SMART OPS: Shared decision making Multidisciplinary Approach; a Randomised controlled Trial in the Older adult Population considering Surgery.

The intervention arm is a shared decision making multidisciplinary team meeting. The MDT includes the patient along with any support persons they would like, an anaesthetist, surgeon, and social worker or Clinical Nurse Consultant relevant to the surgical area. Consultation with any appropriate health care professionals including the participant’s GP will occur as appropriate to each individual patient. Shared decision involves 'choice', 'option' and 'preference' talk: 1. ‘Choice’ talk a. Ensure there is agreement on the nature of the problem b. Introduce the concept that more than one option exists to investigate, manage or treat the problem. There is an acknowledgement that a choice may be a non-interventional option. Explicitly acknowledging uncertainty in medicine and unpredictable outcomes is essential. c. A key component of this section is to highlight that patient’s beliefs, values and preferences are important in working out best options d. It is also essential to check if the patient has understood the choice talk e. It is important at this initial stage to defer closure of the conversation so that the clinician and patient can move to ‘option talk’. 2. ‘Option’ talk a. This may begin by checking for existing knowledge as a starting point for listing options b. A summary list of options may be used, before exploring each option in more detail. This is a way of making sure that the patient does not miss the opportunity to learn about options that they may already have discounted. c. The clinicians may then start by describing what each option entails. This helps to separate the description of each option from the discussion of the risks and benefits of each. d. An essential component of this section is to then explore risks, benefits and consequences and the chances (likelihoods) of these benefits and risks actually occurring. This can take the form of, for example, describing the most relevant and common risk or consequence before describing the benefit. Part of the multidisciplinary preparation for the SDM meeting will be to individualise (as far as possible) this particular patient’s risks. e. The option talk often includes a check by the clinicians that the patient understands what has been discussed about the options and the relevant risk/benefit explanations. f. As above, patient preference should be woven throughout this section 3. ‘Preference’ talk a. Whilst patient preferences/values happen throughout the SDM process, it is essential to actively enquire about the patient’s values and preferences as they assimilate information about options. This section refers to values and attitudes of the patient and not directly to the preference for a particular option. b. At this stage, it is sometimes useful to summarise what has been done and state that it may be appropriate to make a decision at this time c. It is important to recognise that patients may need time for deliberation before a decision is made. Some patients may wish to access more information etc d. It may also be appropriate to help the patient to explore the options in terms of what is important to them. e. If appropriate, patients can, at this point, state their preferences and move to make a decision a. The MDT aims to occur as soon as possible post referral and will varied. This is due to the complexity of gathering the people that are important to attend this meeting. b. Content of the meeting: As above - patient values, risks and benefits for ALL management options including 'do nothing' c. The meeting will be planned for 1 hour and will be 1 face to face with phone follow up and further face to face if necessary for follow up questions d. As above (mode of administration) e. MDT with surgeon, anaesthetist, and social worker f. formal training with follow up training once started. visits to other centers performing SDM. Adherence to SDM protocol (including necessary pre-work, attendance, consultations etc) will be monitored