Shared decision making

What is shared decision making?

Shared decision making can be defined as “The conversation that happens between a patient and their healthcare professional to reach a health care choice together” (NHS Shared decision making 2012).

The idea that health decisions should be made in partnership between the patient and the doctor has gathered attention since the ‘shared decision-making’ model was first described in the late 90s.

It is the process by which healthcare workers and patients work together to choose which tests, treatments, or life changes are selected. It involves sharing information, including uncertainties, about options, and outcomes, and using this with the knowledge, views and experiences of the patient to make decisions. It can involve structured decision making aids or programmes, which are designed to show information about different options, but can also occur through dialogue in a consultation, when the patient is involved in making choices about their health care. 

The UK General medical Council (GMC) guidance on the duties of a doctor registered with them is called, “Good medical Practice”. The most recent guidance published in 2013, advises doctors that they:
must work in partnership with patients, sharing with them the information they will need to make decisions about their care”.

There is also support for shared decision making in the 2012 UK health and social care act. This uses the phrase “no decision about me without me” to describe the UK governments aim to achieve greater patient empowerment and involvement in their care and health decisions. 

Sharing a health decision needs the involvement and commitment of (at least) two parties: a clinician and patient (or family member or carer). Each contributes information from their perspective and the decision is agreed by both.
Typically, the patients contribute their preferences, goals and values, and the clinician brings information about the condition and treatment options. The patient may well also have researched and read about treatment options, and brings this knowledge to the conversation. The patient and their family will also bring their past experiences of healthcare and treatments. This is particularly relevant in chronic health conditions, where the patient may have many years of experience of their symptoms and responses to treatments. This approach, a ‘meeting between experts’, contrasts with other consultation models, for example where the doctor makes a decision about treatment for the patient, or the patient makes their own decision, often based on their own independent research. (See ‘Different types of doctor patient relationships’). The shared model reflects a major shift in ideas about how patients should be involved in healthcare. Research on shared decision-making has suggested that the process of involvement may be more important to patients than their perception of who actually made the decision (which is sometimes unclear, even to those involved).
There is growing evidence that the public want more involvement in treatment decisions. A 2006 survey of 8 European countries by the Picker Institute found that only a quarter of those in a general public survey believed that a doctor should choose the treatment on their own. Half thought that the patient and doctor should make the choice together and the other quarter said that the patient alone should decide.
Shared decisions may be harder to achieve when the patient is faced with a shocking, serious or life threatening diagnosis. But even in these circumstances the ‘best decisions’ are likely to be as close as possible to the patient’s values, goals and preferences. The patient is usually the best source of information about what these are and how they may change during treatment. The following extracts illustrate two women’s different responses to the threat of losing their hair during chemotherapy for ovarian cancer, and show the importance of taking into account peoples personal and family preferences when planning treatment.
Sometimes, once people find themselves heading towards treatment they can find it difficult to call a halt. For example, by the time of her surgery a woman with ductal carcinoma in situ (a form of breast cancer) had already started to wonder if she had made the right decision but did not discuss it further with her team. Despite that she went through with the operation.
This experience is different from that described in the next clip ,where a woman with the same diagnosis as the woman above tells us how she was involved throughout in deciding what treatment she had, and how she was provided with the support to do so.
While two is the minimum for a shared decision many others may be involved, including the wider health care team. Often the patient will choose to discuss their options within their own family and social contacts (which may of course include clinicians). In some situations, family members may need to make decisions for another family member, for example when someone is unable to make the decision themselves, because they are very ill, like on an ITU, or have an illness such as dementia. This can be a difficult situation. There are more examples of people’s experiences of this in the ‘Decisions involving values and difficult personal choices’ section of this website. 
There are advantages to sharing treatment decisions, for example if the patient is involved in making the choice about treatment it is more likely that they will follow the plan they agreed, for example by taking the tablets prescribed for them. Research studies have also found that people who take part in decisions have better health outcomes (such as controlled high blood pressure or diabetes) than those who do not.




Last reviewed February 2016
Last updated February 2014
 

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