Shared decision-making

Shared decision-making (SDM) is an approach where clinicians and patients communicate together using the best available evidence when faced with the task of making decisions, where patients are supported to deliberate about the possible attributes and consequences of options, to arrive at informed preferences in making a determination about the best action and which respects patient autonomy, where this is desired, ethical and legal.

Original definition and scope
One of the first instances where the term ‘shared decision-making’ was used was in a report entitled the ‘President's Commission for The Study of Ethical Problems in Medicine and Biomedical Research. This work built on the increasing interest in patient-centredness and an increasing emphasis on recognising patient autonomy in health care interactions since the 1970s.

Charles described a set of principles for shared decision-making, stating “that at least two participants, the clinician and patient be involved; that both parties share information; that both parties take steps to build a consensus about the preferred treatment; and that an agreement is reached on the treatment to implement". These principles rely on an eventual arrival at an agreement but this final principle is not fully accepted by others in the field. The view that it is acceptable to agree to disagree is also regarded as an acceptable outcome of shared decision-making.

Main components
Elwyn described a set of competences for shared decision-making, which are composed of the steps of defining the problem which requires a decision, the portrayal of equipoise and the uncertainty about the best course of action, thereby leading to the requirement to provide information about the attributes of available options and support a deliberation process. An assessment scale to measure the extent to which clinicians involve patients in decision-making has been developed and translated into Dutch, Chinese, French, German, Spanish and Italian. A talk model has been recently proposed, composed of three different phases: team, option and decision talk. In the first of these phases, clinicians' work to create a supportive relationship with the patient as they introduce the idea of recognizing the existence of alternative actions (options) - this is to form a team with the patient and their family. In the second phase, the work is to introduce the options in a clear way, describing and explaining the probabilities of benefits and harms that might be likely - this is option talk. In the last phase, patients' preferences are constructed, elicited and integrated - this is decision talk. A shorter 5-item version of the Observer OPTION measure has been published based on this model.

The National Shared Decision Making Programme in the UK
The aim of the Right Care Shared Decision Making Programme is to embed Shared Decision Making in NHS care. This is part of the wider ambition to promote patient centred care, to increase patient choice, autonomy and involvement in clinical decision-making and make “no decision about me, without me” a reality. The Shared Decision Making programme is part of the Quality Improvement Productivity and Prevention (QIPP) Right Care programme. In 2012, the programme entered an exciting new phase and, through three workstreams, is aiming to embed the practice of shared decision-making among patients and those who support them, and among health professionals and their educators. One of the components of the National Programme is the work of the Advancing Quality Alliance (AQuA) - who are tasked with creating a receptive culture for shared decision-making with patients and health professionals.

An evaluation of this programme was published recently:

Why do clinicians not refer patients to online decision support tools? Interviews with front line clinics in the NHS. Elwyn G, Rix A, Holt T, Jones D. BMJ Open. 2012 Nov 29;2(6). doi:pii: e001530. 10.1136/bmjopen-2012-001530. Print 2012.

The implementation of shared decision-making
With funding bodies emphasizing knowledge translation, i.e. making sure that scientific research results in changes in practice, researchers in shared decision-making have focussed on implementing SDM, or making it happen. Many studies explore the development of sound, theory-based training programs and decision aids, and the evaluation of their results. Canada has established a research chair that focusses on implementing shared decision-making in primary care contexts. Although patients who are involved in decision-making about their health have better outcomes, healthcare professionals rarely involve them in these decisions. A Cochrane review has synthesized the body of evidence about different interventions that can be used to help healthcare professionals adopt practices to better involve their patients in the process of making decisions about their health. In this review of studies testing interventions to help healthcare professionals adopt practices to better involve their patients in the process of making decisions, five studies were identiﬁed. This review found that educational meetings, giving healthcare professionals feedback, giving healthcare professionals learning materials, and using patient decision aids are some techniques that have been tried and might be helpful. However, the review could not determine from the available studies which of these were best. The review makes some suggestions for how research studies could better evaluate healthcare professionals involving patients in the process of making decisions about their health so that we can understand this better in the future. There is also a need for greater conceptual clarity. Involving patients in decisions is by definition a process that could occur over time and in many encounters. Much of the literature seems to assume that achieving shared decision-making is a matter of giving healthcare professionals enough information.

