Shared decision making in healthcare

Traditionally the patient-clinician relationship was paternalistic, in which the clinician made the decisions on behalf of the patient. However, there has been a paradigm shift away from this type of encounter, and a drive towards more patient-centred care, whereupon the patient is more empowered, informed, and autonomous - a move from a ‘paternalistic’ to a ‘mutualistic’ relationship.¹

Recently, there has been an explosion of interest and research in shared decision making (SDM), which is at the heart of patient-centred care. SDM is a two-way process wherein both the patient and the clinician share information and the responsibility for decision making. It is appropriate in most healthcare encounters, as the majority of treatment decisions involve options, even if one of these is doing nothing.

The definition of shared decision making is:²

a process in which clinicians and patients work together[...]sharing information about options[...]with the aim of reaching mutual agreement on the best course of action

SDM involves a number of essential stages, as defined by Makoul and Clayman³ and Stiggelbout et al⁴ (Figure 1) :

* Define/explain the problem - this should be in layman’s terms.

* Present the options - this should include all options, including doing nothing or maintaining the status quo. The patient should be made aware of a position of equipoise or balance, where there is no right or wrong decision, only a preferred choice.

* Discuss the pros/cons (benefits/risks/costs) - these should be explained together with the respective probabilities, when they are known, as patients often find it easier to weigh up choices they can quantify.

* Clarify patient values/preferences - individuals’ attitudes to, concerns about, and expectations of each option should be explored.

Discuss patient ability/self efficacy - the patient should be made aware that they do not need to make this decision alone and family members and friends should be invited to participate where appropriate. Some patients do not wish to make the decision themselves and it would be counter-productive to force them to. The clinician should support the decision-making process so the patient does not feel abandoned.

* Present what is known and make recommendations - the clinician should present the best available evidence together with their clinical experience and counsel...