Shared decision making in practice

Many medical decisions have more than one defensible answer. Which is right depends on the person, and that is what shared decision making addresses.

Preference-sensitive decisions

• Several options are clinically reasonable.
• They differ in trade-offs rather than in effectiveness.
• The best choice depends on what you value.
• Examples include many surgical versus conservative choices.
• Also screening decisions and some treatment intensities.

Where one option is clearly superior, shared decision making matters less. Where the trade-off is genuine, it matters a great deal.

What each side contributes

• The clinician brings diagnosis, evidence and experience.
• You bring your circumstances and priorities.
• Neither has the complete picture alone.
• The decision should reflect both.

Clarifying what you value

• What are you most trying to avoid?
• What would you accept to achieve it?
• How do you feel about uncertainty?
• What does recovery time cost you practically?
• What matters in the next year versus the next decade?

Answering these before the consultation makes the discussion far more productive than working it out during a short appointment.

The three questions framework

• What are my options?
• What are the possible benefits and harms of each?
• How likely is each of those?

These three cover most of what a patient needs and are easy to remember under stress.

Decision aids

• Structured tools presenting options and outcomes.
• Often include probability information visually.
• Some include exercises to clarify preferences.
• Ask whether one exists for your decision.
• They improve understanding and reduce decisional conflict.

Common obstacles

• Short appointments.
• Assumption that the clinician should simply decide.
• Reluctance to appear difficult.
• Information presented in ways that favour one option.
• Emotional state after a diagnosis.

The last is significant. Major decisions are often discussed immediately after news that makes clear thinking difficult, which argues for a second appointment.

Asking for time

• Most decisions allow a few days.
• Ask explicitly whether you can think about it.
• Ask what the cost of waiting is.
• Use the time to discuss with people you trust.
• Return with questions.

If you prefer the clinician to decide

• This is a legitimate position.
• Say so explicitly rather than staying silent.
• Remain informed about what is being decided.
• You can change your mind about participating.

When the clinician does not engage

• Some are unfamiliar with the approach.
• Asking the three questions usually prompts it.
• Persist politely.
• Consider another clinician if it remains one-sided.

Involving family

• Bring someone to listen and take notes.
• Discuss your priorities with them beforehand.
• Be clear whose decision it is.
• Family preferences may differ from yours.

The third point occasionally needs stating. Support is valuable; substitution of judgement is not what you are asking for.

Across cultures and languages

• Norms about patient participation differ.
• Some settings expect families to lead decisions.
• Language barriers make participation harder.
• Ask for interpretation for important discussions.
• State your preference about how you want to be involved.

Documenting the conversation

• Ask for the options discussed to be noted in your record.
• Ask for your stated preference to be recorded.
• Request a letter summarising the decision.
• This helps if care transfers to another team.

A record of what was discussed and why the chosen path was selected is genuinely useful later, particularly if you move between systems or if a different clinician takes over and needs to understand how the current plan was arrived at.

When the evidence is genuinely thin

• Some situations have little good evidence either way.
• Clinicians should say so when that is the case.
• Decisions then rest more heavily on values and judgement.
• Ask what is known and what is being inferred.
• Uncertainty acknowledged is more trustworthy than confidence asserted.

A clinician who distinguishes clearly between what the evidence supports and what is their own judgement is giving you better information than one who presents both with equal confidence. That distinction is worth asking for directly when a recommendation feels less than fully grounded.

Recording your priorities in advance

• Write down what matters most to you about treatment.
• Note what outcomes you would find hardest to accept.
• Share this with family and with your clinician.
• Revisit it as circumstances change.

Having this written down helps in two situations: when a decision must be made quickly, and when someone else may have to speak for you.

Decisions under time pressure

• Some decisions genuinely cannot wait.
• Even then, a short explanation of options is possible.
• Ask for the essential trade-off in one sentence.
• State your key priority.
• Full deliberation can follow later where the choice is staged.

Even in urgent situations, a brief exchange about what matters most to you is usually possible and changes decisions more often than people assume.

Revisiting a decision

• Circumstances and evidence change.
• A decision made reasonably can be revised.
• Ask what would prompt reconsideration.
• Schedule a review point if appropriate.

Framing a choice as reviewable rather than final makes it easier to make, and many treatment decisions genuinely are staged rather than one-off.

After the decision

• Record what was decided and why.
• Note what you were told to expect.
• Note what would prompt reconsideration.
• Revisit if circumstances change.

Recording the reasoning helps later, particularly if the outcome is disappointing and you find yourself questioning the choice.

Summary

Shared decision making applies where several options are reasonable and the best one depends on what you value. Clarify your priorities before the consultation rather than during it. The three questions — what are my options, what are the benefits and harms, how likely are they — cover most of what you need. And ask for time, since major decisions are often discussed immediately after news that makes clear thinking hard.

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