A 68-year-old man with a history of recurrent GI bleeding and a high CHA2DS2-VASc score told me he does not want a stroke, so no matter how many times he gets admitted to the hospital for GI bleeding, he wants to continue his anticoagulant. On the same day, I had another patient who insisted on not continuing anticoagulation despite a high CHA2DS2-VASc score, as his close relative had bleeding while on an anticoagulant. I would never know their goals, and preferences without engagement in shared decision-making.

Shared Decision-Making (SDM) is an interactive, collaborative process where clinicians focus on the available best scientific evidence and patients’ goals, preferences, and values to make healthcare decisions.1,2 Clinicians assist patients to analyze potential risks, benefits, and outcomes to reach evidence-based and value-congruent medical decisions. In numerous clinical scenarios, multiple viable options can complicate medical and surgical decision-making. The traditional paternalistic approach, where the clinician unilaterally makes decisions and presents them to the patient, may limit patient involvement to mere consent without a detailed discussion and understanding of their preferences or adherence to recommendations.1 Patients have the right to be well-informed and actively engaged in their care decisions, with a comprehensive understanding of potential risks, benefits, and alternatives. To enhance patient participation in healthcare decisions, SDM has been advocated since the early 1980s. The U.S. Preventive Services Task Force (USPSTF) and the Institute of Medicine endorse SDM for preventive health and treatment choices to improve healthcare quality in the United States. The concept of SDM emerged from the phrase “nothing about me, without me,” during a 1998 seminar “Through the Patient’s Eyes”.1 Recent research suggests that most patients prefer an active role in medical decision-making but perceive that physicians often make decisions contrary to their preferences.2 SDM offers a structured bidirectional approach; clinicians enable patients to decide whether to accept certain services or treatments based on their preferences, circumstances, and core values by providing relevant evidence. For instance, patients may opt for different screening tests based on their perspectives and preferences regarding potential risks in screening recommendations where benefits and harm may exist. Similarly, in complex decisions such as anticoagulation for patients with atrial fibrillation and high CHA2DS2-VASc scores and bleeding risks, SDM facilitates understanding patient and surrogate preferences in weighing the risks of bleeding against the risk of thromboembolic stroke. The UK SDM tool, BRAN questions, promotes engagement in shared decision-making.3

  1. What are the Benefits?
  2. What are the Risks?
  3. What are the Alternatives?
  4. What if I do Nothing?

The BRAN tool’s adaptability to various health decision settings, including treatment, investigations, and procedures, expands its potential to enhance patient safety.3

A study published in JAMA demonstrated that SDM is associated with higher patient satisfaction.1,2,4 This increased satisfaction, in turn, correlates with improved treatment adherence.4 Patients who were actively involved in SDM were also significantly less likely to resort to legal action, with an 80% reduction in lawsuits compared to those not engaged in shared decision-making.1,2 Participants in the study rated their physicians more favorably and were less inclined to blame them for any adverse outcomes. These findings highlight the empowering nature of SDM for clinicians, allowing them to view patients as unique individuals which is crucial for safe and exceptional patient-centered care. It’s important to acknowledge that treatment choices are seldom straightforward and often involve uncertainty. Clinical prediction scores, like the Pulmonary Embolism Severity Index (PESI), can provide valuable insights into patient outcomes and risk categories. However, these clinical tools should not replace clinical judgment and the importance of shared decision-making. For example, in cases where patients have a low risk of complications from pulmonary embolism, the American Society of Hematology guidelines may recommend discharge with direct oral anticoagulation (DOAC). However, SDM remains essential in engaging patients and caregivers in discussions about the risks and benefits of anticoagulation, as well as their comfort level and willingness to be discharged on the same day. Informed clinical decisions require careful consideration of diagnostic testing, overcoming biases, and customizing evidence-based practices to suit individual patients’ needs. Facilitating SDM has shown positive associations with improved quality of life and patient outcomes. A meta-analysis involving more than 4,000 patients revealed that SDM significantly reduces decisional conflict and increases patient knowledge.5

