Consumer Enablement Guide

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Shared Decision Making

Shared decision making is a process where the clinician and consumer (and their family, partner or carer) make health decisions together.

What is shared decision making?

Shared decision making is not just about providing education, and it is not the same as informed consent. It involves discussing the risks and benefits of each option available, taking into consideration the person’s values, preferences and circumstances.1

While it normally occurs between one person and their clinician, it can also involve care teams and families, and carers providing care at home. The level of responsibility in the decision-making process can vary2, depending on the situation and whether it should be led by the clinician or consumer.

Why is it important?

When discussing healthcare interventions, most people overestimate the benefits and underestimate the harms.3 Once they are fully informed about the tests or treatment, they tend to make more conservative decisions.4

Discussing options together can help people make an informed decision, reducing the risk of inappropriate or excessive treatment and associated costs.5 It is particularly useful when the evidence does not overwhelmingly support one option over another.

Shared decision making can increase consumer enablement by exploring what matters to people during the decision-making process. It also addresses components that influence how well they can manage their health.

It considers:

  • the benefits and risks of different options (including doing nothing)
  • the person’s knowledge about treatment options
  • psychological issues or barriers
  • the physical benefits and burdens of each option
  • the person’s capacity to access and afford healthcare
  • the person’s personal preferences, values and circumstances
  • cultural considerations, such as who should be in the room
  • whether families and communities need to be involved
  • two-way trust between the clinician and consumer.1 6 7 8

How to practice shared decision making

There is no universally agreed approach for shared decision making. However, it does require strong two- way communication and recognition of each other’s expertise and perspectives.

While shared decision making should be tailored to each person and their situation, it usually involves the following steps.

  • Explain the problem and invite the person to be involved in the decision-making process.
  • Explain the options and the benefits and harms of each, including the likelihood that these benefits or harms will occur.
  • Discuss what matters to the person and clarify how each option fits with their values, preferences, beliefs and goals.
  • Make sure you understand what the person is saying and answer any questions they may have.
  • Continue to deliberate until you all agree on one option (people often move from an initial preference to an informed preference).9 10
  • Make a decision or agree to defer the decision.

You may like to break the decision-making process into three parts:

  • choice talk – helping them understand that options exist
  • option talk – discussing the options and benefits and harms of each
  • decision talk – helping them explore options and make decisions.

You may like to use a series of questions to guide the process.111

  • What will happen if we wait and watch?
  • What are the options?
  • What are the benefits and harms of these options?
  • How do the benefits and harms weigh up for you?
  • Do you have enough information to make a decision?

What skills do you need?

The skills you need to practice shared decision making are in addition to those you already have in communication, relationship-building and evidence-based practice.12 You will need to:

  • use active listening and provide a caring, respectful and empowering environment, so people feel comfortable participating and asking questions
  • consider their health literacy and tailor the amount and speed of information provided to their needs and preferences
  • consider their cultural background, primary language, preferred learning style and any communication or cognitive impairments
  • find out whether and how much they want to participate in shared decision making, or whether it is possible (such as emergency situations).13 14 15

People who are vulnerable or have low health literacy often receive less information and ask fewer questions.16 17 You may need to do more to engage these people in shared decision making.1

Myths and misconceptions

There are some challenges and misconceptions about shared decision making that can hinder its use. These include the following.

Misconceptions

  • The misconception that it will greatly increase the length of consultations.
  • Worrying that people will feel unsupported during difficult decisions.
  • Worrying that people do not want to be involved in shared decision making.
  • Worrying that it is too complex for consumers to be involved.1 18

Myths

  • Limited evidence about the benefits and harms of each option.19
  • Feeling frustrated if someone chooses an option that is different to one you would have chosen (the ‘wrong choice’).15
  • Worrying the person will raise a dispute later if they make a ‘wrong’ choice.

Addressing misconceptions and myths

To address these concerns, make sure you:

  • are well-informed of current evidence for all options available
  • have the skills and tools to interpret and communicate statistical information in an appropriate way
  • review evidence-based strategies used to communicate
  • explain the problem and options in a way that is clear, honest and unbiased
  • check the person has understood the information you have provided
  • record the decision made and the rationale provided by the person in your clinical notes.15 20

Tools for shared decision making

Decision aids are communication tools to facilitate shared decision making. They include information about the options available, the benefits and harms of each option, and exercises to help people think about what matters to them.

