Shared decision making
Shared Decision Making is the process whereby doctor and patient reach a decision together about the course of action to be taken in response to the situation outlined in the consultation. Its use can be justified by several means
- a belief that patients’ views are important and that doctor and patient have equality in the consultation
- an ethical stance emphasising patient autonomy and the legal principle of consent
- studies showing improved clinical outcomes and better compliance with treatment
Shared Decision Making (SDM) generally occurs towards the end of the consultation, after information gathering (history taking and examination) and diagnosis making (or developing a problem list). It uses the skills needed for explaining to help outline the various treatment options available, and aims for the doctor and patient to make a decision together, integrating professional knowledge and values with the patient’s personal values and then negotiate a plan which is both medically appropriate and acceptable to the patient.
In order for SDM to occur effectively, many things are necessary
- the doctor needs to obtain enough information to know what disease process or problems he is dealing with – he has to be a good clinician able to take an accurate history and perform the relevant examination, with or without further investigations
- the doctor must be able to explore the patient’s views about his illness
- the doctor’s diagnostic acumen must allow him to accurately interpret his findings
- the doctor must be up to date with the treatment options for the condition, and know the advantages and disadvantages of each possible course of action
- the doctor must be able to explain the findings to the patient accurately
- the doctor has to create an atmosphere within the consultation in which the patient feels comfortable to express himself and that his views will be listened to
- the patient has to be able to outline what he feels is important in the area of the illness. If necessary the doctor must actively seek out the patient’s values. They must be made explicit because this helps the patient himself clarify what is important to him, and it emphasises to him that the doctor is interested in his opinion.
- the doctor must negotiate with the patient what the objectives of treatment are and which of the options are most appropriate for that patient.
So why should I bother Sharing Decisions with patients?
The GMC suggests that when discussing treatments with patients, you should outline all the available treatments and their associated pros and cons in order to help patients make decisions about their healthcare. That’s much of what SDM requires.
Some studies show better health outcomes for patients who are involved in making decisions about their healthcare. Other studies show that where patients are actively involved in the consultations by their doctor then they are less likely to sue the doctor if things go wrong.
There are two other historic approaches to making decisions between doctors and patients, and these may be seen as lying at either end of a spectrum of patient and doctor involvement in the decision. Either of these might be appropriate at times.
- Paternalistic Decision Making is where the doctor alone decides on the best course of action and implements it, with the intention being that the decision made is in the patient’s best interests. This clearly makes use of professional knowledge but fails to take any account of the patient’s preferences or feelings. In many situations in medicine there is no clear best answer and without it being explored doctors are poor at guessing patient’s values. But faced with an unconscious patient this is likely to be the only course of action open to you unless you know the patient and have discussed the possibilities beforehand. It might also be necessary for the doctor to make the decision alone when faced with a completely incompetent patient [e.g. drunk or demented], but depending on the degree of urgency needed, it might be better to defer the decision until the patient regains competence or to involve those who know the patient to try to clarify what they might want.
- Informed Patient Choice is where the doctor outlines the options and the patient makes the decision unaided. This tended to be the model of decision making in reaction to Paternalism, but it can still lead to the patient making the wrong choice [wrong for them, that is] by failing to make use of the professional’s knowledge and experience and also through not being encouraged to consider which aspects of their own values they ought to take account of. This model can leave patients feeling unsupported, but is clearly the model of choice when the patient states he wants to make the decision alone.
So how do I do it in practice?
- Identify the treatment options in your own mind
- Ask if the patient wants to be involved in choosing the treatment or gently suggest that you’d like her help in choosing the best treatment for her.
- Share your ideas out loud about the options
- Ask if the patient had any other ideas about treatment she wants to discuss
- Discuss the pros and cons of each option (ideally with explicitly stated likelihoods)
- Try to clarify the values of what’s important to the patient (e.g. reducing pain, not wanting to take regular tablets, avoiding invasive procedures, avoiding medicalisation)
- Be honest in situations where there’s no clear best treatment from your professional viewpoint
- Be prepared to state your preferred option from your professional viewpoint and explain why
- Answer any questions the patient has
- Discuss which is the patient’s preferred option
- State what you see as the decision that has been made and check that the patient agrees.
What other resources are available?
There is growing experience of using paper or computer/internet based sources of information for patients and helping lead them through the decision making process. These supply information to the patient, often trying to quantify the likelihoods of different outcomes, but importantly also ask patients to clarify for themselves what aspects of the different outcomes are important for them, who else they might want to discuss things with (e.g. family, religious leaders) and give a better basis for further discussion with the doctor. There are also aids which use computers to provide multi-media information, such as clips of actors or patients discussing real experiences of conditions such as prostate biopsy to give patients a clearer understanding of what is involved with different options. Some work suggests that these can alter the number of procedures undertaken (fewer major operations, no change on minor operations, increases on some screening tests) without adverse effects on patient outcomes.
http://decisionaid.ohri.ca/AZlist.html Ottawa decision aids – home page to access aids on a variety of medical problems
http://decisionaid.ohri.ca/decguide.html Generic decision aid to use for any decision
Silverman J, Kurtz S, Draper J, (2005) Skills for Communicating with Patients, second edition, Radcliffe Publishing. ISBN 1-85775-640-1
Edwards A, Elwyn G, (2001) Evidence Based Patient Choice, Oxford University Press