Table 5:

Comparison of 3 sample transcripts of IDT meetings demonstrating shared decision making

Transcript 1: Discussion in which most (8) SDM elements were observed
NURSE – [Patient] is 70 years old. He’s on service for bladder cancer with multiple metastatic areas especially the chest. I haven’t been able to see him or talk to him since you started that ointment. CAREGIVER – He really is having smells by the groin area because he is starting to have lesions but my worry is I smell something. I think it’s like getting infected. Because it’s bleeding and it’s crusted and peeling off and it’s like his skin is being eaten. (Defining the problem) NURSE – On the chest or on the groin? CAREGIVER – On the abdomen the one that has the crusting. The one on the chest, it’s gotten worse, it’s different now it’s like white and big nodules. So, it’s really gotten worse since the last time you saw it and you took picture. NURSE (wound care) – My name is [NURSE], I’m the wound care NURSE. What your describing sounds like it’s uh, the cancer tumors themselves that have presented onto his abdomen, his groin and on his chest. The way that cancer tumors work, the way that they always function is they go towards blood sources CAREGIVER – Uh huh. NURSE (wound care) -So they go through mini-vessels that will feed them for a little while but because they’re uncontrolled tissue, they end up eating through that and that’s when that white tissue starts to form because that’s when that’s technically dead tissue. The smell that you have is called anaerobic bacteria. It’s not an infection. It’s just because there’s no blood supply to the area to fight it off. CAREGIVER – Okay NURSE (wound care) -The cream that we provided has the metronidazole in it that’s supposed to help with some of the odor. Then as it starts to drain more and get rid of that dead tissue, the odor will become less. But we can look at that too. We can always increase the metronidazole in it or we can tweak the cream as we go along. (Identifying solutions, Discussing risks and benefits of treatment) CAREGIVER – Does it have the metronidazole? I think it only has, what do you call it now, the numbing. DOCTOR – The lidocaine. CAREGIVER – I don’t think is has the metronidazole. DOCTOR – If it doesn’t have Flagyl, we can add Flagyl in it. (Provider recommendation) NURSE (wound care) – Okay, they will add metronidazole to it so that it’ll take care of the odor. Okay? CAREGIVER – Okay. (Make decision) NURSE (wound care) -So that’s helpful to know, I thought we had it already in there. So, you should start seeing an improvement. Now are you doing it four times a day? (Assess caregiver self-efficacy) CAREGIVER – It’s four times a day. NURSE (wound care) – As needed, okay. How often are you doing it every day? (Assess understanding) CAREGIVER – At least twice. NURSE (wound care) – Okay. CAREGIVER – But, one time, one day was like three times. Because he was complaining of a lot of pain. DOCTOR– Okay, So, [NURSE] will be following up with you. And if you’ve got any questions or concerns, you know to call, okay? (Follow up) CAREGIVER – Okay, yeah, thank you very much
Transcript 2: Discussion in which most SDM elements were observed but problematic (no decision made and lack of follow-up to caregiver identified problems)
NURSE: I was just talking to [DOCTOR], we started [Patient] on some steroids because she was having a lot of shooting pains down her leg, and that was just started yesterday. And last night, she was pretty restless, having night sweats and stuff like that, so [DOCTOR] said that if she was really symptomatic she could either not take it or do like half a tablet. She’s only had 4mg. I suggested running a full fan. (Defining the problem) CAREGIVER: The sweating actually started about an hour after she took it. She kind of started pouring sweat. She was using her little fan during the day, and she has one that goes around her neck, [and] has two little fans that point right at her. I told her that [NURSE] said we can do a ½ a tab. …hoping that it might help, so she did take a ½ a tab. She’s having a lot of nausea today, and she’s really tired from not sleeping well last night, and she’s feeling nauseous. So yesterday was a pretty good day, except for the sweating. Otherwise she was having a pretty good day. She hardly needed any pain meds. She was very awake and alert, but maybe a tiny bit agitated, but not bad. But today she is just not feeling good. (Identifying solutions) NURSE: Yeah, and we had just started her on 25 mics of fentanyl, which has been really effective, and she doesn’t need it as much [for] breakthrough pain. [CAREGIVER], since you have the whole team here and [DOCTOR], do you have any questions that you would like to ask him? (Assessing family understanding) CAREGIVER: … I guess I’m just kind of wondering where we are in the progress of things, and it’s so hard to know what the cancer is doing inside her body because you can’t see it. NURSE: I know, that’s a hard question. You just have to keep taking it one day at a time and see how she’s eating and drinking and keep her as comfortable as you can. CAREGIVER: Yeah, she’s definitely resistant to the morphine. She really doesn’t like how it knocks her out and makes her feel. I can get her to take an Oxy [Contin] … but she’s really resisting that morphine. We did it a couple times, and it just knocked her on her butt, and she just didn’t want it. She didn’t want to take anything the next day, and I had to remind her that the Oxy[Contin] is not bothering her, it’s the