Defining Shared Decision-Making
DefinitionTogether, patients and health care teams clarify all acceptable options, ensure that both parties are well informed, and choose a course of care consistent with the patient’s values and preferences as well as the best available medical evidence.
In other words: Helping patients evaluate all available options—weigh their personal values, goals and priorities against unbiased medical evidence—in order to make informed decisions at every stage of their care.While shared decision-making differs from informed consent, the concepts complement and augment one another. In a sense, shared decision-making is “perfected informed consent.” If we do shared decisionmaking well, then informed consent is real and genuine. By doing informed consent well, we verify that shared decision-making was successfully executed.
- Shared decision-making happens “upstream” from informed consent, before the patient commits to an intervention. In choosing a treatment plan, both patient and health care team need to gather information and gain the knowledge needed to shape the decision.
- Informed consent occurs before the intervention but well after the treatment plan has been established. It is the closing of the transaction—the moment where the patient and health care team finally commit to the plan of care.
- A clinician on the health care team presents an unbiased view of the pros and cons for all options, including “do nothing.” This may require the patient do to homework (read about a treatment, watch a video, etc.) and then return for further discussion.
- The patient tells the clinician about personal factors that might make one option seem better than another. These include personal values, goals, preferences and circumstances.
- Together, the patient and health care team use this information to decide which option best reflects the patient’s needs and values.
Opportunities for Shared Decision-MakingShared decision-making is at the heart of patient-centered communication. It is the health care team’s responsibility to offer opportunities for shared decision-making. It can occur in any setting and take many different forms.
- One-time treatment decisions. Example: initial treatment of breast cancer.
- Possible serial treatments. Example: low back pain.
- Preventive care or screening. Example: PSA test; mammogram.
- Lifestyle decisions. Example: smoking cessation.
- Chronic care decisions. Example: diabetes management
- Life stage decisions. Example: move in with family, assisted living, hospice.
How do I know when genuine shared decision-making has occurred?
- Proper preparation: – A situation presents itself as suited to shared decision-making. – Any involved party initiates the conversation. – A balanced relationship is maintained between the parties making the decision.
- Reaching a decision: – Together, the parties create a shared understanding of the information needed to make the decision. – The parties use developed resources, methods and tools. – The patient and health care team seek a mutually satisfying decision in which they both have confidence.
- Following up: – The parties follow up with next steps once the decision is made, including a plan for ongoing decision-making needs.
Framing the Conversation: an Example
“We have reached a point where a decision needs to be made: whether to do X, Y or Z. I can give you the medical information you need; you can help me understand how each option might fit with your own goals and preferences.”
“You can take as much time as you need to consider the choices. Then, we can decide together what the best option might be.”
“Is there anyone else who should be a part of this discussion? Is it safe to say that the final decision belongs to you?”
Required for Complete Shared Decision-Making
Have you worked to establish a balanced relationship?Strategies to consider:
- Acknowledge the roles of all parties in the decision-making process (clinician, patient, family, others), including who is responsible for the final decision.
- Acknowledge that both clinician and patient bring different areas of expertise to the discussion (i.e., patients “know self best”).
- Address any health care team biases. For instance, a surgeon might involve nonsurgical specialists to ensure that all options are objectively presented to the patient.
- Remind patients to take as much time as needed/available to consider the decision.
Do all parties have the information they need to make a decision?For genuine shared decision-making to occur, all parties should understand:
- The decision that needs to be made and the timeline.
- Who should (and shouldn’t) offer support and advice. For instance, patients might avoid advice from family members who contribute to decisional conflict.
- The condition, diagnosis and likely course of disease.
- All available options (including “do nothing”), along with their benefits and risks/burdens (including financial burdens).
- Which burdens and benefits matter most to patient (i.e., “concordance,” or values matching: the relationship of the risks/benefits to the patient’s values/preference).
Have you used proven strategies to support decision-making?For example:
- Active listening
- A universal-precautions approach to health literacy
- Cultural sensitivity
- Teach-back technique to assess 1) patient’s understanding of medical information and 2) provider’s understanding of patient’s goals and preferences. Teach-back is used throughout the discussion, not just at end.
- Non-biased patient education, discussion guides or decision aids (handouts, videos, tools to assess activation or readiness for shared decision-making, etc.).
Have you sought a mutually satisfying decision in which both have confidence?Create space for the patient to reconsider, change his/her mind, and loop back with the provider. “Mutually satisfying” is the goal, but in the end, it is the patient’s decision—and satisfaction with that decision— that matters most. If the health care team disagrees with the decision, professional pathways exist to resolve health care team discomfort (such as seeking a second opinion) or decide whether to keep working with that patient.