A Model for Shared Decision Making

  1. Build a partnership

    1. Discussion of the patient’s role in decision making
      1. Patients should be offered a role in decision-making, even if some will decline, preferring to defer to the physician.
      2. Assess patient’s desire for others’ input. Who else would the patient like to consult?
      3. Examples:
        1. “I’d like us to make this decision together.”
        2. “It helps me to know how you feel about this.”
        3. “Is there anyone else you’d like to help make the decision with you?”
    2. Understand the patient and family’s expectations, foster patient involvement
      1. Explore the “context” of this decision in the patient’s life? How will the decision impact the patient’s daily life? What factors are important to the patient? Ask the patient what they expect to get out of this interaction.
      2. Understanding the patient’s concept of risk. What risks are they willing to accept?

  2. Discussion of the clinical issue or nature of the decision

    1. A clear statement of what is at issue.
      1. Helps clarify what is being decided on and allows the physician to share some of his/her thinking about it.
      2. Examples:
        1. “This is medication that would help with…”
        2. “The blood test will tell us…”
    2. Discussion of the alternatives
      1. A decision is always a choice among certain options, including doing nothing at all. This is not always clear to the patient without an explicit discussion.
      2. Example:
        1. “You could try the new medication or continue the one you are on now.”
        2. “We can attempt a trial of new medicines and reassess your response.”
    3. Discussion of the pros (potential benefits) and cons (risks) of alternatives
      1. We frequently discuss the pros of one option and the cons of another without fully exploring the pros and cons of each. A more balanced presentation allows the patient’s decision to be more informed. Provide evidence where available.
      2. “The new medication is more expensive, but you only need to take it once a day.”
      3. “Screening for colon cancer using the stool cards is easier for you, but it may not pick up all disease. At your age, the flexible sigmoidoscopy is more sensitive test, but it is somewhat invasive.”
    4. Discuss uncertainty. How can you convey the likelihood of success?
      1. While often difficult, a discussion of uncertainties is crucial for a patient’s comprehensive understanding of the options. Thoughtful discussion can promote trust and encourage adherence.
      2. Examples:
        1. “The chance that this will help is excellent.”
        2. “Most patients with this condition respond well to this medication, but not all.”

  3. Assessment of the patient’s understanding

    1. Once the core disclosures are made, the physician must check in with the patient to know if what he/she has said so far makes sense. Fostering understanding is really the central goal of informed decision making. Have the patient repeat back their understanding.
    2. Examples:
      1. “Does that make sense to you?”
      2. “Are you with me so far?”

  4. Exploration of patient preference

    1. Physicians may assume that patients will speak up if they disagree with a decision, but patients often need to be asked for their opinion. It should be clear to the patient that it is appropriate to disagree or ask for more time.
    2. Examples:
      1. “Does that sound reasonable?”
      2. “What do you think? Toward which decision are you leaning and help me understand why.”

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