Decision aids can be printed or electronic and may contain a short video or a series of questions. They can be used by people before they see a health professional, during the consultation, or afterwards.1 4

Research shows that compared to usual care or other options, decision aids can help people:

  • improve their knowledge about their health
  • communicate better with health professionals
  • have a more accurate perception of the benefits and harms of interventions
  • feel better informed
  • increase participation in collaborative decision making
  • make choices that better reflect their personal values and preferences
  • feel more confident about their decisions and the decision-making process.4

Using a decision aid does not mean that shared decision making has occurred. Shared decision making takes place during conversations between the health professional and consumer, and can be achieved without a decision aid. In fact, for most health decisions, decision aids do not exist. The most important thing is to follow the process and discuss the problem, the options and each other’s preferences together.

References

  1. Hoffmann TC, Légaré F, Simmons MB, et al. Shared decision making: what do clinicians need to know and why should they bother? MJA. 2014;201(1):35-9.
  2. Kon AA. The Shared Decision-Making Continuum. JAMA. 2010;304(8):903-4.
  3. Hoffmann TC, Del Mar C. Patients’ Expectations of the Benefits and Harms of Treatments, Screening, and Tests: A Systematic Review. JAMA Internal Medicine. 2015;175(2):274-86.
  4. Stacey D, Légaré F, Lewis K, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews: John Wiley & Sons, Ltd; 2017.
  5. Moynihan R, Doust J, Henry D. Preventing overdiagnosis: how to stop harming the healthy. BMJ. 2012;344(7859):19- 23.
  6. Elwyn G, Gulland A. Salzburg Global Seminar: Salzburg statement on shared decision making. BMJ. 2011;342(7801):794- 5.
  7. Elwyn G, Edwards A, Kinnersley P, et al. Shared decision making and the concept of equipoise: the competences of involving patients in healthcare choices. British Journal of General Practice. 2000;50(460):892-9.
  8. Müller-Engelmann M, Donner-Banzhoff N, Keller H, et al. When Decisions Should Be Shared: A Study of Social Norms in Medical Decision Making Using a Factorial Survey Approach. Medical Decision Making. 2013;33(1):37-47.
  9. Elwyn G, Durand MA, Song J, et al. A three-talk model for shared decision making: multistage consultation process. BMJ. 2017;359.
  10. Joseph-Williams N, Lloyd A, Edwards A, et al. Implementing shared decision making in the NHS: lessons from the MAGIC programme. BMJ (online). 2017;357:j1744.
  11. Irwig L, Irwig J, Trevena L, et al. Smart health choices: making sense of health advice. Rev. and updated. London: Hammersmith; 2008.
  12. Hoffmann TC, Montori VM, Del Mar C. The Connection Between Evidence-Based Medicine and Shared Decision Making. JAMA. 2014;312(13):1295-6.
  13. Institute of Medicine (US) Committee on Health Literacy. Health Literacy: A Prescription to End Confusion. Washington: The National Academies Press; 2004.
  14. Australian Commission on Safety and Quality in Healthcare. Patient and Consumer Centred Care . Sydney: ACSQHC; n.d. [cited 2018 Jan 15].
  15. Hoffmann T, Tooth L. Shared decision making. In: Hoffmann T, Bennett S, Del Mar C, editors. Evidence-based practice across the health professions. 3rd ed. Sydney: Elsevier; 2017.
  16. Smith SK, Dixon A, Trevena L, et al. Exploring patient involvement in healthcare decision making across different education and functional health literacy groups. Social Science & Medicine. 2009;69(12):1805-12.
  17. McCaffery KJ, Holmes-Rovner M, Smith SK, et al. Addressing health literacy in patient decision aids. BMC medical informatics and decision making. 2013;13 Suppl 2:S10-S.
  18. Légaré F, Witteman HO. Shared decision making: examining key elements and barriers to adoption into routine clinical practice. Health Affairs (Project Hope). 2013;32(2):276.
  19. O'Connor AM, Légaré F, Stacey D. Risk communication in practice: the contribution of decision aids. BMJ. 2003;327(7417):736-40.
  20. Trevena LJ, Zikmund-Fisher BJ, Edwards A, et al. Presenting quantitative information about decision outcomes: a risk communication primer for patient decision aid developers. BMC Medical Informatics and Decision Making. 2013;13(Suppl 2):S7- S.

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