now weighing whether to chose the implantation of radioactive seeds, or try the cryoablation described by Dr. Stormont, who performs the procedure. “If we had just gone straight to the doctor’s office and heard all of these options it would have been too much. It was good to be knowledgeable and review all of the possible side effects of different treatments first.”