Shared decision making

Evidence is one of the tools we can use to care for patients.[1] Evidence-based practice works best when it is individualized, so that diagnosis and treatment are considered alongside each patient’s values and preferences, and fit within their personal and social context.[2] One way of tailoring care to the individual is shared decision making (SDM).

Shared decision making as a method to individualize care occurs in the discussions between patients and clinicians. Through these discussions, patients and clinicians work together to understand the patient’s choices. Together they evaluate available options as hypotheses, testing them in conversation until it becomes clear how best to care for this patient, including how the patient wants to be cared for.[3]

To practice shared decision making, patients and clinicians need accurate information about the medical situation and about the value of the available diagnostic and treatment options. Clinicians need the skills to appraise and apply the evidence to the patient situation and to understand patients' reasons for proceeding in one way or another.

In seeking the most reasonable way forward, clinicians must create the conditions to optimize patient involvement, yet be flexible enough to work with varying levels of patient participation in decisions. A very sick patient, for example, may prefer clinicians to make treatment decisions on his or her behalf, while the same patient in better health may be the most vocal advocate of no decision about me without me.

The conversation is the medium in which patients and clinicians make sense of the patient situation and of the evidence from clinical care research and from the patient’s biology and biography. In conversation, patients and clinicians can think, talk, and feel their way through the situation at hand (e.g., how to treat my out-of-control diabetes) and test different hypotheses (e.g., adding a new medicine, intensifying lifestyle changes, obtaining full-time employment) that might meet the demands of the situation. These conversations create the environment in which information and deliberation turn into care; the outcome of this care is a course of action that is best for the patient and his or her family.[3]

Individualization of care is not easy. Lack of reliable evidence (e.g., uncertainty about the effectiveness of a treatment, and about its safety given the patient comorbidities) and clarity about patient preferences and context, and the lack of training, tools, and time to have productive conversations make this process difficult. Encounter Aids are tools that enable shared decision making and help clinicians and patients create a space for these conversations to happen.[4] These tools improve knowledge about options, calibrate prognosis about the condition and expectations about the impact of treatment options, and thus contribute to efficiently and confidently attempting these conversations.[5] Not only can shared decision making improve individualized care, but by furthering the partnership between patients and clinicians and bringing the patient situation into sharp definition, it may also improve clinician satisfaction and reduce burnout.

The task of individualizing care for each patient, in an era where standardizing algorithms rule, is huge. Yet it remains a central skill for clinicians and should be a reasonable expectation of patients. To make evidence into care, we need a dance. To dance productively, we need shared decision making. Because shared decision making is central to the provision of careful and kind patient care.

Authors: Juan P. Brito MD, MSc, Marleen Kunneman PhD, and Victor M. Montori MD, MSc. Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN, USA

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References

1. Montori VM, Guyatt GH. Progress in evidence-based medicine. JAMA 2008;300(15):1814-16. doi: 10.1001/jama.300.15.1814
2. Hargraves I, Kunneman M, Brito JP, et al. Caring with evidence based medicine. BMJ 2016;353:i3530. doi: 10.1136/bmj.i3530
3. Hargraves I, LeBlanc A, Shah ND, et al. Shared Decision Making: The Need For Patient-Clinician Conversation, Not Just Information. Health Aff (Millwood) 2016;35(4):627-9. doi: 10.1377/hlthaff.2015.1354
4. Montori VM, Breslin M, Maleska M, et al. Creating a Conversation: Insights from the Development of a Decision Aid. PLOS Medicine 2007;4(8):e233. doi: 10.1371/journal.pmed.0040233
5. Stacey D, Legare F, Col NF, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2014(1):CD001431. doi: 10.1002/14651858.CD001431.pub4