1.Introduction
1.1 What is the Outcome Prioritisation Tool (OPT)?
The OPT is a conversation aid. The goal of the OPT conversation is for the healthcare provider to engage in a conversation with the patient about what matters to them. This information is crucial for determining an appropriate treatment plan. This link shows an animation that briefly explains the OPT Outcome Prioritization Tool (English version) – YouTube
1.2 The OPT conversation
A conversation using the OPT can help the patient articulate and prioritize their goals and preferences. The OPT offers four health outcomes:
- Life Extension: living as long as possible.
- Maintaining Independence: remaining as independent as possible.
- Pain Reduction: reducing or preventing pain.
- Reducing Other Complaints: reducing or preventing other complaints, such as nausea, shortness of breath, cognitive decline etc. This goal also allows room for other priorities to be mentioned. What other goals or preferences are important to you? For example: no matter what happens, you do not want to be separated from your dog; or you want to experience less discomfort from side effects like tingling in your hands because you want to keep playing guitar; or you want your memory not to decline further.
During the conversation, after explanation of the four health outcomes, the patient is asked to rate and prioritization these four goals in order of importance. The ‘trade-off’ principle is applies here. Pursuing one goal can come at the expense of another. For example, intensive treatment aimed at life extension may compromise independence.
In the OPT conversation, it is not about the ‘numbers’ but primarily about the reasoning of the patient (and their loved ones) for prioritizing one goal over another. The prioritization is a starting point for a conversation about priorities and trade-offs. During this conversation the healthcare professional explores what the patient means by the prioritized goals and the reasoning behind the order of these goals. Note that patients are often not fully aware of their own goals and preferences regarding treatment choices and/or may struggle to articulate them. It can sometimes be helpful to mention that there are no right or wrong answers.
2. Using the OPT in practice: the OPT conversation
2.1 Introducing the OPT
The OPT can be introduced as follows (see further for more example sentences): “We/I would like to know what is important to you.”
This does not have to relate to treatment or illness. Detaching this conversation from treatment choices can help the patient get out of ‘illness’ thinking. For instance, you might say: “I would like to understand what is important to you in your life.”
Explain that each treatment goal receives a score from 0 to 100. The higher the score, the more important the specific goal is. The patient is expected to provide a ranking; no goal may receive the same score. The numbers do not need to add up. Ultimately, it is not about the ‘numbers’ but primarily about the reasoning of the patient (and their loved ones) for prioritizing one goal over another.
Sometimes, it can help to broaden the goal. For example, if someone states that they currently have no pain, they may know of others who do or might want to prevent pain. Another example: for ‘other complaints,’ it might be about preventing memory problems, or other things they might worry about. It is also important to ask what the patient specifically means by their prioritization. What does independence mean to them? What must absolutely not be lost? For one person, the need for home care may already be unacceptable, while another may mainly want to avoid becoming in a vegetative state.
2.2 Example Sentences
Introducing the OPT:
- “I/we would like to know what is important to you in life.”
- “This is a tool to have a conversation about what is important to you.”
- “It’s about getting a clear picture of what you value, and there’s no right or wrong in that.”
- “Here you see four goals, outcomes of treatment. Which is the most important to you?”
- “It’s about thinking about what you find most important and creating a kind of order.”
- “Choosing one goal can have consequences for another goal. For example, treatment aimed at extending life may negatively impact your independence or cause side effects like pain or nausea.”
2.3 Core of the OPT Conversation
During the conversation, the patient gives the four goals a score between 0-100 and the healthcare provider asks follow-up questions about what the patient means by their choices and why those choices are made.
Example sentences that can help:
- “The scores are not so important; I mainly want to know why you make certain choices.”
- “Let’s say you experience pain. Is that something you absolutely want to avoid? Or do you say, if the pain can be managed and my life can be extended, that’s more important? Or do you say, my social contacts are the most important to me, as long as I can keep those?”
- (Addressing the patient): “What do you find most important?”
- “I hear you saying:….. [rephrasing the essence of what the patient has shared].”
- “I notice that you seem a bit shocked/sad/unsure/angry about this…” [Brief reflections on the patient’s feelings] (emotional reflection)
- “Let’s dig deeper into what the goals/values mean for you and make them concrete:
- What does ‘living as long as possible’ mean for you?
- What does ‘maintaining independence’ mean?”
2.4 Loved ones and their role in this conversation
Sometimes a loved one may also express an opinion about the goals, for example, following a previous conversation. A dialogue may arise between the patient and their loved ones. This need not be problematic and can sometimes be helpful.
3.Concluding the Conversation
3.1 Summarizing
At the end, summarize: “So if I understand correctly, for you… is the most important because you… … is also important to you, but if you have to make a choice, you would choose… Is that correct?”
3.2 Documentation
Document the score for each goal and the reasoning in the patient’s file. The numbers can support this and sometimes emphasize the priority of a goal. For example, if someone gives independence 90 points and the other goals 10, 20, and 40, the reasoning is what’s most important. For instance: “For this patient, life extension is the priority; the patient wants to see her grandchild born.” Or, “Maintaining control over her own life is paramount, even if it means sacrificing life extension.”
4.Discussing in a Multi-Disciplinary Team Meeting
A good description of this also aids in discussing these results in the MDT. In the MDT, it is essential to indicate what the patient’s most important goal is and why. Other goals may also be mentioned, especially if there are notable aspects. For example: “During the conversation, it became clear that being able to pursue his hobby of train watching, for which he needs to travel, makes life worthwhile for him. He prioritized maintaining independence as the highest goal.” Or: “The patient indicated that she wants to alleviate pain at all costs, even if it means she will need to use a wheelchair and move. Reducing pain is her top priority.”