Opportunities for Shared Decision-Making in Clinical Practice

The National Academy of Medicine recommends a shared decision-making approach when discussing medical treatments; however, an overview of evidence presented by Terrance Lynn Albrecht, PhD, Associate Center Director, Population Sciences, Karmanos Cancer Institute, and Chief of Oncology, Wayne State University School of Medicine, Detroit, at the 2016 American Society of Clinical Oncology annual meeting suggests that clinicians are not very effective in following this recommendation.

Shared decision-making requires equal investment by the patient and the oncologist. Communication about the reasons, values, and preferences for different treatment options is needed between the 2 parties, Dr Albrecht said.

“Doctors should be pragmatic about what shared decision-making means before and after the decision is made,” she said.

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 the benefits and risks for each option
3. Elicit and help patients express their questions, thoughts, opinions, concerns, and expectations about treatment options, benefits, and side effects. 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 patients say they want to share in the decision-making with their doctors, said Dr Albrecht, but it depends on how you ask the question. Thus, it is important for doctors to emphasize a therapeutic alliance with their patients early in the relationship.

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

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

According to Dr Albrecht, the second pragmatic issue is that perceptions matter. After the decision is made, doctors and patients do not necessarily agree that shared decision-­making has occurred, even though they have 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, because uncertainty is inherent in the 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 controversy. According to Dr Albrecht, critics have argued that it could lead to requests for needless, expensive, and 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.”

To promote trust, clinicians should address questions and requests with evidence and sensitivity to the patient’s fears, as well as recognize the patient’s need for understanding and resources, Dr Albrecht concluded.