Shared Decision Making: Putting The Patient at the Center of Healthcare

By explicitly recognizing a patient’s right to make decisions about their care, shared decision-making can help ensure that care is truly patient-centered.

As gravity shifts away from health care providers as the sole keeper of medical information, the importance of sharing decisions, as opposed to clinicians making decisions on behalf of patients, has been increasingly recognized.

Shared decision-making (SDM) is the conversation that happens between a patient and clinician to reach a healthcare choice together.

Examples include decisions about surgery, medications, self-management, and screening and diagnostic tests. While the process commonly involves a clinician and patient, other members of the health care team or friends and family members may also be invited to participate. The clinician provides current, evidence-based information about treatment options, describing their risks and benefits; and the patient expresses his or her preferences and values. It is thus a communication approach that seeks to balance clinician expertise with patient preference.

While informing patients about options is important, true patient-centered care requires a new model of decision-making in which responsibility is shared between patient and clinician. Implementing this model will require a shift toward health care in which clinicians and patients work together to manage complex conditions, and make decisions on the basis of not only the best scientific evidence but also the patient’s biological characteristics, preferences, values, and life circumstances.

The best decision takes into account evidence-based information about treatment options, the physician’s knowledge and expertise, and the patient’s preferences, values, and goals — Toliman

Before physicians can really know what the proper treatment is for a patient, they must understand the particular needs of their patients.

This approach recognizes that clinicians and patients bring different but equally important forms of expertise to the decision-making process. The clinician’s expertise is based on knowledge of the disease, likely prognosis, tests, and treatment; patients are experts on how a disease impacts their daily life, and their values and preferences.

For some medical decisions, there is one clearly superior treatment path (for example, acute appendicitis necessitates surgery); but for many decisions, there is more than one option in which attendant risks and benefits need to be assessed.

In these cases, the patient’s own priorities are important in reaching a treatment decision. Patients may hold a view that one treatment option fits their lifestyle better than another. This view may be different from the clinician’s. Shared decision-making recognizes a patient’s right to make these decisions, ensuring they are fully informed about the options they face.

In its definition of shared decision-making, the Informed Medical Decisions Foundation , a non-profit that promotes evidence-based shared decision-making, describes the model as “honoring both the provider’s expert knowledge and the patient’s right to be fully informed of all care options and the potential harms and benefits. This process provides patients with the support they need to make the best-individualized care decisions while allowing providers to feel confident in the care they prescribe.”

By explicitly recognizing a patient’s right to make decisions about their care, SDM can help ensure that care is truly patient-centered.

In Making Shared Decision-Making A Reality: No Decision About Me Without Me, the authors recommend that shared decision-making in the context of a clinical consultation should:

• support patients to articulate their understanding of their condition and of what they hope treatment (or self-management support) will achieve;
• inform patients about their condition, about the treatment or support options available, and about the benefits and risks of each;
• ensure that patients and clinicians arrive at a decision based on mutual understanding of this information;
• record and implement the decision reached.

The most important attribute of patient-centered care is the active engagement of patients in decisions about their care.

“No decision about me, without me” can only be realized by involving patients fully in their own care, with decisions made in partnership with clinicians, rather than by clinicians alone.

This has been endorsed by the Salzburg Statement on Shared Decision Making, authored by 58 representatives from 18 countries, which states that clinicians have an ethical imperative to share important decisions with patients.

Clinical encounters should always include a two-way flow of information, allowing patients to ask questions, explain their circumstances, and express their preferences. Clinicians must provide high-quality information, tailored to the patient’s needs and they should allow patients sufficient time to consider their options.

Similarly, in Shared Decision Making: A Model for Clinical Practice, the authors argue that achieving shared decision-making depends on building a good relationship in the clinical encounter so that patients, carers, and clinicians work together, in equal partnership, to make decisions and agree on a care plan.

According to the Mayo Clinic Shared Decision Making National Resource Center, this model involves “developing a partnership based on empathy, exchanging information about the available options, deliberating while considering the potential consequences of each one, and making a decision by consensus.” Good communication can help to build rapport, respect and trust between patients and health professionals and it is especially important when decisions are being made about treatment.

Decision Aids

One of the most important requirements for decision-making is information. There are a number of tools available to support the process such as information sheets, DVDs, interactive websites, cates plots, or options grids.

Decision aids provide balanced information on diagnostic and treatment options, including risks and potential outcomes, and help patients consider what factors are most important to their decision. The goal is to help patients identify the diagnostic technology or treatment that best meets their needs, goals, and circumstances. Studies of such tools have found that they increase patients’ knowledge and understanding of benefits and risks and encourage them to participate in decisions.

Discussing their options and preferences with health professionals enables patients to understand their choices better and feel they have made a decision that is right for them.

Case Study

Breast Advocate®, founded by Dr. Minas Chrysopoulo, an internationally recognized expert in breast cancer reconstruction and shared decision-making is the world’s first shared decision-making app for breast cancer treatment and breast reconstruction.

Barriers to Shared Decision-Making

Barriers to shared decision-making include poor communication, for example, doctors using medical terminology which is incomprehensible to patients; lack of information, and low health literacy levels.

It is worth noting that not everyone wants to be involved in shared decision-making with their doctors; and not every doctor wants to take the time. Some patients come from cultural backgrounds that lack a tradition of individuals making autonomous decisions. Some health professionals may think they are engaged in shared decision-making even when they are not.

Shared Decision-Making — An Ethical Imperative

With this proviso in mind, it is nevertheless clear that the tide is turning toward more active patient participation in decisions about health care. Research has shown that when patients know they have options for the best treatment, screening test, or diagnostic procedure, most of them will want to participate with their clinicians in making the choice.

A systematic review of patient preferences for shared decision making indicates 71% of patients in studies after 2000 preferred sharing decision roles, compared to 50% of studies before 2000.

The most important reason for practicing shared decision-making is that it is the right thing to do. The Salzburg Statement goes so far as to say it is an ethical imperative and failure to facilitate shared decision-making in the clinical encounter should be taken as evidence of poor quality care. Evidence for the benefits of shared decision-making is mounting.

Providing patients with current, evidence-based information, relevant decision aids, and giving them time to explore their options and work through their concerns, will help patients choose a treatment route that best suits their needs and preferences, and ultimately lead to better health outcomes for all.

This article originally appeared on Patient Empowerment Network