Intended learning outcomes
Define ‘shared decision-making’.
Describe the ethical, legal, professional and sociological drivers for shared decision-making.
List the benefits of shared decision-making.
Give examples of how shared decision-making may be implemented in practice.
Describe potential barriers to the implementation of shared decision-making in practice.
Case history
A mother visited a clinic with her 12-year-old daughter and was adamant that the child should undergo a tonsillectomy. The doctor informed her that it may be worth waiting because, around this age in a child, the number of episodes of tonsillitis decreases. The mother was still insistent about a tonsillectomy, as her child had been missing school because of this condition.
Question to be answered
How can healthcare professionals support decision-making with patients that is based on clinical evidence while supporting the patient’s values and preferences?
Discussion
Background
The past four decades have seen a shift from the concept of medical paternalism towards patient-centred care. Additionally, from the 1980s onwards, a series of publications criticised physician ‘domination’ [1] and called for more patient autonomy in the form of greater choice and control over medical decisions [2].
A new emphasis was placed on a model of ‘shared decision-making’, whereby clinicians and patients work in partnership to exchange information and treatment preferences [3]. The clinician has expertise in making a diagnosis and providing viable treatment options, and the patient is well aware of what matters to them, their preferences and values [4].
Drivers
Ethical factors
Ethically, respect for autonomy requires the disclosure of information and possible avenues of action needed for autonomous decision-making [4]. Shared decision-making supports beneficence (acting for the good of the patient) and non-maleficence (do no harm), enabling clinicians to support patients through the decision-making process to define outcomes that reflect the individual’s values and preferences.
Professional factors
The UK General Medical Council requires doctors, when making medical decisions, to take active steps to elicit patients’ concerns and preferences, to tailor discussions according to the individual’s values and priorities and to provide information on all options, including the option of no treatment [5]. The principles of shared decision-making are a key focus in the updated GMC guidelines on decision-making and consent, which came into effect on 9 November 2020 [5].
Legal factors
The Montgomery vs Lanarkshire Health Board case in 2015 places UK clinicians under a duty to make patients aware of any material risks involved in any treatment, including options [6]. This marked a shift towards a new patient-oriented standard of informed consent from the previous ‘Bolam test’. Importantly, this new test of materiality is based on the individual patient, with a legal duty to disclose risks to which that specific patient might reasonably attach significance [7]. Clinicians must therefore make efforts to elicit patients’ values and priorities to understand which risks will matter the most to the individual.
Sociological factors
Traditional models of illness, such as Parsons’ ‘sick role’ model, emphasise the physician as the decision-maker. In this model, an individual who is unwell seeks help from an expert doctor who uses their knowledge to decide upon an intervention, after which the patient recovers and resumes their social role [8]. This narrative of a single, self-limiting illness has a limited application today, when patients are living with multiple, complex and chronic comorbidities.
Instead, decisions require a complex assessment of competing short-term and long-term symptoms, side effects, risks, and psychological, social and financial factors. In perioperative medicine, the question of morbidity is particularly important: a patient may be capable of surviving the surgery, but at what cost? Quality-of-life assessments necessitate patient involvement because they are inherently subjective considerations that make the patient the expert.
Evidence-based factors
Shared decision-making improves patient satisfaction [9], increases patient confidence to ask questions [10] and decreases patient decisional conflict related to feeling uninformed [11]. Decision aids have a positive effect on patient–clinician communication [11], and doctors have reported higher rates of satisfaction and displayed a higher number and appropriateness of patient questions following consultations when using shared decision-making than when using usual care [10].
Theory into practice
Although shared decision-making has received widespread acceptance as a concept, its adoption into clinical practice has been less straightforward. Several methods have been developed and implemented. Yet there is no clear evidence for which of these interventions is effective [12].
Three-talk model
This model outlines a ‘team talk, option talk and decision talk’ structure [13, 14] (Fig. 1). The consultation is framed by setting the agenda of partnership in decision-making, discussing the options, considering patient preferences and reaching a decision. The clinician’s role at each stage is to support deliberation.
Elwyn’s three-talk model of shared decision-making.
Source: British Medical Journal.
Implementation in clinical practice
As part of the Health Foundation’s MAGIC (Making Good Decisions in Collaboration) programme, National Health Service (NHS) Trusts in Cardiff and Newcastle led quality improvement projects across seven clinical areas, including breast and prostate surgery, aimed at embedding shared decision-making into routine care. Departments designed and tested their own implementation methods, which were evaluated centrally. The resulting report provides multiple insights into the processes and challenges of implementing shared decision-making in clinical practice.
This project did not highlight one superior method of implementation, but it highlighted that ‘a combination of changes in attitude, skills and infrastructure is required to effectively facilitate shared decision-making’ [15].
A multi-intervention approach
Multiple concurrent interventions targeting (1) patients, (2) staff and (3) healthcare systems in which they work are required.
An example of a patient-targeted intervention is the Choosing Wisely UK ‘BRAN’ (Benefits, Risks, Alternatives, do Nothing) initiative through the use of patient-facing promotional materials – flyers, handouts and posters – encouraging patients to ask these questions [15, 16] (Fig. 2).
Four questions from Choosing Wisely UK. Also known as the BRAN model.
Source: Academy of Medical Royal Colleges.
Online learning and face-to-face workshops are conducted to train clinicians in shared decision-making (Figs. 3 and 4) [17, 18, 19]. Staff training sessions and the identification of clinical champions within teams and departments may also promote staff engagement and increase confidence [16].
