Shared Decision Making

Overview
Since the patient’s well-being and health are at the center of all health care team decisions, it is important that the patient is involved in their care decisions, when possible. Shared Decision-Making (SDM) is “the crux of patient-centered care” (Légaré, et al, 2010), and health care stakeholders have been emphasizing the inclusion of patients as partners in their continued care.

Légaré & Witteman, 2013 elaborate: “At its core, shared decision making is an interpersonal, interdependent process in which the health care provider and the patient relate to and influence each other as they collaborate in making decisions about the patient’s health care.”

Definitions
“Shared decision making is the process of interacting with patients who wish to be involved in arriving at an informed, values-based choice among two or more medically reasonable alternatives (which may include ‘watchful waiting’)” (O’Connor, Llewellyn- Thomas, & Flood, 2004)

“…involvement of both the patient and the doctor, a sharing of information by both parties, both parties taking steps to build a consensus about the preferred treatment, and reaching an agreement about which treatment to implement” (Charles, Gafini, & Whelan, 1997)

Benefits of Shared Decision-Making
Shared decision-making in the clinical setting has resulted in better quality of care, increased satisfaction for patients and medical staff, and improved self-esteem for patients (Crawford, et al, 2002; Elwyn & Edwards, 2009).
Légaré, et al, argue that shared decision-making is perceived as desirable because of its potential to:

  • Reduce overuse of options not clearly associated with benefits for all
  • Enhance the use of options clearly associated with benefits for the vast majority
  • Reduce unwarranted practice variations
  • Foster the sustainability of the healthcare system
  • Promote the right of patients to be involved in decisions concerning their health

Three Essential Elements for Shared Decision-Making (Légaré & Witteman, 2013)
Both the provider and patient must recognize and acknowledge that a decision is required
They must both know and understand the benefits/risks of each option
Decisions must take into account both the provider’s guidance and the patient’s values/preferences

Barriers to Shared Decision-Making
According to Gravel, Légaré, and Graham (2006), the three most common barriers to shared decision making are as follows:

  • Timethis is the most commonly cited barrier to implementing shared decision-making, though re-search is conflicting, in regards to evidence about the time required to engage in shared decision-making.
  • Patients’ Characteristicsshared decision-making is not a technique that is appropriate for all patients. Crawford, et al (2002) “identified reports in which patients described dissatisfaction with the process.” This will require the judgment of the health care team, through discussions with the patient, when determining whether or not shared decision-making should be used.
  • Clinical Situationsjust as above, shared decision-making may not be appropriate in all clinical situations. This will also require the judgment of the health care team, through discussions with the patient, when determining whether or not shared decision-making should be used.

Adopting Shared Decision-Making
Elements and training that support the successful integration of shared decision-making include possessing the competencies for effective shared decision-making, and the use of patient decision aids. These will be described below.

Competencies for Shared Decision-Making
Towle and Godolphin (1999) identified eight competencies that health providers should possess in order to successfully adopt effective shared decision-making:
1. Develop a partnership with the patient
2. Establish or review the patient’s preferences for information
3. Establish or review the patient’s preferences for role in decision making and the existence and nature of any uncertainty about the course of action to take
4. Ascertain and respond to patient’s ideas, concerns, and expectations
5. Identify choices and evaluate the research evidence in relation to the individual patient
6. Present evidence, taking into account competencies 2 and 3, framing effects—help patient to reflect on and assess the impact of alternative decisions with regard to his or her values and lifestyle
7. Make or negotiate a decision in partnership with the patient and resolve conflict
8. Agree on an action plan and complete arrangements for follow up

Patient Decision Aids
Shared Decision-Making becomes more effective with the adoption of Patient Decision Aids . These are defined as “standardized, evidence-based tools intended to facilitate [shared decision making]” (O’Connor, Llewellyn-Thomas, & Flood, 2004).

References
Barry, M.J. (2002). Health decision aids to facilitate shared decision making in office practice. Annals of Internal Medicine, 136(2), 127-135
Charles, C., Gafini, A., & Whelan, T. (1997). Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Social Science & Medicine, 44(5), 681- 692
Crawford, M.J., Rutter, D., Manley, C., Weaver, T., Bhui, K., Fulop, N., & Tyrer, P. (2002). Systematic review of involving patients in the planning and development of health care. British Medical Journal, 325(7375), 1263-1266
Elwyn, G., Edwards, A. (2009). Chapter 1: Shared Decision-Making in Health Care: Achieving Evidence-Based Patient Choice. New York: Oxford University Press. Retrieved fromhttp://fds.oup.com/www.oup.com/pdf/13/9780199546275_chapter1.pdf
Gravel, K., Légaré, F., & Graham, I.D. (2006). Barriers and facilitators to implementing shared decision-making in clinical practice: a systematic review of health professionals’ perceptions. Implementation Science, 1(16). doi: 10.1186/1748-5908-1-16. Retrieved fromhttp://www.biomedcentral.com/content/pdf/1748-5908-1-16.pdf
Légaré, F., Ratté, S., Stacey, D., Kryworuchko, J., Gravel, K., Graham, I.D., & Turcotte, S. (2010). Interventions for improving the adoption of shared decision making by healthcare professionals. Cochrane Database of Systematic Reviews, 5. doi: 10.1002/14651858. CD006732.pub2
Légaré, F. & Witteman, H.O. (2013). Shared decision making: examining key elements and barriers to adoption into routine clinical practice. Health Affairs, 32(2), 276-284. doi: 10.1377/htlhaff.2012.1078
O’Connor, A.M., Llewellyn-Thomas, H.A., & Flood, A.B. (2004). Modifying unwarranted variations in health care: shared decision making using patient decision aids. Health Affairs, VAR 23-63. doi: 10.1377/hlthaff.var.63
Ottawa Hospital Research Institute. (2013). Alphabetical list of decision aids by health topic. University of Ottawa. Retrieved fromhttp://decisionaid.ohri.ca/AZlist.html.
Towle, A. & Godolphin, W. (1999). Framework for teaching and learning informed shared decision making. British Medical Journal, 319(7212), 766-771. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1116602/pdf/766.pdf