Setting (and Achieving) Goals Together with Our Patients

This article was written by Michael W. Hess, MPH, RRT, RPFT

As clinicians, we are often called upon to make recommendations. We have access to peer-reviewed research, so we typically have an idea of the most appropriate therapy for a given situation. Wheezing? That calls for some bronchodilators. Hypercapnea? We may consider noninvasive ventilation. We tend to be confident that we know the best thing to do in most cases.

Despite our best efforts, sometimes there is a mismatch between what is in the textbook and what our patient truly needs. In our enthusiasm to provide optimal care, it can be easy to miss that those two things are not always the same. Unfortunately, when we lose sight of that, we can take our patients down a path where expectations do not match reality. That, in turn, leads to frustration and a lack of trust, which can have a devastating effect on therapy adherence and outcomes. That is why collaboration and the process of shared decision-making in goal setting and planning is essential to care.

A Little More Conversation

So, what is shared decision-making? It's clear, open communication between the clinician and the patient that facilitates the development of a therapy plan that balances the patient's needs and values against potential risks and outcomes.¹ Historically, many (if not most) clinical decisions were left to the people carrying the stethoscopes, and patients would dutifully carry out their instructions (or not). Studies have indicated that this model often led to decisions being made not by evidence but by the preferences of the ordering clinician, leading to massive inconsistencies in care.² This, combined with the patient perceiving that he or she has no say in a treatment plan, can have a significant negative impact on the likelihood of adherence to that plan. However, when medical decisions are made collaboratively, people are often more likely to accept and stick with their prescriptions and therapies.³

Shared decision-making can also facilitate behavior change. According to the Transtheoretical Model, the process of change takes place in stages ranging from pre-contemplation to maintenance of the change.⁴ It should be obvious that the more people understand the potential risks and benefits of a change, the more likely they are to stick with it. Each person looking to make a change must have some level of “buy-in” to see results. The tricky part is figuring out how to achieve that. Take tobacco treatment for example. Most people who smoke know it is bad for them, and most have repeatedly been advised to quit, because that is what is best. Yet many continue to smoke. So, how can YOU be successful when everything else has failed? You must first find out what motivates that individual patient. Do they want to get healthier? Do they want to spend less money or be a better example for their kids or grandkids? A real one-on-one conversation, rather than just listing off instructions, enables you to start building a connection.

Building on that connection, you can begin to see what realistic goals are. For a personwho smokes a full pack of cigarettes a day, quitting altogether may seem like a daunting challenge. That person likely tried quitting previously and then felt guilty about not being successful. But, perhaps it's possible to cut it down to half a pack. Once that goal is met, you can work with your patient to make further progress. Each person's finish line is in the same place - whether it takes 50 steps or 500; the important part is helping them reach it.

Getting S.M.A.R.T. with Goals

Once you have established common ground with your patient, you can start setting realistic goals. Health care providers can take a page from the business world here because S.M.A.R.T. goals allow for the observation of concrete progress. If you are not familiar with S.M.A.R.T. goals, they are:

• SPECIFIC: "I want to quit smoking," or "I want to exercise longer."
• MEASURABLE: The number of cigarettes smoked, or steps taken in a day.
• ATTAINABLE: Is the person willing and able to achieve a goal based on your shared conversations?
• RELEVANT: Is the goal something that resonates with the person's motivations based on your shared conversations?
• TIME-BASED: "I want to quit smoking by the end of the year."

You will note that shared decision-making is a key component to several of these goals. Those conversations are essential to creating reasonable S.M.A.R.T. goals and empowering your patient to take control of his or her condition.

Bringing it Together

Paradoxically, the best answer is not always the right answer. By collaborating with your patients, you give them the ability to deal with the pros and cons of procedures or other therapies. You enable them to make informed decisions based on their values and their priorities, and you increase their odds of sustained success. In the end, isn't that what is best for all?