REVIEW

CURRENT
OPINION Decision aids in anesthesia: do they help?
Warren A. Southerland a, Leah J. Beight b, Fred E. Shapiro a,
and Richard D. Urman c

Purpose of review
Patient decision aids are educational tools used to assist patients and clinicians in healthcare decisions.
As healthcare moves toward patient-centered care, these tools can provide support to anesthesiologists by
facilitating shared decision-making.
Recent findings
Downloaded from https://journals.lww.com/co-anesthesiology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3hIW04IhZ9AvNyXiDskTJpGAYXztNG71dMzsxvxmZhgI= on 04/12/2020

Recent research has shown that patient decision aids are beneficial in the clinical setting for patients and
physicians. Studies have shown that patients feel better informed, have better knowledge, and have less
anxiety, depression, and decisional conflict after using patient decision aids. In addition, a structured
approach for the development of patient decision aids in the field of anesthesia has been established.
Summary
Patient decision aids can support patient-centered care delivery and shared decision-making, especially in
the field of anesthesia. Current research involves implementing the use of patient decision aids in the
discussion for monitored anesthesia care. Further development of quality metrics is needed to improve the
decision aids and maximize decision quality.
Keywords
decision aid, monitored anesthesia care, patient-centered, perioperative, shared decision-making

INTRODUCTION challenging. Two regional anesthesia decision

The Institute of Medicine has written two reports, To
Err is Human: Building a Safer Health System and
Crossing the Quality Chasm: A New Health System
for the 21st Century, which focus on improving
patient safety [1,2]. Crossing the Quality Chasm
has mandated that healthcare be safe, effective,
patient-centered, timely, efficient, and equitable
aids have been developed by the American Society
of Anesthesiologists (ASA) Committee on Profes-
sional Liability and the shared decision-making
team at the University of Washington under a
grant from the Agency for Healthcare Research
and Quality. A standardized format for the develop-
ment of patient decision aids has been created,
&&

[2]. The Institute of Medicine has promoted
patient-centered healthcare to allow patients to
express their wants and thoughts for a more person-
alized healthcare. In addition, proper patient edu-
specifically for anesthesia [14 ]. Current research
includes evaluation of a newly developed Monitored
Anesthesia Care (MAC) patient decision aid for
its decision quality and improvement of patient
&

cation with evidence-based data is paramount for education [15 ].

patients to make ideal healthcare decisions. To meet
this standard, patient decision aids have been cre-
ated for various fields of medicine and surgery,
including cardiology, urology, gynecology, endocri-
nology, and oncology [3–10] As various anesthetic
options are available for patients, such as sedation,
regional anesthesia, and general anesthesia, patient
engagement is important in the decision-making
process. The International Patient Decision Aid
Standards Collaboration states these aids ‘are
designed to support patients’ and ‘help them to
arrive at informed choices’ in the healthcare setting
[11]. In the perioperative setting, however, achiev-
ing this level of shared decision-making can be
a
Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel
Deaconess Medical Center, bDepartment of Health Sciences, North-
eastern University and cDepartment of Anesthesiology, Perioperative and
Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts,
USA
Correspondence to Richard D. Urman, MD, MBA, Department of Anes-
thesiology, Perioperative and Pain Medicine, Brigham and Women’s
Hospital, 75 Francis Street CWN L1, Boston, MA 02115, USA.
Tel: +1 617 732 8486; fax: +1 617 277 2192;
e-mail: rurman@bwh.harvard.edu
Curr Opin Anesthesiol 2020, 33:185–191
DOI:10.1097/ACO.0000000000000832