Possible systemic changes include restructuring patient pathways, for example, offering preliminary discussion appointments before decision appointments; appointing shared decision-making champions at a Trust level; monitoring, improving and rewarding shared decision-making activities within the Trust; and making routine use of decision-making aids/tools and ensuring that these tools are readily available (either in the printed form or on the hospital intranet). Examples of these aids include written and online material, DVDs and option grids.
Example of an open access e-learning module in perioperative shared decision making. This course was a joint collaboration between the Australian Commission on Safety and Quality in Health Care, the Academy of Medical Royal Colleges (UK) and Winton Centre for Risk and Evidence Communication (University of Cambridge).
UK workshops in perioperative shared decision-making; Royal College of Anaesthetists-approved workshops at Guy’s and St Thomas’ NHS Foundation Trust, London.
Barriers
Staff engagement
One key barrier is staff engagement. This stems from a lack of understanding of the concept, a lack of tangible or perceived benefit and the perception that shared decision-making is already being delivered [20, 21]. Clinicians underestimate a patient’s desire for information and discussion [9, 22]. This barrier can be overcome. In the MAGIC programme, workshops focused on challenging clinicians’ perceptions. Staff members subsequently reported a shift in attitude from ‘we are already doing it’ to ‘I probably have not involved patients as much as I have thought in the past’ and ‘we could do this better’ [15, 23]. This has been mirrored in workshops at national and local levels delivered as a collaboration between the Royal College of Anaesthetists and Choosing Wisely UK.
The MAGIC report also highlights the importance of establishing senior champions of shared decision-making to encourage engagement from within the team [15].
‘Patients do not want shared decision-making’
Some clinicians argue that many patients do not want shared decision-making [23, 24], and research suggests a minority may prefer a passive role [23].
Clinicians are at risk of misperceiving a reticence towards decision-making as unwillingness to engage in the shared decision-making process. Clinicians may underestimate a patient’s desire to obtain information and overestimate the patient’s desire to make a final unsupported decision [9, 22]. Many patients undervalue their own expertise in this context, and the onus is on the healthcare professional to support them in activation and empowerment [24]. Patients want to be involved, but they do not want to feel ‘abandoned’ [13].
Patient activation campaigns give patients permission to participate in shared decision-making and have confidence in their own expertise. In the UK, the use of BRAN is being encouraged through Choosing Wisely UK [17].
Systemic deficiencies
There is a perceived lack of available tools and validated resources. Although clinicians perceive a lack of available tools, multiple websites and resources are in fact available to support the use and development of option grids [25, 26, 27]. Relating this to perioperative care, multiple national and international decision aids are available for certain surgeries; however, developing local decision aids based on local outcome data will promote individualised decision-making. Patients exposed to decision aids are able to take a more active role in decision-making [12]. However, overemphasis on decision aid tools should be avoided, as summarised in the MAGIC programme’s conclusion that ‘skills trump tools, and attitudes trump skills’ [23]. The timing of using decision support tools is highly important, ideally early when surgery is first contemplated to allow patients time to consider their own values before secondary care consultations.
Current patient pathways and appointment systems may not allow for optimal shared decision-making; for example, the anaesthetist may examine the patient for the first time after informed consent has been sought by the surgeon. It may be difficult for the patient to objectively consider the risks and benefits of their options, including the option of not having the surgery, when there is an underlying presumption that surgery will be performed. The redesign of the perioperative pathways to ensure those discussing perioperative risk, such as anaesthetists or geriatric medicine clinicians, align contemporaneously with surgical consent seems a prudent first step. Individualised risk assessment and clear risk communication will support high-quality shared decision-making. Currently, there is a lack of standardisation on how multidisciplinary teams communicate this between themselves and then extend this to discussion with the patient.
Future developments in perioperative medicine
To facilitate shared decision-making, clinicians need access to accurate data about the risks and benefits faced by an individual when considering surgery. The Perioperative Quality Improvement Programme, established in 2016, will continue to provide updated information on complication rates and patient outcomes in major non-cardiac surgery across the UK [28].
The OSIRIS (optimising shared decision-making for high-risk major surgery) programme is a major project of UK research that aims to understand and improve the shared decision-making process for patients at high risk of medical complications, as they contemplate major surgery [29]. Alongside this, Choosing Wisely UK continues to provide education and training for clinicians and patient information resources in partnership with NHS England. As part of a pilot plan, Choosing Wisely UK will be looking to implement professional and patient resources into a single perioperative pathway, informing large-scale trials such as OSIRIS.
Summary
Shared decision-making has strong ethical, legal, professional and sociological justifications as well as evidence-based benefits. Models, such as the ‘team talk, option talk, decision talk’, provide us with a framework for delivering shared decision-making, and the MAGIC programme offers possible methods and interventions for the implementation of shared decision-making within perioperative care. Gaining staff commitment and buy-in is a prudent step and requires training, workshops and the appointment of senior champions. Patient empowerment and systemic institutional changes are needed to complement staff engagement. A variety of decision aids is available, but institutions should also consider developing tools based on local data. Future perioperative research will equip clinicians and patients contemplating surgery to make decisions together based on the patient’s values and preferences.
Disclaimer
This Narrative article is adapted with permission from Case Studies in Perioperative Medicine, a UCL Press open access educational resource, available from https://doi.org/10.14324/111.444.9781787356917.18
Declarations and conflicts of interest
Research ethics statement
Not applicable to this article.
Consent for publication statement
Narrative articles are based on clinical vignettes and created to provide a framework for discussion and maximise learning. These are not based on real individual patients and do not describe discrete patient interactions or outcomes. The objective is to summarise an interesting topic in perioperative medicine in response to a specific clinical question posed by the authors.
Conflicts of interest statement
The authors declare no conflicts of interest with this work.
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