Janet Schuerman: Shared Decision Making, Part 2

Unweaving the relational elements of Shared Decision Making (SDM) is at best a two-blog process. Part One of this blog explored the overall supporting framework for SDM.

In quick review, the SDM Relational Elements graphic below pictorially represents SDM within a series of concentric circles. The largest circle and the overarching support for SDM is patient and family centered care. The Institute of Patient and Family Centered Care defines this as an approach to health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families.

The next supportive element is Collaborative Conversations. This approach creates an environment conducive to SDM through which providers, family, patient, and other members of the care team adopt a collaborative approach to exploring the patient’s values and preferences.

Patient and family centered care and collaborative conversations support the star of our show – SDM. Dr. France Légaré et al (http://tinyurl.com/24yog8j) describe SDM thus: “SDM is an approach whereby practitioners and patients communicate around decisions, referring to the best available evidence and deliberating upon the consequences of each option. In the process, patients’ autonomy is respected, patients are helped to establish their values and preferences, and final treatment decisions are reflected through agreement between patients and their practitioner(s) rather than a unilateral decision.”

This definition resonates with me because it so elegantly captures the complexity of the concept yet eloquently expresses integral facets that are often left unarticulated. This definition specifies using the best evidence available to explore, without prejudice, the advantages and disadvantages of potential choices.  Moreover, it addresses the “shared” part of SDM. It details a balance between the care team and the patient while working collaboratively to reach a decision that is consistent with the patients’ values and preferences. The shared part is the key kernel of the entire concept. It requires a shift in perspective from the belief that any one party knows best. This shift in perspective needs to start in Collaborative Conversations and be continually fostered throughout the decision making process.

The next circle in the SDM Relational Elements graphic is Decision Support, which SDM encompasses. Although SDM can exist without Decision Support, often Decision Support is required to help a party resolve decisional conflict. When such conflict occurs, there is sufficient indecision over which action to take that a decision cannot be made. Any member of the care team, the patient, or the family can experience decisional conflict. Often, a tool like the Ottawa Personal Decision Guide can be sufficient to help resolve decisional conflict, paving the way for SDM to occur. This guide may also point out areas where additional support is required.

For those needing more specific information about the choices available for specific conditions or procedures, a myriad of Decision Aids are available. Evidence-based and unbiased in outlining the pros and cons, Decision Aids help the patient and family become more knowledgeable about the implications of their choices. With this specific knowledge in hand, the patient and family may now be ready for the SDM process.

Let’s go back through the concentric circles. Patient and Family Centered Care is an approach in which the care team and the patient and family are equals in determining health care choices. Collaborative Conversations create the environment where the care team, patient, and family clarify the patient’s values and preferences. SDM occurs when the care team and the patient and family are equals sharing in a mutual decision. Decision Support is key for those not yet ready to engage as an equal in SDM. It often helps resolve decisional conflict. If even more support is required, Decision Aids provide very specific information about the pros and cons of choices related to a particular disease or procedure.

SDM is an important and complex compilation of intertwined parts which, when successfully assembled, result in care consistent with the patient’s values and preferences. There is a very real temptation to skip over some of these components and as a consequence the “shared” part might be missed.  Fortunately, it is right there in the name to remind us that patient-centered health care decisions require  – Shared Decision Making.