Table 1 The CONtext shared decision making process

Based on the shared decision making models of Elwyn et al. and van de Pol et al. [11, 12, 17] a quality improvement project, CONtext, was implemented at the Medical Oncology department of the Radboudumc in Nijmegen, the Netherlands. CONtext was integrated in five healthcare chains: gastroenterological oncology, gynaecological oncology, melanomas, urological oncology, and breast oncology. The project is based on collaboration between several departments: Centre for Oncology; Departments of Medical Oncology; Anaesthesiology, Pain and Palliative Medicine; Primary and Community Care; and Geriatrics.

CONtext improves shared decision making for patients with incurable cancer should a decision be needed regarding their cancer treatment. This concerns moments when based on diagnostics (usually a CT scan) current therapy no longer seems to work or the disadvantages of current therapy no longer outweigh the benefits. CONtext explicitly focuses on the care process in the consultation room and offers patients opportunities to consciously think about their values and wishes within their contexts to deliberately decide about treatment. Moreover, it stimulates offering patients time-outs to discuss this with their general practitioner (GP) and their relatives. It also gives healthcare professionals tools to optimise this conversation with their patients.

The implementation of the CONtext project included:

1) Training medical oncologists (and fellows) and case managers in shared decision making and in applying the elements of the CONtext project. Almost all followed two small-group workshops and were invited to follow an eLearning course on shared decision making developed by, amongst others, the Dutch Federation of Cancer Patient Organizations. In addition, minimally two practical observations in the consultation room and group feedback sessions were organised by a member of the Person-centred Care Support team from the advisory group ‘Process Improvement and Innovation of the Radboudumc’. Moreover, the ‘Kantelkaart (Dutch)’, developed in the Connected Case Project of the Radboudumc was used to train healthcare professionals in discussing personal context and support patient in the decision making process. This card contained three questions for the patient to identify patient’s context and three reflection questions for the healthcare professional to support the patient. The patient questions were: 1. What is important to you right now? 2. What do you need for that? 3. How can I support you with that? The reflection questions for the healthcare professional were: 1. How can I ensure that the care for this patient is aligned with what he/she considers important? 2. What do I need for that? 3. Who can help me with that?

2) Discussing the choices and treatment options considering the patient’s context, needs, wishes, and values in an outpatient consultation with the medical oncologist (in training) and case manager (choice and option talk). The medical oncologist (in training) focused on the medical context. After the outpatient consultation, the patient had a consultation with the case manager to further discuss the choices and treatment options focused on the wishes, values and needs of the patient in the patient’s context. Patients were prepared for shared decision making by explicitly mentioning the option of shared decision making and providing the ‘Kantelkaart’ to inventory personal context.

3) Informing and inviting the GP (if the patient agrees) to remain actively involved in the patient’s care trajectory and help the patient with decision making.

4) Striving for a two-week time-out period after the first consultation with the patient before making a medical decision. The patient could then consider and discuss the options with relatives or the GP. The case manager called the patient during these 2 weeks to offer support in the shared decision making process.

5) Making the final decision about treatment in an outpatient consultation together with the medical oncologist (in training) and the case manager (decision talk).

The CONtext shared decision making process is evaluated in, amongst others, a qualitative research project, where medical consultations are analysed and interviews with the involved medical oncologists, case managers, GPs, and patients are used. However, the family caregiver perspective remained unexplored, making the present research a valuable addition for the CONtext project evaluation.

More information (in Dutch): www.qruxx.com/context