Table 6.

Illustrative Quotes of Theme 2, Shared Decision Making Is Not a Simple Discussion

Respondent 2How are you going to present this to a patient? You want to present it as best as you can in a nonbiased way, but you also want to be honest. So, I would say to them, “[LCS] is available. It’s something we can do, but then we have to think about the next step because I never order a test without having a plan for what I’m going to do with the results. If we get a negative result, that’s great, right? If we get a positive result where we see something that really looks suspicious, is treatment something that you would eligible for and that you could tolerate, right?”
I’m very honest. I say, “When they did the study, this is what they found when they studied the population, but for people like you, maybe you wouldn’t have been included in the study or maybe it’s not as clear given your age or that you have these other medical conditions, it’s not clear that this would be as beneficial to you as other patients and there could be more risks involved,” and also, the question is, “Are you someone who’s eligible to act on the results?” I think that’s really the bigger issue, right?
Respondent 5I do have to talk [about] if the goal is to cure at that point and ask them what do they want the last years of their life to look like and what interventions, if anything, are they looking into, right? At that point, it’s sort of like, “Do you want to continue screening for colon cancer, breast cancer, lung cancer?” Right? If they do, then I’m like, “Okay, well, you are at higher risk for any complications given your lung capacity or your heart condition, or whatever. So, I’m going through the shared decision-making conversation with you partly because if a complication were to happen, you may have a higher morbidity than others. It may curtail your life more.”
Respondent 7I always talk about the stress of knowing for what I think is something that’s not appropriate, so I’ll start with the emotional aspect of “Do you really want to know? This is something that you might be at risk for. Do you really want to have a test that may lead to need for biopsies and other testing?” As you know, these things are very sensitive and so all these patients have nodules so it becomes anxiety provoking for patients. So I address the emotional aspects of knowing, that you have a lung nodule that we may not do anything about. So that is one way I approach it.
Respondent 11I mean, if they’re like really frail, I will bring it up and like that this is something that we could do, but that I’m not sure that it would be the right thing for them given everything that they’re already going through like seeing 15 specialists. They’re man-aging all their comorbidities.
Respondent 12Like I kind of lay down the facts. I would say, “Okay. If you went through screening and then they find something, and then you have to go a biopsy, and then it’s cancer. Then you’d get a treatment, which potentially involves like X, Y, Z. Then how would you manage that? Like how would you do all those things, go to all those appointments? Do you have any help at home? I mean, the treatment might potentially be very toxic. You could have a lot of weakness. Like, you might not be able to eat. That can be very painful.” Things like that.
Respondent 13Asking them what they would do with the abnormal findings should they happen and then the patients which really have like things that are—have other issues that are outstanding, they have other—like I said, really, if they have prior strokes, or if they have ... heart failure, if they have heavy-duty stuff, not your typical mild asthma, that’s [unintelligible]. But if they have a lot of things that are like, may not put them in a position that they would be able to go easily for further evaluation and workup, I probably definitely bring it up. But I have that discussion with them where I kind of say, “Well, you know, if we find something there that is accepted maybe for invasive testing, would that be something you would be up to?” I usually do that with a really sick patient.
  • LCS = lung cancer screening.