Shared decision making and personalised care support planning: pillars of integrated care for older people

Abstract

Shared decision making (SDM) is a process in which individuals and clinicians work together to select tests, treatment and agree on management decisions based on the best available evidence, individual preferences, and values. SDM is based on a two-way communication on what matters most to individuals and empowers both the individual and clinician to arrive at a final management decision, which also includes medication management, self-care, and lifestyle changes. SDM is associated with better outcomes and greater patient satisfaction. Older people are a heterogeneous group of individuals whose needs often span several domains including social, psychological, cognitive as well as physical and as such require a different approach to SDM. Personalised care support planning is a future focused conversation that supports older people living with multimorbidity, frailty and disability. Goals for long term treatment and management plans are obtained through holistic, multidisciplinary led Comprehensive Geriatric Assessment (CGA).