Training health professionals in shared decision-making attracts the attention of policy makers when it shows potential for addressing chronic problems in healthcare systems such as the overuse of drugs or screening tests. One such program, designed for primary care physicians in Quebec, Canada, showed that shared decision-making can reduce use of antibiotics for acute respiratory problems (ear aches, sinusitis, bronchitis, etc.) which are often caused by viruses and do not respond to antibiotics.

While some medical schools (e.g. in Germany, the UK and Canada) already include such training programs in their residency programs, there is increasing demand for shared decision-making training programs by medical schools and providers of continuing professional education (such as medical licensing bodies). A 2012 inventory of existing programs (regularly updated) showed that they vary widely in what they deliver and are rarely evaluated. These observations led to an international effort to list the skills necessary for practising shared decision-making and to prioritize them. The effort generated debate among researchers around what core competencies should be taught and how they should be measured, which brought the discussion back to basic questions: what exactly is shared decision-making, do decisions always have to be shared, and how can it be accurately evaluated?

Harvey Fineberg, Head of the US Institute of Medicine, has suggested that shared decision-making should be shaped by the particular needs and preferences of the patient, which may be to call on a physician to assume full responsibility for decisions or, at the other extreme, to be supported and guided by the physician to make completely autonomous decisions. This suggests that, just as with interventions, which need to match the patient's style and preferences, patient's preferences for degree of involvement also need to be taken into account and respected.

Measuring shared decision-making
Several researchers in this field have designed scales for measuring to what extent shared decision-making takes place in the clinical encounter and its effects, from the perspective of patients or healthcare professionals or both, or from the perspective of outside observors. The purpose of these scales is to explore what happens in shared decision-making and how much it happens, with the goal of applying this knowledge to incite healthcare professionals to practise it.

Expanding the field of shared decision-making
Researchers in shared decision-making are increasingly taking account of the fact that involvement in making healthcare decisions is not always limited to one patient and one healthcare professional in a clinical setting. Often more than one healthcare professional is involved in a decision, such professional teams involved in caring for an elderly person who may have several health problems at once. Some researchers, for example, are focussing on how interprofessional teams might practise shared decision-making among themselves and with their patients. Researchers are also expanding the definition of shared decision-making to include an ill person’s spouse, family caregivers or friends, especially if they are responsible for giving the person medicine, transporting them or paying the bills. Decisions that ignore them may not be based on realistic options or may not be followed through.

Related gatherings
Many researchers and practitioners in this field meet every two years at the International Shared Decision Making (ISDM) Conference, which have been held at Oxford in 2001, Swansea in 2003, Ottawa in 2005, Freiburg in 2007, Boston in 2009, Maastricht in 2011, and Lima, Peru in 2013. Shared decision-making is also closely associated with the use of decision support interventions, also known as decision aids. Much of the research and implementation studies to date are contained in the following publication: ''Shared Decision Making in Healthcare: Evidence-based Patient Choice. 2nd ed. Oxford: Oxford University Press, 2009.

In December 2010 a Salzburg Global Seminar focused on "The Greatest Untapped Resource in Healthcare? Informing and Involving Patients in Decisions about Their Medical Care." Powerful conclusions emerged among the 58 participants from 18 countries: not only is it ethically right that patients should be involved more closely in decisions about their own medical care and the risks involved, it is practical – through careful presentation of information and the use of decision aids/pathways – and it brings down costs. Unwarranted practice variations – where one area may have many more interventions than another, but with no better outcomes – are reduced, sometimes dramatically. So why is it that this ‘win-win’ approach is not better understood? Following the seminar the participants created the Salzburg Statement on Shared Decision Making launched in London by the BMJ, one of the world’s leading medical journals, and released it to the press worldwide to stimulate attention and debate.