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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Ethics, economics and outcome
KEY POINTS
 Patient decision aids can support patient-centered care
delivery and shared decision-making, especially in the
field of anesthesia and the perioperative setting.
 Studies have shown that patients feel better informed,
have better knowledge, and have less anxiety,
depression, and decisional conflict after using patient
decision aids.
 Two regional anesthesia decision aids have been
implemented with positive outcomes.
 A decision aid for Monitored Anesthesia Care has
been created and is in the b-testing process for
quality analysis.
 Further evaluation into quality and patient satisfaction
of newly developed patient decision aids is needed to
improve decision outcomes and increase
decision quality.
PATIENT DECISION AIDS
Patient decision aids are forms of media (i.e., web-
sites, videos, prints) that educate patients, encour-
age their participation during decision-making, and
help evaluate their preferences and values in their
healthcare choices [16]. These aids describe choices
that need to be made, alternative options, risks and
benefits, and potential outcomes [11,17]. Impor-
tantly, they are not biased between the healthcare
choices they provide and are used as a tool for
physicians, not a replacement for consultation.
Patient decision aids improve the decision quality
and quality of care when the patients’ wants and
opinions are appreciated and heard throughout the
decision-making process [2,18]. Ideal scenarios to
use these aids are ones that have multiple practical
healthcare options with various benefits and risks
(or ‘preference-sensitive’) or for clinical situations in
which the available choices are equipoise
[2,16,19,20]. An example of the format of a standard
&&
decision aid is provided in Table 1 [14 ].
A Cochrane Database systematic review has
shown decreased indecision, improved patient par-
ticipation, and more patient satisfaction with the
overall decision-making process when using patient
decision aids [21]. Increased understanding of
healthcare options, clearer expectations, and less
anxiety in decision-making are other improvements
seen with patient decision aids [3,4,22]. As men-
tioned previously, two regional anesthesia decision
aids have been produced and used during preanes-
thesia clinic evaluation. According to Posner et al.
[23], patients using decision aids have increased
discussion, participation, and knowledge of regional
186 www.co-anesthesiology.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Table 1. Suggested format for patient decision aid
Describe procedure/therapy
Benefits – space for patient to write down benefits that matter to
them
Risks – space for patient to write down concerns for risks
Adverse effects
Choices – questions/concerns about options
Space for questions about what other information needed, where
to get it, from whom?
Quiz for understanding
Provide references
&&
Adapted from Reference [14 ].
anesthesia options in their decision-making process
by using the aforementioned aids, whereas not
increasing anxiety and uncertainty. These positive
outcomes for the regional anesthesia decision aids
mandates further action to create aids for other
aspects of anesthesia to increase patient-centered-
ness and shared decision-making in perioperative
care.
SHARED DECISION-MAKING
Shared decision-making is a process that allows
patient to have open communication with physi-
cians about their healthcare plans, using clinical
evidence and patients’ preferences to make a choice
[16]. Physician input and judgment is maintained
throughout the decision-making process [19,20].
Shared decision-making is appropriate when there
is no medically ‘best’ choice, and decisions should
depend on individual preferences (‘preference sen-
sitive’) [2,19,20].
Over one-third of the preoperative patients have
deficits in preoperative decision-making, and many
perioperative clinicians do not discuss the patients’
preferences, goals, and values [24,25]. Reasons for
these deficits include varying education levels, lan-
guage barriers, and inadequacies in the informed
consent process [24]. Anxiety and discomfort from
being in a hospital and the upcoming procedure
adds to the lack of understanding [24]. Cooper et al.
[25] discusses that nonwhite races, older age, and
patients with lower educational levels are factors
that lower decisional quality in the perioperative
setting. Time constraints during the perioperative
period limit physicians’ ability to discuss important
decisional concepts with patients [25]. Owing to the
fast-paced nature of the perioperative setting,
patients and their families may not make the best
possible choice for themselves because of their lack
of understanding. An informed consent by itself is
not shared decision-making or equivalent to high
Volume 33  Number 2  April 2020
 Decision aids in anesthesia: do they help? Southerland et al.

