What is shared decision making?
Shared decision making (SDM) is the process of clinician and patient jointly participating in a health decision after discussing the options, the benefits and harms, and considering the patient’s values, preferences, and circumstances.
Why is shared decision making important?
SDM is seen internationally as a hallmark of good clinical practice, an ethical imperative1 and a way of enhancing patient engagement and activation.
It is the nexus of communication and evidence skills, providing the route to evidence-based practice in the consultation1. Implementation of SDM into routine health care further facilitates a positive environment for patient and clinician communication.
An Australian survey reported that over 90% of women preferred a shared role with their doctor in making decisions about screening and diagnostic tests2,3. However, studies indicate that SDM is poorly taken up in clinical practice with few attempts to facilitate patient involvement or adjust care to patient preferences4,5.
What is the clinician’s role in this process?
SDM can be used to guide decision-making about most aspects of clinical management (e.g. screening, diagnosis and treatment) and it is relevant to all clinicians (e.g. medical, nursing and allied health).
Clinicians have a role in guiding the following process during discussions with the patient by:
- Listing the options for management (usually including the option of ‘doing nothing’)
- Setting out the benefits and harms of each option, together with their likelihoods
- Exploring the patient’s individual preferences and circumstances
- Coming to a shared decision (perhaps at a later consultation if more time is needed).
What is the patient’s role in this process?
SDM promotes the right of patients to be fully informed and involved in decisions concerning their health, including the right to refuse treatment, and provides patients with an opportunity to do so.
It enables patients to consider the evidence, along with their values and preferences, and to participate in decisions about their healthcare. This approach is fundamental to the rights of consumers, who are entitled to be comprehensively informed and engaged in all phases of health treatment and to have open and collaborative communication between them and the various members of their treatment team2.
How does this benefit the patient?
SDM enables the patient to consider the evidence, along with their values and preferences, and to participate in decisions about their healthcare.
The benefits of SDM can include enablement of both evidence and patient preferences to be incorporated into a consultation; improving patient knowledge, risk perception, accuracy and patient–clinician communication; reducing decisional conflict, reducing feelings of being uninformed and exposure to inappropriate tests and treatments3.
How does this benefit the health care system?
SDM serves as a mechanism for translating research evidence into clinical practice, fostering the sustainability of the healthcare system6.
The flow-on benefits to the health system include reduced inappropriate use of tests and treatments where the health benefits for most Australians do not clearly outweigh the harms, and a reduction in unwarranted healthcare practice variations.
Promotion of the integration of SDM into routine health care is a strategy for enhancing health care safety and quality. Health services and health care providers should review current practices and available resources in areas where SDM has been shown to improve outcomes and plan for their implementation.
When is shared decision making used?
SDM should be incorporated into routine clinical practice in Australia when discussing medical decisions with a patient. It is not a single step to be added into a consultation, but rather a process that can be used to guide decisions about screening, investigations and treatments6.
While shared decision making is applicable to most situations, it is especially important in certain circumstances; for example, where the evidence does not strongly support a single clearly superior option (most clinical decisions) or where a preference-sensitive decision is involved. That is, when there is uncertainty as to which option is superior, each option has different inherent benefits and harms, or the decision is likely to be strongly influenced by patients' preferences and values6.
Areas which appear to have the greatest need are screening for cancer (with current debate highly active in Australia for prostate and breast cancer), discretionary surgery and the management of chronic diseases.
How can shared decision making be used in practice?
Various approaches can be used to guide clinicians through the process of SDM. For example one approach breaks the decision-making part of the consultation into choice talk (helping patients to know that options exist), option talk (discussing the options and their benefits and harms) and decision talk (helping patients explore options and make decisions)7. Five simple questions can be used when discussing medical decisions with a patient6.
- What will happen if the patient waits and watches?
- What are the test or treatment options?
- What are the benefits and harms of each option?
- How do the benefits and harms weigh up for the patient?
- Does the patient have enough information to make a choice?
What is the difference between shared decision making and decision aids?
