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Opportunities for Shared Decision-Making in Clinical Practice

Although the Institute of Medicine recommends taking a shared decision-making approach to discussions about medical treatments, an overview of evidence at the 2016 ASCO Annual Meeting suggests that clinicians are not very effective in actually following this recommendation. According to Terrance Lynn Albrecht, PhD, this approach requires equal investment by both patient and oncologist in the treatment decision and communication about the reasons, values, and preferences for different options.

“Doctors should be pragmatic about what shared decision-making means before and after the decision is made,” said Dr Albrecht, Associate Center Director of Population Sciences at Barbara Ann Karmanos Cancer Institute and Professor and Chief of Oncology at Wayne State University School of Medicine, MI. “Signal to your patient up front that your relationship is a partnership while appreciating the need for perceived control.”

Dr Albrecht summarized the 4 basic steps to collective decision-making:

  1. Outline treatment options for a patient to consider, which should include no treatment or stopping treatment. This is especially important for patients looking for end-of-life options
  2. Describe the probabilities of benefits and the risks for each option
  3. Elicit and help patients express their questions, thoughts, opinions, concerns, and expectations about options, benefits, side effects, etc. Although it takes a lot of time, this is what the formal process involves
  4. Share responsibility for decisions and assess each partner’s preferred roles in the partnership

Pragmatic Approaches to Sharing Treatment Decisions

Most, but not all patients say they want to share decisions with their doctors, said Dr Albrecht, but it depends on how you ask the question. Thus, it’s important for doctors to emphasize a therapeutic alliance with their patients early in the relationship.

“You need to signal to your patient up front that your relationship is a partnership,” Dr Albrecht advised. “Let them know that their values are important and need to be a part of the discussion.

“Also, don’t just focus on the decision itself,” she added, “but on patients’ preference for the outcomes they want to see happen.”

According to Dr Albrecht, the second pragmatic issue is that perceptions matter. After the decision is made, doctors and patients don’t necessarily agree that shared decision-making has occurred, even though they’ve gone into the process with that in mind.

“Doctors and patients often need to have a sense of personal control, which is about feeling heard and feeling a sense of influence over the course of the discussion,” said Dr Albrecht, who stressed that acknowledging the roles each party will play is an important step in strengthening the alliance.

In addition, since uncertainty is inherent in estimated benefits and risks, shared decisions based on patient values are essential.

“Risks and benefits are never so easily portrayed, particularly for individual patients,” she said. “They vary by type, probability, degree, timing, and frequency for each patient and need to be adapted as such.”

There are also costs to be considered. With everything that happens in treatment, said Dr Albrecht, there is a tolerable price: the amount a patient is willing to pay for a positive outcome or to minimize a negative one.

Finally, this approach is not without its controversy. According to Dr Albrecht, critics have argued that it could lead to requests for needless, expensive, and/or risky procedures. Although this certainly could happen, she said, a central tenet of shared decision-making is “the ethical right of patients to make requests, to ask questions, and to express needs and concerns.”

“Doctors must promote trust by addressing these with evidence, sensitivity to the patient’s fears, need for understanding, and need for resources,” Dr Albrecht concluded.

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