Shared decision-making with patients makes it possible for a patient and their physician to choose an appropriate care plan that they’re both happy with.
A patient stands in front of you complaining about hip pain that he's had for years. You're thinking of offering surgery but are concerned that the patient may not follow through with physical therapy afterward. Or it may be that your patient is a poor surgical candidate or you're concerned that he doesn't understand the disease process. It's difficult to know how to move forward, but trying out shared decision-making with patients can lead to a plan that's satisfactory for both parties.
In the past, physicians used a more paternalistic model of decision-making: We did what we thought was best for our patient without considering what the patient wanted. In a life-and-death trauma situation when critical decisions need to be made quickly, this model is still appropriate. Otherwise, this paternalistic attitude is considered outdated because it only reflects the physician's values and not necessarily the patient's.
Instead, the idea of informed consent became popular. With informed consent, the physician shares their knowledge, informing their patient about their illness and their options for treatment and then letting them decide how to proceed. The problem with this approach was the assumption that the patient had a certain level of medical literacy and truly understood their illness and the need for treatment. During a particularly vulnerable time like just prior to a surgery, this approach may simply make the patient anxious.
What is shared decision-making?
In his lecture "Ethics of Shared Decision Making with Patients," available for CME credit on AudioDigest, Dr. Martinez-Dubouchet offers a better approach. Shared decision-making with patients leads to a shared responsibility as well as the patient being involved in medical management decisions. It allows for collaboration between the patient and patient's family as well as the physician and the care-giving team. However, it does come with challenges for the physician. You need to share knowledge in a way that the patient can comprehend.
Tools can help with this. You can create a grid that outlines the best- and worst-case scenarios if the patient chooses surgery vs. other treatments. This gives the patient a visual tool to take home and look at later as well as a way to share this information with their other doctors.
During the shared decision-making process, physicians should make sure they learn the patient's goals. Maybe they want to be able to hike after surgery or just be pain-free. It's also important to know about their values. For example, cancer patients may want to pursue treatment only to a certain extent or already know what they want to do about end-of-life decision-making.
Dr. Martinez-Dubouchet offers suggestions for how to go about shared decision-making with patients. Some best practices to follow include:
- Encouraging family members to be present and involved during these discussions
- Offering emotional support and empathy by asking open-ended questions like "How do you feel about this?"
- Making sure the patient understands how their disease will progress and the options available to them. By alternating asking, telling and asking again, you give the patient space to express their understanding of the situation.
- Emphasizing that patients have autonomy and choices and that they are integral to the decision-making process
- Asking patients to clearly state their outcome goals as well as their understanding of what it will take to get there
Barriers to shared decision-making
Even if it represents an improvement over paternalism and informed consent, shared decision-making comes with its own challenges.
One barrier to shared decision-making with patients is that some patients simply don't want to be involved - they want their physician to make all the decisions. Other patients lack the healthcare literacy to understand how the disease will progress or their treatment options. There are also the challenges that come with not having the time for a thorough discussion or for developing decision aids and training your staff to use them. You also may not always be reimbursed for your time.
However, when you engage in shared decision-making with a patient, you develop a better relationship and cultivate trust. It will also lead to a better treatment plan, one based on the patient's values. In addition, when patients are actively involved in decision-making, they may be more motivated and compliant with the treatment plan.