Shared Decision Making: A Model for Clinical Practice

The skills of SDM are unlikely to be developed, let alone exhibited, unless the clinician agrees with the guiding ethical principles. At its core, SDM rests on accepting that individual self-determination is a desirable goal and that clinicians need to support patients to achieve this goal, wherever feasible. Self-determination in the context of SDM does not mean that individuals are abandoned. SDM recognizes the need to support autonomy by building good relationships, respecting both individual competence and interdependence on others. These are the key tenets of both self-determination13 and relational autonomy.14 Self-determination theory is concerned with our intrinsic tendencies to protect and preserve our well-being.13 Relational autonomy is the term used to describe the view that we are not entirely free, self-governing agents but that our decisions will always relate to interpersonal relationships and mutual dependencies.15 As King and Moulton have noted, these principles extend the concept of informed consent beyond that of simple information transfer towards honoring informed preferences.16 We acknowledge that good clinical practice balances these principles with those of beneficence and justice.17

However, some healthcare professionals express doubts, saying that patients don’t want to be involved in decisions, lack the capacity or ability, might make ‘bad’ decisions, or worry that SDM is just not practical, given constraints such as time pressure. Others claim they are ‘already doing it’, though data from patient experience surveys indicates that this is not generally the case.18,19 It is therefore clear that the first step for those advocating the uptake of SDM is to ensure that clinicians and others support the underlying rationale.

Before doing so however, we need to note the challenges that clinicians will be navigating. Low health literacy or low numeracy will be barriers to SDM and some patients come from cultural backgrounds that lack a tradition of individuals making autonomous decisions. We cannot therefore emphasize too strongly that SDM has to be built on the core skills of good clinical communication skills, as recognized in many seminal texts,20, 21, 22, 23 including building rapport and structuring the consultations.24

We propose that achieving SDM depends on tasks that help confer agency, where agency refers to the capacity of individuals to act independently and to make their own free choices.27,28 SDM aims to confer agency by 1) providing information and 2) supporting the decision making process.

Supporting Deliberation

The second task is to support patients to deliberate about their options (see Fig. 1), by exploring their reactions to information. When offered a role in decisions, some patients feel surprised, unsettled by the offer of options and uncertainty about what might be best.30 If all responsibility for decision making is transferred to patients they may feel ‘abandoned’.31 Some patients initially decline decisional responsibility role, and are wary about participating.32

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To accomplish SDM, we propose a three-step model for clinical practice (see Fig. 1). We want to emphasize that this is a simplified model that illustrates the process of moving from initial to informed preferences. We acknowledge that this process also has psychological, social and emotional factors that will influence this deliberation space and that will need to be managed by an effective clinician-patient dialogue, seeking what Epstein has termed a ‘shared mind’.33 However, accepting these requirements, we aim for parsimony.

We describe three key steps of SDM for clinical practice, namely: choice talk, option talk and decision talk, where the clinician supports deliberation throughout the process (Fig. 1 and Boxes 1, 2 and 3). Choice talk refers to the step of making sure that patients know that reasonable options are available. Option talk refers to providing more detailed information about options and decision talk refers to supporting the work of considering preferences and deciding what is best. The model outlines a step-wise process, although it is important to recognize that the model is not prescriptive—clinical interactions are by necessity fluid. Decision support tools provide crucial inputs into this process.

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Patients will want time to study new information and to consider their personal preferences, particularly for futures that are unknown to them, to think about outcome states that they have never experienced.34,35 Deliberation may, in part, be done outside the clinical encounter, although often patients wish to consolidate their views with a trusted clinician. Individuals often want to discuss options with others and it would be best if those involved could potentially use the same information resources (see below). Rapley has referred to this need to talk to others, at different times and places, as a ‘distributed’ deliberation process.36 Recognizing this need, and allowing time for it, is a cornerstone for effective SDM .33,37

The model also includes the use of decision support interventions,38 which summarize information in formats that are accessible to patients, using the most up to date evidence about the harms and the benefits.39 Some tools also include preference clarification exercises.39 Decision support for patients can be in concise formats, such as in brief text or diagrams, and used during encounters to initiate SDM. They can also be extensive: typical of the many tools already developed—booklets, websites, videos, DVDs—to used by patients, their family and friends, outside the encounter, and at different time points38—see Box 1, 2 and 3, and synopsis in Box 4.

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We use the term "deliberation" (see Fig. 1) to describe a process of considering information about the pros and cons of their options, to assess their implications, and to consider a range of possible futures, practical as well as emotional. This ‘deliberation’ space, colored grey in the figure, encompasses the need to work collaboratively with professionals as well as with the wider networks that patients will use.36 Deliberation begins as soon as awareness about options develops. The process is iterative and recursive, and the intensity increases after options have been described and understood.