Aortic dissection (AD) is a serious life-threatening cardiovascular disease, which has garnered much attention in recent years. AD has an acute onset and a variety of initial symptoms. The incidence is approximately 6/100,000, and the mortality rate is second only to acute myocardial infarction [1]. With the development of medicine and biotechnology, the treatment of AD is a long-term dynamic clinical exploration and practice process that includes thoracotomy, minimally invasive surgery, hybrid surgery, and other treatment schemes. It cannot be ignored that the treatment decisions for either type A or type B AD are risky decisions made in a limited time, because regardless of which treatment is chosen, patients may have risks of bleeding, pain, AD rupture, and reoperation, among others [1]. In addition, most AD patients are in a sedative and analgesic state before surgery, making them lose decision-making ability; thus, their medical decisions are mostly made by family members [2]. Affected by the uncertainty of disease trajectory and individual differences, most AD decision-makers have negative emotions such as anxiety and helplessness [3]. Our previous study showed that approximately 99.09% of AD patients and 98.91% of their family members had decisional conflicts, which were not related to the type of AD [2, 4].

The decision-making of AD is complex, and not only requires doctors to inform disease information within a limited time but also needs consideration of patients’ views and other nonmedical factors. The guidelines for the diagnosis and management of aortic disease jointly issued by the American College of Cardiology/American Heart Association strongly recommend that patients and medical staff jointly decide on treatment plans to determine the endoluminal surgery, thoracotomy, hybrid surgery, etc. [5] Shared decision-making (SDM) is key to improving the quality of decision-making and is a concrete embodiment of “patient-centered” care in clinical practice. SDM is a process by which medical staff and patients work together to integrate care plans that are responsive to patients’ goals and values [6]. It has been advocated as a clinical counseling approach that improves disease knowledge, and reduces anxiety and decisional conflict by encouraging patients to participate in clinical decision-making [7].

At present, SDM has been widely applied to the decision-making process of patients and their surrogate decision-makers in orthopedics [8], cancer [9], and so on, but there are few reports on critical cardiovascular diseases [10, 11]. Under the guidance of the Ottawa Decision Support Framework (ODSF) and the International Patient Decision Aid Standards (IPDAS), we developed a patient decision aid (PtDA) for AD decision-makers. We used PtDA on admission day, preoperative conversation and discharge day, which we termed a “patient-centered SDM”, to be used as part of the medical decision-making of AD. The whole decision-making process was jointly performed by doctors, nurses, patients and their family members with a clear division of labor. The primary objective of this study was to assess the impact of SDM on the decisional conflict of AD decision-makers. Secondarily, this study quantified differences between intervention and control groups on the decision preparation, satisfaction, participation role, final surgical method, postoperative complications, duration of consultation, post-operative intensive care unit (ICU) stay time and hospital stay time.

Ten participants were excluded from the intervention group due to different reasons, including preoperative death (n = 2), tensions between doctors and patients (n = 1), giving up treatment (n = 1), and withdrawal (n = 6). Moreover, 10 cases were ruled out from the control group due to different reasons, including preoperative death (n = 3), giving up treatment (n = 3), and withdrawal (n = 4). Finally, 160 people were included in the study (Fig. 4).

Fig. 4.

Patient flowchart.

Heart and macrovascular diseases are important areas of SDM. We developed a PtDA for AD incorporating decision needs, patient education, preference assessment, and personalized estimations of clinical outcomes, which were presented in the form of words, tables and pictures. We used PtDA in the SDM of AD, defined the tasks of doctors, nurses, patients and family members, and emphasized building trust relationships between medical staff and patients in the process of communication. Compared with traditional preoperative conversations, this study evaluated the impact of SDM on the outcome of AD surgery. Our study demonstrated that the implementation of SDM for patients undergoing AD surgery was possible and effective in our institution. SDM was capable of improving the quality of decision-making without changing the choice of surgical methods or impacting medical outcomes.

