Abstract
BackgroundShared decision making (SDM), utilising the expertise of both patient and clinician, is a key feature of good-quality patient care. Multimorbidity can complicate SDM, yet few studies have explored this dynamic for older patients with multimorbidity in general practice.AimTo explore factors influencing SDM from the perspectives of older patients with multimorbidity and GPs, to inform improvements in personalised care.Design and settingQualitative study. General practices (rural and urban) in Devon, England.MethodFour focus groups: two with patients (aged ≥65 years with multimorbidity) and two with GPs. Data were coded inductively by applying thematic analysis.ResultsPatient acknowledgement of clinician medicolegal vulnerability in the context of multimorbidity, and their recognition of this as a barrier to SDM, is a new finding. Medicolegal vulnerability was a unifying theme for other reported barriers to SDM. These included expectations for GPs to follow clinical guidelines, challenges encountered in applying guidelines and in communicating clinical uncertainty, and limited clinician self-efficacy for SDM. Increasing consultation duration and improving continuity were viewed as facilitators.ConclusionClinician perceptions of medicolegal vulnerability are recognised by both patients and GPs as a barrier to SDM and should be addressed to optimise delivery of personalised care. Greater awareness of multimorbidity guidelines is needed. Educating clinicians in the communication of uncertainty should be a core component of SDM training. The incorrect perception that most clinicians already effectively facilitate SDM should be addressed to improve the uptake of personalised care interventions.
Highlights
The population is ageing and the ‘older’ age group is widening
Clinician perceptions of medicolegal vulnerability are recognised by both patients and GPs as a barrier to shared decision-making and should be addressed to optimise delivery of personalised care
The incorrect perception that most clinicians already effectively facilitate shared decision-making should be addressed to improve the uptake of personalised care interventions
Summary
The population is ageing and the ‘older’ age group is widening. The prevalence of multimorbidity (two or more long-term conditions[1]) in older people is high and predicted to rise[2]. Older patients with multimorbidity have higher rates of disability and functional decline, increased mortality, and reduced wellbeing when compared with younger, healthier patients[3,4,5,6,7]. Clinical decision-making with older patients with multimorbidity can be complex and challenging[8,9,10,11,12]. Older patients with multimorbidity have high primary care usage and increased costs of care when compared with younger, less complex patients[13, 14]. Providing care to this patient group contributes significantly to time and workload pressures experienced by GPs[15]. Multimorbidity can complicate shared decisionmaking, yet few studies have explored this dynamic for older patients with multimorbidity in general practice
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