morphine that does that. [I’m] just concerned as things progress … that she’s going to be very resistant to the morphine when she needs it. (incorporating patient/family values and preferences) DOCTOR: She might be better off with the Fentanyl, which is a little smoother without the ups and downs, and I think hanging in there with the steroids would be worth another try, both for the nausea, pain, [and] just general energy level. I think it could help in just every regard. (Discussion of risks and benefits) CAREGIVER: Yeah, that’s why I … told her let’s not give up on it yet …. The sleeping part will get better in a few days, and let’s do ½ a tab. It’s better than not doing anything. SOCIAL WORKER: Hi, [CAREGIVER]. It’s [Social Worker]. I just wanted to check in and see how you are holding up. (Assess family self-efficacy) CAREGIVER: Um, pretty good. Actually, I started feeling like I was crashing a little bit, so I took the day off work yesterday, and [Patient]’s other caregiver was here, and I just got out of the house and went and did some stuff to basically recharge myself, so that was very helpful. SOCIAL WORKER: Good self-care. CAREGIVER: Yeah, I was like, I’m going to have to do that. I’m going to be useless if I don’t, so it was very helpful—exactly what I needed—to do something that felt like normal. CHAPLAIN: This is [Chaplain]. I was there last Wednesday and provided a visit to you and your mother. I just wanted to give you a suggestion: You can always reach out to me and call the office if you need that emotional support via a phone call or even if you want me to come out and, you know, do a visit with you one-on-one—give you some reaffirmation that you are doing everything that you can do. You know, I’m here. The team is here for you. (Provider recommendation and Follow up) CAREGIVER: Okay. Thank you.
Transcript 3: Discussion in which many SDM elements were not observed
CAREGIVER: [Patient] loses his ambulatory skills and all that stuff. You know, things are getting a little bit harder. He feels like he can still do all these things, and so it’s difficult, you know, not to argue with him, you know saying, like he wants to get up and not be late for school. And he has to go, so it’s hard to help him understand that he doesn’t have to go to school. You know, but in his mind he still thinks he’s late. (Defining problem) HOME HEALTH AIDE: He gets seen 3 times a week, and he is a two-person transfer. CAREGIVER: Is somebody talking to me? NURSE: No. She was giving her report that he is seen. Who is next? CAREGIVER: Okay. CHAPLAIN: Hi, [CAREGIVER]. This is the Chaplain. I’m one of the chaplains, but it is someone else who is [Patient]’s chaplain. Looks like he visits at least once a month …. CAREGIVER: Right CHAPLAIN: And he hasn’t made a visit in the last two weeks. CAREGIVER: No, he has not. CHAPLAIN: Okay. But he remains available. CAREGIVER: Okay. I mean, [Patient]’s pastor does come out or his, you know, [Priest] comes out and gives him communion. Typically, every week. He’s on vacation right now, but he does come out and give him communion quite a bit. CHAPLAIN: That’s good. Okay. VOLUNTEER COORDINATOR: Hi. This is [Volunteer Coordinator] from the Volunteer Department. And currently we have no volunteer assigned to [Patient]. CAREGIVER: Yes, and I was thinking about that—that maybe he does need, you know, just someone to come and talk to him and help him understand some of the things. You know, because honestly, every single one of us that are taking care of him, you know, we are, we don’t have that outside voice. You know, we’re his sisters, you know. Does he really pay attention to us? (Identifying solution) Volunteer Coordinator: Okay. CAREGIVER: And, you know, maybe help him understand what is happening. Because I do think he is forgetting what’s going on with him. Volunteer Coordinator: Alright. If we assign a volunteer to him, they’re for companionship. CAREGIVER: And that’s all it is? Just somebody to talk to? Volunteer Coordinator: Right. They wouldn’t be able to do any healthcare discussions. They would just be there to support him. (Assessing caregiver understanding) CAREGIVER: Oh. Well, even with that we could try it. You know, just somebody … for him to bond with or something. Volunteer Coordinator: Alright. Okay. Alright, I will give that message to Sherry, and she will see what she can do for you then. NURSE: I’m just reading through [another nurse]’s reports here. She’s got that he’s got some increased confusion. (Defining a problem) CAREGIVER: Yes. NURSE: Yeah. Also he’s been having more increased difficulty with walking and balancing, having more trouble like sitting up. (Defining a problem) CAREGIVER: Yes. He cannot hold. He cannot sit in a chair without falling to his right, and if there is any tilt to it at all, he slides out of the chair. He doesn’t realize that he’s falling over because we have to tell him that, so we try to make sure that if he is in a recliner that he is leaning back so that he doesn’t have that stress on him. But no, … he cannot sit up straight …. This past week … I don’t know what he did, but I found him on the floor, and during the night and for two days he had a backache. But I think it was from laying on the floor. Because I don’t know how long he was there. (Defining a problem) NURSE: Yeah, the first couple of days are usually the worst after a fall. Okay. Alright. Well if you ever have any questions, you know you can always give us a call. We can answer any questions 24/7, or we can send a nurse out if we need too. (Follow up)