Shared decision making: Concepts, evidence, and practice

https://doi.org/10.1016/j.pec.2015.06.022Get rights and content

Highlights

  • Shared decision making (SDM) became much debated in the last decades of the 20th century.

  • Four steps can be distinguished anad our paper provides suggestions how to perform these.

  • The steps have been found not be widely implemented in clinical practice.

  • For implementation various strategies are needed, targeting both professionals and patients.

Abstract

Objective

Shared decision-making (SDM) is advocated as the model for decision-making in preference-sensitive decisions. In this paper we sketch the history of the concept of SDM, evidence on the occurrence of the steps in daily practice, and provide a clinical audience with communication strategies to support the steps involved. Finally, we discuss ways to improve the implementation of SDM.

Results

The plea for SDM originated almost simultaneously in medical ethics and health services research. Four steps can be distinguished: (1) the professional informs the patient that a decision is to be made and that the patient's opinion is important; (2) the professional explains the options and their pros and cons; (3) the professional and the patient discuss the patient's preferences and the professional supports the patient in deliberation; (4) the professional and patient discuss the patient’s wish to make the decision, they make or defer the decision, and discuss follow-up. In practice these steps are seen to occur to a limited extent.

Discussion

Knowledge and awareness among both professionals and patients as well as tools and skills training are needed for SDM to become widely implemented.

Practice Implications

Professionals may use the steps and accompanying communication strategies to implement SDM.

Section snippets

Background

Shared decision making (SDM) is increasingly advocated as the preferred model to engage patients in the process of deciding about diagnosis, treatment or follow-up when more than one medically reasonable option is available. The phrase “sharing of decision making” was used for the first time in 1972 by Veatch [1], in his paper “Models for Ethical Medicine in a Revolutionary Age: What physician-patient roles foster the most ethical relationship?” Yet, the concept SDM started did not appear in

Ethics

The first and most obvious line of thinking that leads people to advocate SDM arose in ethics. In 1972, Veatch discussed four models of the professional-lay relationship in the context of ensuring people's right to health care [1]. Following both the biological revolution (‘cure of disease is possible’) and the social revolution (‘all men are to be treated equally’), healthcare had become “a human right, no longer a privilege limited to those who can afford it” (p. 5). Veatch pleaded for a

Shared decision making: concepts and definitions

Thus, SDM had been put on the agenda via two different fields, medical ethics and health services research. The major breakthrough came with two papers by Charles and colleagues [2], [19] that tried to elucidate the concept, “(…) for it is by no means clear what shared decision making really means or the criteria by which to judge what falls within or outside the boundaries of this model.” [2] They described an important aspect that distinguishes SDM from previous models of treatment decision

Are the four SDM steps implemented in clinical practice?

To date little evidence is available on the effects of SDM on patient outcomes, particularly health outcomes [22]. One reason for this absence of evidence is the lack of good measurement instruments, particularly to assess the actual realization of SDM [23], [24]. Research on methods to assess SDM appeared relatively late. It showed that there is little agreement between patient-, professional-, and observer-based reports on the occurrence of SDM [25]. Earlier studies had mostly used the SDM-Q

Shared decision making: elaboration of the steps and communication propositions

Clinicians may think that the process described below is lengthy. Indeed, the evidence so far shows a small increase in consultation time if time is invested in SDM [15], [42]. Yet, if taken carefully, the steps may lead not only to decisions that better fit the individual patient and as a result provide more satisfaction, but also to better professional-patient relations, fewer repeat consultations, fewer requests for second opinions, and, in the long term better treatment adherence and

Discussion

In 2015, over 40 years after the first mentioning of the term SDM, and over 15 years after Charles et al.’s publications, SDM has finally reached the implementation agenda and become the target of educational programs in many countries around the world. Yet, there is still little evidence for its occurrence in clinical practice. Therefore, there is on-going debate on how to improve implementation, through training and tools, both for professionals and patients [62], [63]. A number of

Conflicts of interest

No conflicts of interest declared.

Author’s contribution

All authors have individually contributed to the article: in drafting the article and revising it critically for important intellectual content and have approved the final version submitted.

Acknowledgements

We would like to thank Marleen Kunneman for proof-reading of the paper, and two anonymous reviewers for their helpful suggestions.

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