What is the best approach to patient decision making in healthcare?

Shared Decision-Making is the Best Approach to Patient Decision Making in Healthcare

The shared decision-making model should be the default approach to patient decision making in healthcare as it recognizes the central roles of both the patient and healthcare practitioner in reaching decisions based on medical evidence and patient preferences and values. 1

Understanding Shared Decision-Making (SDM)

Shared decision-making exists on a continuum of decision-making models:

• Provider-driven approach: Offers least control to patients
• Autonomous model: Offers greatest patient control with least provider guidance
• Shared decision-making: Middle ground that balances provider expertise with patient values 1

The SDM process involves several key components:

1. Deliberation: A process where patients become aware of choices, understand options, and have time to consider what matters most to them 1
2. Information exchange: Clinicians provide clear information about treatment options, risks, and benefits 1
3. Values elicitation: Patients share information about their values, goals, and preferences 1
4. Collaborative deliberation: Both parties engage in back-and-forth discussion about options 1
5. Decision agreement: Clinicians and patients agree on the decision to implement 1

Why SDM is Superior to Other Approaches

Research demonstrates that SDM leads to:

• Greater patient satisfaction: Patients engaged in SDM report significantly higher satisfaction (96%) compared to autonomous (88%) or provider-driven models (63%) 1
• Increased knowledge and confidence: SDM enhances patient knowledge, confidence, and active participation 1
• Better alignment with patient values: Decisions better reflect what matters most to patients 1
• Improved quality of life outcomes: By focusing on patient preferences alongside medical evidence 1

Implementing SDM Effectively

1. Assess Patient's Role Preference

Patient preferences for decision-making are dynamic and context-dependent:

• Preferences change as patients become more familiar with healthcare environments
• Preferences vary depending on the specific decision at hand
• Preferences are influenced by relationships with healthcare team members 1

Rather than asking about decision-making preferences once, clinicians should:

• Discuss preferences in real-time as difficult decisions arise
• Use prior interactions to understand patient preferences
• Draw upon experience with other patients to match practice with patient preferences 1

2. Explain Treatment Options Clearly

Effective communication is essential:

• Avoid medical jargon when communicating with patients
• Ask patients if they understand terms used
• Define any words patients don't understand 1
• Present complete information about medically appropriate options, including risks and benefits 1

3. Elicit Patient Values, Goals, and Preferences

When patients can communicate (even with limited capacity):

• Seek opinions directly from patients rather than assuming they cannot contribute
• Review any advance directives or other written statements
• Communicate with family members to understand prior expressions of values 1

For patients who cannot communicate:

• Seek input from family and friends to understand core values
• Ask patient-focused questions (e.g., "If your father could speak for himself right now, what do you think he would choose?") 1

4. Deliberate Collaboratively

Effective deliberation involves:

• Active back-and-forth discussions about options
• Eliciting thoughts and concerns from all parties
• Asking patients to explain medical facts in their own words to check understanding
• Correcting any misunderstandings 1

Healthcare providers should:

• Offer recommendations based on both medical facts and patient values
• Explain the rationale behind recommendations
• Clarify which recommendations are based on medical facts versus personal beliefs
• Be aware of the weight their recommendations carry 1

Special Considerations

Decision-Making for Those Without Capacity

For patients who have never had decision-making capacity or never articulated clear preferences:

• Decisions should be based on the patient's best interests 1
• For children, decisions should generally be based on the child's best interests 1

Addressing Common Pitfalls

1. Misunderstanding SDM as unlimited patient choice: SDM does not mean patients can demand any intervention they want. Clinicians are bound to practice within accepted standards of care 1

2. Assuming one approach fits all: Decision-making preferences vary widely among patients. Some prefer greater control, while others prefer to cede more control to clinicians 1

3. Ignoring behavioral economics: Patients have predictable biases that affect decision-making, such as loss aversion (weighing losses more heavily than equivalent gains) 1

4. Failing to adapt to time constraints: While SDM is ideal, the approach may need modification in time-sensitive settings like emergency departments 2

5. Viewing SDM as transaction-focused: SDM works best within an ongoing partnership between clinician and patient, not as part of an isolated encounter 3

Conclusion

The shared decision-making model represents the optimal approach to patient decision-making in healthcare. By balancing clinical expertise with patient values and preferences, SDM leads to decisions that are medically sound while respecting patient autonomy. Healthcare providers should develop skills in SDM and adapt their approach based on individual patient preferences, clinical context, and time constraints.