Shared Decision Making

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What is it?

Shared decision making (SDM) is the process whereby patients and clinicians work together to make evidenced based decisions centred on patient values and preferences. This may be to select a test or intervention such as going ahead with surgery. SDM ensures individuals are supported to make decisions which are right for them.

Patients who are effectively involved in making decisions about their care have fewer regrets about treatment, better reported communication with their healthcare professionals, improved knowledge of their condition and treatment options, better adherence to the selected treatment and an overall better experience with improved satisfaction. 

Shared decision making is appropriate for decisions in both primary (GP) and secondary care (hospital) settings some examples include whether to:

• undergo a screening or diagnostic test
• undergo a medical or surgical procedure
• participate in a self-management education programme or psychological intervention
• attempt a lifestyle change

Shared decision making explicitly acknowledges the fact that there is usually more than one way to treat a problem, including ‘no treatment’ and patients may require support to weigh up the benefits and harms of the options in order to determine the best choice for them.
 

Is this a new idea?

Not at all. Shared decision making has been a concept in healthcare for over thirty years, first mentioned in the President’s Commission for Study of Ethical Problems in Medicine and Biomedical and Behavioural Research Report (1982), which questioned whether consent for treatment was valid when a patient isn’t aware of all reasonable treatment options. 

The concept of involving patient in decisions about their health remains just as topical today, as displayed by the recent Montgomery vs Lanarkshire Health Board (2015) ruling which has fundamentally changed the ethics of how healthcare professionals gain consent. In the UK, clinicians are now encouraged to discuss ‘material risks’ with active participation by patients in deciding the best course going forward.

Shared Decision Making Example

Does it work?

There is good evidence that SDM benefits patients, improving the quality and appropriateness of treatments. A Cochrane Review of 115 randomised control trials, which systematically reviews the evidence base, found that use of patient decision aids leads to improved knowledge and more accurate risk perceptions by patients, greater participation in decision-making, and more appropriate treatment decisions. Specific studies have shown reduced demand for some screening procedures, such as prostatic specific antigen tests and surgical procedures, such as hysterectomies and knee replacement operations.

It is also an effective strategy for tackling over-diagnosis and over-treatment.  For example, interventions to promote SDM, including SDM skills training, have been shown to lead to better understanding surgical options such as wide local excision versus mastectomy for breast cancer.

Across the world, more evidence is building on how to put shared decision making into practice. In the UK, Optimising Shared Decision-Making for high Risk major Surgery (OSIRIS) is a study at the forefront of SDM in the perioperative period. OSIRIS aims to explore perceptions of both patients and professionals to inform the development of specific tools to support shared decision-making. The ultimate output from OSIRIS will be a targeted intervention which solves the key challenges in the implementation of SDM. 

Making the most of an appointment

Having a medical appointment can be daunting for patients, and perhaps more-so where decisions need to be made. Patients and clinicians should aim to get the most out of each appointment. Using a framework to support the process of making decisions, such as the one featured below developed by Choosing Wisely UK, helps support conversations where decisions need to be made – both in preparation for an appointment and during the appointment. ‘BRAN’ (Benefits, Risks, Alternatives and doing Nothing) has been endorsed by the national arm of an international initiative in shared decision making called Choosing Wisely.

Model for Shared Decision Making

In 2017, a model was proposed to support shared decision making consultations called the ‘three-talk model’. This model splits the conversation in consultations into "team talk," "option talk," and "decision talk," to depict a process of collaboration, active listening and deliberation.

• Team talk places emphasis on the need to provide support to patients when they are made aware of choices, and to elicit their goals as a means of guiding decision making processes.
• Option talk refers to the task of comparing alternatives, using risk communication principles.
• Decision talk refers to the task of arriving at decisions that reflect the informed preferences of patients, guided by the experience and expertise of health professionals.

The revised three-talk model of shared decision making depicts conversational steps, with an emphasis on ensuring the conversation opens with an agreement to work together and then discusses options and arrives at a decision. 

Support for SDM

At a national level in the UK, there is a strong commitment to deliver SDM, with multiple bodies working synchronously and collaboratively working to make SDM a reality. These include:

• the National Institute of Health and Care Excellence (NICE) 
• NHS England, Health Education England (HEE)  
• the Academy of Medical Royal Colleges (AoMRC) and their Choosing Wisely programme

Together working with patients and clinicians across primary and secondary care, CPOC hopes to enable ‘no decisions about me without me’.