The process of SDM can be supported by a variety of decision support tools, such as patient decision aids, question prompt lists, option grids, communication frameworks, evidence summaries, and decision (fact) boxes4. However SDM is the underlying process: support tools alone do not constitute SDM, and SDM can occur in the absence of decision support tools.
Are there any harms from shared decision making?
No harm has been found from SDM; there is no evidence of increased consultation time8,9 or patient anxiety with the use of SDM5,10.
Misconceptions about shared decision making
One reported claim about shared decision making is that it is philosophically incompatible with evidence based medicine. In practice however, shared decision making is inextricably linked to the evidence, without which the steps involved in shared decision making, and any resulting decisions, cannot be truly informed2.
For example, discussions with patients about the natural history of a condition, the possible options and the benefits, harms and quantification of these options must be informed by the best available research evidence to ensure the patient can make an informed decision11.
Other misconceptions about SDM include practitioner concerns about additional consultation time, assumptions about the preferences of patients and their ability to participate, and concerns about increasing patient anxiety and concern. There is a body of research that refutes these common misconceptions6.
Further information about shared decision making
The Australian Commission on Safety and Quality in Health Care is undertaking a national work program on SDM.
Examples of how SDM has been incorporated into health practice include the UK National Health Service programs: MAGIC (Making good decisions in collaboration); Right Care and the “Ask 3 questions” campaign (a component of MAGIC programs). The Health Foundation and the Informed Medical Decisions Foundation also provide educational information on SDM.
Relevant NHMRC publications and information
Consumer engagement in research
- Statement on Consumer and Community Participation in Health and Medical Research (the Statement on Participation) (2002)
- Cultural Competency in Health (2006): A guide for policy, partnerships and participation
Ensuring health advice has the end user in mind
- General Guidelines for Medical Practitioners on Providing Information to Patients (2004)
- Communicating with Patients: Advice for Medical Practitioners (2004)
Promoting dialogue between consumers and health professionals
- The Toolkit for Making Decisions About Tests and Treatments: a Guide to Better Communication Between Health Consumers and Health Professionals (2005)
Consumer involvement in the development of Guidelines
- Procedures and requirements for meeting the 2011 NHMRC standard for clinical practice guidelines (2011 NHMRC standard)
1 Elwyn G, Tilburt J, Montori VM. The ethical imperative for shared decision-making. Eur J Pers Cent Healthc 2013;1:129–131
2 Hoffmann TC, Montori VM, Del Mar C. The connection between evidence-based medicine and shared decision making. JAMA 2014;312:1295-96
3 Davey HM, Barratt AL, Davey E, et al. Medical tests: women's reported and preferred decision-making roles and preferences for information on benefits, side-effects and false results. Health Expect 2002; 5: 330-340.
4 Légaré et al., 2010, et al. Interventions for improving the adoption of shared decision making by healthcare professionals, Cochrane Database Syst Rev.
5 Couet N, et al. Assessments of the extent to which health-care providers involve patients in decision making: a systematic review of studies using the OPTION instrument. Health Expect 2013; doi: 10.1111/hex.12054
6 Hoffmann TC, Legare F, Simmons MB, McNamara K, McCaffery K, Trevena LJ, Hudson B, Glasziou P, Del Mar C. Shared decision making: what do clinicians need to know and why should they bother? Med J Aust 2014;201:35-9
7 Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med 2012; 27: 1361-1367.
8 Stacey D, Legare F, Col NF, Bennett CL, Barry MJ, Eden KB, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2014;1:CD001431.
9 Dimoska A, Tattersall MH, Butow PN, Shepherd H, Kinnersley P. Can a "prompt list" empower cancer patients to ask relevant questions? Cancer 2008;113:225-37
10 Edwards et al., 2013, Personalised risk communication for informed decision making about taking screening tests, Cochrane Database Syst Rev.
11 Australian Commission on Safety and Quality in Healthcare. The Australian Charter of Healthcare Rights. A guide for patients, consumers, carers and families (PDF, 569KB).