Stiggelbout, Peiterse, & De Haes (2015). Shared decision making: Concepts, evidence, and practice – Article summary

Shared decision making (SDM) is a model to engage patients in the process of deciding about diagnosis, treatment or follow-up when more than one medically reasonable option is available. It hasn’t been fully implemented in clinical practice yet.

The shared decision making model arises from the themes beneficence (1), non-maleficence (2), patient autonomy (3) and justice (4). In effective decisions, there is sufficient evidence on benefit-harm ratios and harms are small compared to benefits. In effective decisions, there is one optimal strategy. In preference-sensitive decisions, there is no best strategy as there is either insufficient evidence or the ratio depends on the patient’s values.

Practice variation could be countered by using SDM and this could also reduce health care costs. Patient’s preferences vary widely (1), are often different from physician preferences (2) and cannot be predicted by patient characteristics (3). In the treatment decision making process, there are three steps; information exchange (1), deliberation (2) and making a decision (3).

There essential aspects of SDM are define or explain the problem (1), present options (2), discuss the pros and cons (3), assess patient’s values or preferences (4), discuss patient’s ability or self-efficacy (5), provide doctor knowledge or recommendations (6), check or clarify understanding (7), make or explicitly defer decision (8) and arrange a follow-up (9).

SDM consists of four steps:

1. The professional informs the patient that a decision is to be made and that the patient’s opinion is important
   The clinician should make explicit that the decision is preference-sensitive.
2. The professional explains the options and the pros and cons of each relevant option
   The clinician should explain options in a neutral way. It is relevant to consider what information is relevant (1), what prior knowledge does the patient have (2), is information complete (3), how is risk conveyed (4) and does the patient understand the information (5). Risk communication should be done by using percentages and absolute risks should be discussed rather than relative risks.
3. The professional and patient discuss the patient’s preferences and the professional supports the patient in deliberation
   The clinician should raise the issue of relevance of outcomes to the patient and pose open questions to aid the patient’s preference formation.
4. The professional and patient discuss patient’s decisional role preference and make or defer decision and discuss a possible follow-up.
   The clinician should assess whether the patient wants to take the decision himself or hand over the responsibility to the professional.

In practice, most clinician’s present a decision as a fact and do not discuss alternative options. The patient’s preferences are also not assessed often.

Patients often believe that the doctor will make the right decision as he knows what is best. However, some decisions are not evidence based because of a lack of evidence and thus preference-based.

A pitfall in communicating benefits and harms of treatment is implicit normativity (i.e. presenting the information in a way that implicitly steers the patient towards one specific option).

There are several methods to support SDM in clinical practice:

1. Ask questions to the patients in order to encourage the patient to ask questions to the clinician (i.e. three questions approach).
2. Use patient decision aids (i.e. tools that support patients in SDM by providing information and help in the process of forming a preference).
3. Other medical professionals can provide pros and cons of the treatment options.
4. Medical professionals can use SDM in their communication-skills curriculum.
5. Raise knowledge and awareness of SDM.