In our article recently published in Medical Decision Making, we qualitatively explored the experience of shared-decision making (SDM) in the setting of acute myocardial infarction (AMI), from the point of view of both cardiologists and patients. We conducted 20 interviews with older adults (age ≥70) who had been hospitalized with AMI, and 20 interviews with cardiologists. Six major themes emerged from our analysis:
1) patients felt their only choice was to undergo an invasive procedure;
2) patients placed a high level of trust and gratitude toward physicians;
3) patients wanted to be more informed about the procedures they underwent;
4) for cardiologists, age was not a major contraindication to intervention, while cognitive impairment and functional limitation were;
5) while cardiologists intuitively understood the concept of SDM, interpretations varied;
6) cardiologists considered SDM to be useful in the setting of non-ST elevated myocardial infarction (NSTEMI) but not ST-elevated myocardial infarction (STEMI).
Our most salient finding was that patients felt they had no choice but to undergo intervention, whereas cardiologists stated there was a need for deliberate shared decision making about intervention in older adults with NSTEMI because of the increased risks involved with catheterization in older patients who present with greater comorbidities.
This discrepancy suggests that, from the patient perspective, conversations in practice were often inadequate to be fully informational. Solutions to this shortfall are complex, especially in light of time constraints in current inpatient settings. However, we suggest in our article that a decision aid may help to provide standardized information to patients, as well as individualized risk prediction (e.g., for risk of contrast-related acute kidney injury). This may alleviate some of the stress and uncertainty involved in discussing evidence-based risks for physicians, and it could increase patients’ awareness of a choice.
Our study had several limitations, including the typical bias in research studies of enrolling “healthier” participants (e.g. cognitively intact) who may have had the most to gain from an intervention. Moreover nearly all patients interviewed underwent invasive coronary angiography (rather than conservative management with medications alone), which omits the decisional needs of patients who chose to decline the procedure. This finding likely reflects a combination of institutional practice, national trends toward more invasive procedures in older adults, and selection bias.
Despite these limitations, to our knowledge this is the first study of SDM in the setting of AMI that incorporates both patient and cardiologist perspectives. We hope (1) it highlights the importance of capturing this dual perspective when discussing SDM and (2) SDM can be made more effective for older adults with NSTEMI with the implementation of a decision aid to help physicians faced with a lack of clear evidence for this older population, and patients who may benefit from being more informed.
By Eleonore Grant, MD Candidate 2022
Perelman School of Medicine at the University of Pennsylvania