Table 2. The Ottawa Decision Support Framework Table 3. The Foundation for Informed Medical Decision
Determine the patients’ and clinicians’ needs for decision-making Making’s eight-step implementation process
Assist patients in making choices Engage providers and staff
Analyze the outcomes Target individuals or populations
Identify conditions
Adapted from Reference [28]. Distribute decision aids
Encourage viewing
decision quality [26,27]. Patient decision aids can Provide support
better inform patients of their healthcare options, Measure impact
leading to better understanding during informed Provide feedback
consent. This allows open conversation about
patients’ circumstances, desires, and goals for ther- Adapted from Reference [30].

apy and has shown to increase decision quality,

increase the number of positive surgical outcomes,
and decrease inappropriate procedures [25].
Attempts to make structured approaches for
shared decision-making have led to the creation
of the Ottawa Decision Support Framework (ODSF)
[28]. It follows three steps, as seen in Table 2 [28].
Along with the Ottawa Decision Support Frame-
work, the Agency for Healthcare Research and Qual-
ity and the Informed Medical Decisions Foundation
have funded multiple institutions, including Uni-
versity of Washington, Dartmouth-Hitchcock Med-
ical Center, New York University, and Massachusetts
General Hospital, to research shared decision-mak-
ing [29]. Through the funding, the University of
Washington established eight steps to implement
shared decision-making in the healthcare setting,
shown in Table 3 [30]. These steps contribute to the
formation of shared decision-making programs and
further development and implementation of
patient decision aids.
DEVELOPMENT OF PATIENT DECISION
patient involvement in their development, and
evaluation of their effectiveness. In addition, using
Delphi consensus techniques, the International
Patient Decision Aid Standards (IPDAS) Collabora-
tion established the standard quality criterion
checklist (Table 5) [11]. Using these basic principles,
&&
Urman et al. [14 ] have developed a comprehensive
format for creation of patient decision aids (Table 6).
This format guides the development of patient deci-
sion aids and proper evaluation for future analysis. It
follows the 12 quality domains established by the
IPDAS and the principles of patient decision aids, as
defined by ODSF and Informed Medical Decisions
Foundation [28,31]. It is divided into three stages:
synthesis, analysis, and implementation, each being
crucial to the comprehensive development and eval-
uation of newly made patient decision aids. The
framework tackles the common limitations of cur-
rent patient decision aids, including increasing
patient input during development, thoroughly eval-
uating data included in the aids, and integrating a
cyclic review of the supplement’s tools before and
after their use [15 ].
&

AIDS
Institutions have created models for the develop-
ment of patient decision aids, as shown in Table 4 ADVANCEMENTS AND CURRENT
[28,31]. Along with the previously mentioned RESEARCH
ODSF, these frameworks all establish the need for Today, patient decision aids have been used in
patient decision aids, promoting physician and various specialties of medicine and surgery, ranging

Table 4. Existing models for development of patient decision aids

The Ottawa Decision Support The Informed Medical Decisions The International Patient Decision
Framework (ODSF) Foundation (IMDF) Aids Standards (IPDAS)

Determine the patients and clinicians’
needs for decision-making
Assist patients in making choices
Analyze the outcomes
Involve physicians from relevant fields Defining and assessing the need for
for the decision aid decision support
Involve patients at various stages of Formation of teams for development
development and review
Evaluation of the decision aids by both Composition and review
patients and physicians before its Testing of the aids
implementation Critical external peer review

Adapted from References [28,31].

