What is Shared Decision Making in Healthcare?
Shared decision-making (SDM) is a collaborative process that allows patients, or their surrogates, and clinicians to make healthcare decisions together, taking into account the best scientific evidence available, as well as the patient's values, goals, and preferences. 1
Core Definition and Framework
The American College of Critical Care Medicine (ACCM) and American Thoracic Society (ATS) formally endorse this definition, which represents the consensus standard across critical care and increasingly all medical specialties. 1 This approach fundamentally shifts medical decision-making from a purely paternalistic model to one that respects patient autonomy while leveraging clinical expertise. 1
The Three Essential Elements of SDM
Clinicians should use as their default approach an SDM process that includes three main elements: information exchange, deliberation, and making a treatment decision. 1, 2
1. Information Exchange
- Clinicians share: Treatment options with their risks and benefits, prognosis information (including both mortality risk and functional outcomes), and the option of palliative care without life-prolonging interventions. 1, 2
- Patients/surrogates share: The patient's values, goals, and preferences that are relevant to the decision at hand. 1
2. Deliberation
- Both clinicians and patients/surrogates engage in joint deliberation about which option is most appropriate for the patient, discussing advantages and disadvantages of various options. 1, 2
- This phase explicitly incorporates how the patient's values and preferences influence the choice. 2
3. Making the Treatment Decision
- Clinicians and patients/surrogates agree together on the care plan to implement. 1
- The decision and its rationale should be clearly documented, linking it to the patient's expressed values. 2
When SDM Should Be Used
Clinicians should engage in SDM to define overall goals of care (including decisions regarding limiting or withdrawing life-prolonging interventions) and when making major treatment decisions that may be affected by personal values, goals, and preferences. 1
Once overall goals are established, clinicians have fiduciary responsibility for routine day-to-day decisions (such as choice of vasoactive drips, laboratory testing, fluid rates) that align with those goals. 1 However, when important preference-sensitive choices arise during the ICU stay or clinical course, clinicians must employ SDM. 1
The Spectrum of Decision-Making Models
A wide range of decision-making approaches are ethically supportable, including patient- or surrogate-directed and clinician-directed models, and clinicians should tailor the decision-making process based on the preferences of the patient or surrogate. 1
Patient-Directed Model
When patients/surrogates wish to exercise significant authority, the clinician determines and presents the range of medically appropriate options, and the patient/surrogate chooses from among these options. 1 The patient/surrogate bears the majority of the responsibility and burden of decision-making in this model. 1
Clinician-Directed Model
When patients/surrogates prefer that clinicians bear the primary burden in making even difficult, value-laden choices, this approach is ethically acceptable. 1 Research shows that many patients/surrogates prefer to defer highly value-laden choices to clinicians. 1
Equal Partnership Model (Default)
Data suggest that most patients/surrogates prefer an approach in which they and their clinician(s) are equal partners in decision-making, so this model should be used as the default and then adjusted to match patient/surrogate preferences. 1 The authority and burden of decision-making is shared relatively equally in this model. 1
Critical Communication Skills Required
Clinicians should be trained in communication skills necessary to create effective partnerships in treatment decisions. 1
Core categories of skills include: 1
- Establishing a trusting relationship with the patient/surrogate
- Providing emotional support
- Assessing patients'/surrogates' understanding of the situation
- Explaining the patient's condition and prognosis
- Highlighting that there are options to choose from
- Explaining principles of surrogate decision-making
- Explaining treatment options
- Eliciting patient's values, goals, and preferences
- Deliberating together
- Making a decision
Common Pitfalls to Avoid
Leaving decisions largely to the discretion of surrogates without providing adequate support can cause surrogates to struggle with patient-centered decisions and experience psychological distress. 1 This represents abandonment rather than true shared decision-making. 1
Making treatment decisions without attempting to understand the patient's values, goals, and preferences results in decisions predominantly based upon the clinicians' values rather than the patient's. 1 Surrogates may feel unfairly excluded from highly personal and consequential decisions for their loved ones. 1
Assuming one uniform approach fits all patients ignores the reality that patient and surrogate preferences for decision-making roles vary significantly. 1 While the majority prefer equal sharing of responsibility, a non-trivial minority prefer either significantly greater control or prefer to cede control to clinicians. 1
Impact on Patient Outcomes
Poor SDM is associated with worse patient-reported physical health scores (OR: 1.17) and mental health scores (OR: 1.53), lower use of established quality care metrics like statins and aspirin, and increased emergency department utilization. 3 Conversely, effective SDM improves patient outcomes and satisfaction. 4