Shared Decision-Making (SDM) becomes particularly crucial for older adults with multimorbidity, as the best treatment for each disease may not be the most suitable option for the elderly patient as a whole. The elderly patient population is diverse, ranging from highly independent individuals to those with multiple chronic conditions requiring significant assistance with daily activities. In conversations involving elderly patients with multiple chronic conditions, their caregivers, and the medical team, the focus should be on preferred health outcomes to guide discussions and treatment choices, rather than addressing each medical condition in isolation. There are obstacles to SDM in clinical encounters with elderly patients. One significant challenge is undiagnosed cognitive impairment, which can hinder effective communication and decision-making. Additionally, disabling hearing impairment affects a substantial portion of elderly patients, potentially leading to misunderstandings, as hearing loss might be mistaken for cognitive impairment. The use of tools like the Mini-Cog, which can quickly assess cognitive impairment, can be valuable in such cases. Stereotypes about advanced age can also influence healthcare professionals, leading to unintentional paternalistic attitudes that hinder SDM in geriatric medicine.

Low health literacy is another common issue among older adults and can contribute to suboptimal SDM discussions, emphasizing the need for clear and patient-friendly communication during medical encounters. Furthermore, the lack of representation of geriatric patients in clinical trials, particularly those over 80 years old, poses challenges for healthcare professionals trying to apply evidence-based medicine to this specific population with multiple chronic conditions. The involvement of family members and caregivers in the care of older patients can both support and complicate SDM. While family members can provide valuable insights into the patient’s values and priorities, they may also have their own perspectives that may not fully align with those of the patients. By acknowledging and addressing these various factors and challenges, healthcare providers can ensure that older patients receive the most appropriate and patient-centered care for their unique circumstances.

Time constraints are frequently identified as a significant barrier to implementing SDM in clinical practice. The limited duration of a typical 15-20-minute physician’s office visit may not allow sufficient time to listen to patients, address their emotional concerns, and help them make well-informed decisions that align with their values and preferences. A recent study examining the mean time required for a primary care physician to provide guideline-recommended care estimated that they would need 26.7 hours per day, with substantial time allocated to preventive care, chronic disease management, acute care, and administrative tasks.1 Clinicians can optimize clinical encounters by directly inquiring about the main reason for the visit. Sitting at the patient’s level and avoiding a computer screen between the clinician and the patient can also contribute to a positive tone and improved communication during the visit. Quality and quantity of time are crucial in cultivating strong patient-clinician relationships, conducting patient-centered interviews, and promoting patient satisfaction. The patients could also be reluctant to engage in SDM due to concerns about feeling rushed during appointments or feeling uncomfortable asking too many questions.

In conclusion, SDM is a critical aspect of patient-centered care, where clinicians incorporate patients’ needs, values, and goals into their treatment plans. SDM plays a pivotal role in enhancing patient satisfaction, and treatment adherence. By involving patients and caregivers in the decision-making process and considering their unique preferences and circumstances, clinicians can deliver more personalized and effective care, ultimately leading to better patient experiences and outcomes.

References

  1. Hoque F. Shared decision making: Pinnacle for patient-clinician relationships. J BMANA. 2023; 2(1): 1-4. https://bmanaj.org/admin/assets/article/pdf/60_pdf.pdf. Published February 2023. Accessed September 15, 2023.
  2. Hoque F. PERSPECTIVE. Shared decision making: A win-win situation for both patients and physicians. Am J Hosp Med. Apr;7(2): 2023. https://medicine.missouri.edu/sites/default/files/ajhm/Shared_Decision_Making-A_Win-Win_Situation.pdf. Published June 2023. Accessed September 15, 2023.
  3. Lal R, O’Halloran T, Santhirapala R, et al. Implementing shared decision-making according to the choosing wisely programme: Perioperative medicine for older people undergoing surgery. J Eval Clin Pract. 2023 Aug;29(5):774-780. doi:10.1111/jep.13827. Epub 2023 Apr 11.
  4. Thibau IJ, Loiselle AR, Latour E, et al. Past, present, and future shared decision-making behavior among patients with eczema and caregivers. JAMA Dermatol. 2022 Aug 1;158(8):912-918. doi: 10.1001/jamadermatol.2022.2441.
  5. Mitropoulou P, Grüner-Hegge N, Reinhold J, et al. Shared decision making in cardiology: A systematic review and meta-analysis. Heart. 2023;109:34-39.

Issue

Topic

Clinical Practice, Hospital-based Medicine, SGIM

Author Descriptions

Dr. Hoque (farzanahoquemd@gmail.com) is an associate professor of medicine at the Saint Louis University School of Medicine and Medical Director of Bordley Tower at SSM Health Saint Louis University Hospital.

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