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Ethics, economics and outcome
Table 5. International Patient Decision Aid Standards
(IPDAS) Collaboration checklist for users (selected items)
Systematic development process
Providing information about options
Presenting probabilities
Clarifying and expressing values
Using patient stories
Guiding or coaching in deliberation and communication
Disclosing conflicts of interest
Delivering patient decision aids on the internet
Balancing the presentation of options
Using plain language
Basing information on up-to-date scientific evidence
Establishing effectiveness
Adapted from Reference [11].
from psychiatry to orthopedics [3–10,32–35].
Numerous studies have shown increased patient
knowledge [3,4,7,10] and improved shared deci-
sion-making [4,9,35] with the use of decision aids.
Anxiety and depression about making medical deci-
sions and decisional conflict were shown by these
studies [3,4,9]. Patients who use patient decision
aids choose evidence-based treatments and have
better outcomes according to Watts et al. [32].
Recent studies have shown that patient decision
aids have positive outcomes by decreasing indeci-
sion, while increasing patient participation and
understanding of choices [22,36]
As previously mentioned, two anesthesia
patient decision aids, Epidural and Spinal Anesthe-
sia and Peripheral Nerve Blocks, were created by the
ASA Committee on Professional Liability and have
shown favorable outcomes according to a study by
Posner et al. [23] in 2015 [12,13]. Currently, the ASA
Committee on Patient Safety and Education is
Table 6. The checklist for developing perioperative patient
decision aids
Synthesis
Creation of multidisciplinary team
Literature review of major databases
Creation of focus groups
Drafts of the patient decision aid
Analysis
a testing
b testing
Implementation
Dissemination of the educational materials
Continuous analysis and evaluation
Adapted from Reference [14
&&
].
188 www.co-anesthesiology.com
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working on a new decision aid for Monitored Anes-
thesia Care (MAC). The goal of the MAC Decision
Aid is to improve patients’ understanding of differ-
ent anesthetic options, specifically the difference
between sedation and general anesthesia, and
patient engagement in the decision-making process.
An article published in the Wall Street Journal
demonstrated how the general public does not
understand the difference between general anesthe-
sia and sedation (i.e., MAC) [37]. The author
described a ‘disturbing’ experience of awakening
during a surgery performed under sedation. She
claimed it was ‘anesthetic awareness,’ which is
untrue given that the patient was not under general
anesthesia, which is defined as ‘a drug-induced
reversible depression of the [central nervous system]
resulting in the loss of response to and perception of
all external stimuli’ [37,38]. Sedation may lead to a
level of consciousness ranging from removal of
nervousness to a deep sleep in which the patient
only responds purposefully after repetitive painful
stimuli [38]. Awakening during sedation is consis-
tent with what is to be expected from this anesthetic
method. This article shows how important patient
education about anesthesia is for healthcare and
emphasizes the necessity of preanesthesia patient
decision aids.
To follow the steps laid out by the ‘Concepts for
the Development of Anesthesia-Related Patient
&&
Decision Aids’ [14 ], our research team is creating
the decision aid, vetting the decision aid, and b
(beta) testing the decision aid at Beth Israel Deacon-
ess Medical Center (BIDMC), Boston, Massachu-
&
setts, USA [15 ]. To evaluate the decision aid, a
randomized-controlled trial is being conducted to
determine if the tool allows patients to better dif-
ferentiate sedation and general anesthesia. Patient
engagement and experience undergoing MAC are
evaluated, as well.
&&
Urman et al. [14 ] pointed out that ‘current
dissemination of guidelines and educational mate-
rials have been more inclined to assist physicians
and healthcare professionals rather than patients.’ A
study by Trevena et al. [22] have found that ‘more
interactive formats such as computerized versions
appear to have a greater effect size compared to
paper booklets or audio-booklets’. In light of this,
Shapiro and colleagues at BIDMC are using a cus-
tomized smartphone application platform (LAMP-
‘‘Learn, Assess, Manage, Prevent’’, Division of Digi-
tal Psychiatry at Beth Israel Deaconess Medical Cen-
ter, Boston, MA) that allows easy access to up-to-
date medical knowledge and the MAC decision aid
for patients. For the study, after the patients have
taken a pre-Decision Aid survey (Table 7) on the
LAMP app, they will receive an electronic copy of
Volume 33  Number 2  April 2020
 Decision aids in anesthesia: do they help? Southerland et al.

Table 7. Pre-anesthesia clinic survey: monitored anesthesia care

Section 1: To be completed before the visit

Please answer a few questions about your background and feelings

1. What is your age?

& 20–29 years
& 30–39 years
& 40–49 years
& 50–64 years
& 65þ years
2. Are you male or female?
& Male
& Female

3. What is the highest grade or level of school that you have completed?
& 8th grade or less & Some college or 2-year degree
& Some high school, but did not graduate & 4-year college graduate
& High school graduate or GED & More than 4-year college degree
& Other__________________
4. What types of anesthesia have you had in the past? (check ALL that apply)
& Epidural or spinal anesthesia
& Labor analgesia/labor epidural
& Peripheral nerve block (for example, arm or leg block, shoulder block)
& Sedation/monitored anesthesia care
& General anesthesia
& Other:___________________
& I’m not sure
5. Choose the one (1) answer that best describes you:
& I prefer to make the decision about which treatment I will receive.
& I prefer to make the final decision about my treatment after seriously considering my doctor’s opinion.
& I prefer that my doctor and I share responsibility for deciding which treatment is best for me.
& I prefer that my doctor makes the final decision about which treatment will be used, but seriously considers my opinion.
& I prefer to leave all decisions regarding treatment to my doctor