Decisional conflict is a state of uncertainty in the course of action that exists and permeates the decision-making process of AD, increasing the pressure on decision-makers [25]. Previous studies have shown that for each unit increase in DCS score, decision-makers are 59 times more likely to change their minds and 23 times more likely to delay their decisions [26, 27]. AD surgery is risky and uncertain, and the delay in treatment leads to increased complications, which greatly increases the risk of death [28]. Encouragingly, we found that SDM could reduce decisional conflict, which was consistent with the results of previous randomized controlled trials [29]. Subscale analysis showed that decision uncertainty and decision uncertainty factors scores compared between the two groups were statistically significant (p 0.001, p = 0.005). The AD PtDA is comprehensive, objective, and fair. It provides disease information and stress relief methods that are practical needs, which can improve patients’ and families’ knowledge of disease and surgical risks, and reduces the influence of uncertainty factors on the decision-making process. The perceived effectiveness of the two groups was not statistically significant (p = 0.058). This is because AD decisions are made before surgery, and medical staff and decision-makers cannot guarantee that no risks will arise during the procedure. Uncertainty about disease risk leads to a lack of confidence in the results of decision-making [30]. Some studies have indicated that SDM is not significant in reducing decisional conflict [31]. This may be related to disease characteristics, health literacy, etc. [32]. The effects of objective and subjective health literacy on patients’ accurate judgment of health information need to be investigated in the future.

Decision control preference reflects the desire of patients and their families to make decisions independently. The results showed that the actual decision-making participation in the control group was mostly passive decision-making (77.50%), and the intervention group was SDM (52.50%). Low decision control preference means high treatment expectations [33]. SDM reduces the gap between the expectation and reality of surgical results, and attaches importance to the doctor-patient relationship based on trust. In the PtDA, we sorted out and objectified the issues most concerned by decision-makers and encouraged them to actively ask questions, enhancing their perception of decision-making participation. The PtDA was an optimized logical path that included four steps: determining the current decision needs, providing decision information support, clarifying the values of the decision-makers, and guiding decision-making, which can help decision-makers choose options consistent with their values according to a fixed process and help them realize the situation they are facing. In this study, the use of SDM improved the decision readiness of participants. We used PtDA on the admission day to assess the decision needs of patients and help them gain an initial understanding of AD. During the preoperative conversation, we present the pros and cons of various treatment options in the form of drawings and tables to enhance their understanding of AD, and encourage them to express values. A systematic review in 2016 showed that using SDM could improve decision-makers’ confidence and promote a positive healthcare experience and decision-making process, regardless of their final surgical decision [34].

It should be noted that the core of high-quality decision-making is that the results are consistent with patients’ values, goals, and preferences. Increasing knowledge alone is not enough to make high-quality decisions, especially emotional decisions about life and death [35]. Similarly, encouraging the decision-maker to determine the surgical plans in fear and denial cannot guarantee satisfactory results. After the intervention, the total score of decision satisfaction was significantly improved, especially the information and decision subscale, consistent with the results of Alden [36]. On the one hand, the PtDA for AD improved the decision makers ability to grasp disease knowledge and reduced the inner fear caused by lack of information. On the other hand, in the process of intervention, medical staff respected patients and encouraged them to express their values, which helps to build trust and improve decision-making satisfaction.

We also found that the use of PtDA did not improve the communication between doctors and patients. With the rapid development of AD, decision-making time is limited, and it is difficult to ensure timely communication between doctors and patients. Nurses have the longest contact with patients and their families. With the transformation of nurses’ functions and their prominent role in the SDM process, nurses can transmit information and improve the efficiency of communication.