GED, general education diploma.

the MAC Decision Aid. After reviewing the MAC
Decision Aid, the patients will take a post-Decision
Aid survey on the LAMP app to determine the
impact of the educational material.
A recent abstract for the study has shown the
&&
preliminary data for the study [39 ]. To date, 21
patients have completed the study, of which 71% of
the participants are college graduates with a median
&&
age of participants being 45 years (Table 8) [39 ].
The patient population in the study are women
undergoing MAC for breast surgery. There was sta-
tistically significant reduction in time in answering
&&
the post survey questions [39 ]. Although patients
required more time to answer the post survey anes-
thesia questions (P ¼ 0.00936), a greater number of
anesthesia-related questions were answered cor-
rectly in post survey compared to presurvey
(P ¼ 0.021823), indicating that the educational
&&
material likely made an impact [39 ]. As the study
progresses, a larger sample size would help to ana-
lyze pre and post survey results regarding their level
of understanding of MAC, their preference about
informed decision-making for anesthesia, and their
overall impression about anesthesia. We believe that
100 patients is an acceptable target sample size as
this would be in keeping with other pilot studies of
patient decision aids [20].
In the preliminary implementation of this
study, there have been observed benefits and chal-
lenges to using an electronic version of the decision
aid. Benefits include the convenience of having the
decision aid on the phone, flexibility where and
when the decision aid is completed, and the ability
of gathering survey results electronically. Patients
were encouraged to complete the pre and post sur-
vey during clinic visits. However, on a few occasions

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Ethics, economics and outcome

Table 8. Descriptive data of preliminary participants who observed was patients forgetting their phone access
completed pre- and post-survey identification password, thus removing themselves
from the study.
Predictor Number

Age (years)
CONCLUSION
18–29 5
Patient decision aids can support patient-centered
30–39 1
care delivery and shared decision-making, especially
40–49 5
in the field of anesthesia. Studies have shown that
50–59 4
patients feel better informed, have better knowledge
60–69 2 about anesthetic choices, and have less anxiety and
70–79 3 decisional conflict after using patient decision aids.
80þ 1 Two regional anesthesia decision aids have been
Gender previously implemented with positive outcomes. A
Female 21 decision aid for MAC has been created and is in the
Male 0 b-testing process for quality analysis. Further evalua-
Education tion into quality and patient satisfaction of newly
8th grade or less 0 developed patient decision aids is needed to
Some high school, but did not graduate 0
optimize decision outcomes and increase decision
quality.
High school graduate or GED 5
Some college or 2-year degree 1
Acknowledgements
4-year college graduate 11
None.
Graduate degree 4
There are no disclosures. No funding was received for this
GED. general education diploma.
work.

Financial support and sponsorship

when patients had limited time and needed to leave
before completing presurvey, researchers were able
to guide patients through the downloading process
and follow-up at a later time. This allows for a more
systematic comparison of outcomes by download-
ing completed datasets rather than manual data
entry.
Conversely, an electronic patient decision aid
format presents multiple new challenges. The first
was technologic difficulties using the application. In
its first few months of patient enrollment, data
collected from the application was not saved to
the proper study. Patient enrollment was limited
in the preoperative holding area since some patients
did not have their phone accessible. Downloading
the application can be difficult to explain over the
phone, and therefore it was performed on-site. A
second challenge researchers observed was the
amount of time required to download the applica-
tion and limited patient time constraints. When
downloading the application, patients connected
to the campus WiFi network observed a longer wait
time for download completion. A third challenge is
the cellular service. In a particular preoperative area
cellular service was significantly slower than that in
the clinic. As a result, patients often express concern
and frustration for time. This barrier was mitigated
by connecting patients to adjunct WiFi service pro-
vided by the research team. Another challenge
None.
Conflicts of interest
There are no conflicts of interest.
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