In contrast to some research results, our study did not find that SDM changed patients’ choice of surgical plans and postoperative situation [37]. At the same time, it did not shorten the time of hospitalization and stay in ICU. For AD patients, the survival advantage of surgery is certain. The choice of surgical plans and the occurrence of complications is affected by medical conditions, such as surgical techniques and basic conditions of patients. The time of hospitalization and stay in ICU are also affected by the operation effect [38]. Although PtDA have deepened the understanding of disease knowledge of decision-makers, enabling them to view the occurrence of risks objectively and rationally, they cannot change the medical outcomes of patients. In addition, the use of PtDA did not have a significant impact on the duration of the conversation, which was consistent with the results of Kunneman et al. [39]. PtDA optimizes and supplements the content of informed consent, but does not simplify the medical decision-making process. The SDM 3 Circle Model, the three-stage conversation model, and the SDM model mediated by the decision-making coach, were used to improve the decision-making efficiency [40]. In the future, similar theories can be combined to optimize the intervention process, shorten the preoperative talk time, and improve the quality of decision-making.

Income, education, and residence were the main influencing factors of decisional conflict. In China, the median hospitalization cost for patients with acute AD was as high as 115,296 RMB [41]. Restrictions on medical insurance, post-discharge medication, and rehabilitation, etc., place greater financial pressure on AD patients. Although SDM has been widely used in the clinic, high-income decision-makers have a relatively light economic burden, fewer adverse emotions, and more firm decision results. Highly educated decision-makers have high health literacy and the ability to acquire and understand disease knowledge [42]. They can more effectively receive the information transmitted by medical staff and make medical decisions. Compared with urban patients, the lack of knowledge and medical resources may cause decision-making conflict among rural patients.

To the best of our knowledge, this was the first study to assist decision-makers in participating in the SDM of AD patients through the PtDA. The results was gratifying, which proved the feasibility and effectiveness of PtDA in AD patients. However, some limitations need to be considered. First, the study was conducted in a relatively developed city in China, with strict inclusion and exclusion criteria, which may limit the generalizability of the research results. Second, we could not measure the subjects’ mastery of disease knowledge due to the lack of an AD knowledge scale. Third, we only evaluated each decision-maker once and did not design a follow-up study. Fourth, the acceptance of AD complications, rehabilitation expectations, and other clinical outcome indicators were important. However, due to the lack of specific evaluation methods, we did not conduct an investigation. Moreover, convenience sampling was used and most of the data were self-reported. It was unable to avoid potential selection bias. Finally, this was a before-and-after comparison study. We did not randomize the patients, which weaken the conclusions that we can draw. A larger controlled trial is warranted to evaluate the effectiveness of such an approach and to measure the change in behavior over a longer term.

In view of the complexity of decision-making in AD, this study shows that the use of SDM can reduce decision-making conflict, improve decision-making participation, and improve decision-making readiness and decision satisfaction, without affecting the choice of surgical methods and complications. It is suggested that SDM should be rationally incorporated into the process of informed consent of AD. Income, education level, and residence are the influencing factors of decision-making conflict. It is necessary to improve the family’s economic burden by strengthening medical insurance, and ensuring the readability and objectivity of the content of PtDA to improve decision-making conflicts.

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

DZ, JL, LSZ, KLH, QSW—conception of the study, major drafting of the work, analysis and interpretation of data, final approval and agreeing to the accuracy of the work. YRZ, XXW YMP, ZZ, ZBZ—conception of the study, help in the design of the study, drafting of the work, final approval and agreeing to the accuracy of the work. HYZ, ZLC, KPBN—supervision, acquisition of data, analysis of data, final approval and agreeing to the accuracy of the work. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

Informed written consent was collected from all participants in the study. The study was conducted in accordance with the Declaration of Helsinki and was approved by the Research Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (approval number: s146).

We are very grateful to Doctor Gabriella Ricciardi from the department of Cardiac Surgery, Leiden Universitair Medisch Centrum, Leiden, Netherlands, for providing us with many beautiful hand drawings.

Yanrong Zhou received fund support from Huazhong University of science and technology (2021-3-10, 202008).

The authors declare no conflict of interest.