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Shared decision-making


Shared decision-making (SDM) is an approach in which clinicians and patients communicate together using the best available evidence when faced with the task of making decisions.

Patients are supported to deliberate about the possible attributes and consequences of options, to arrive at informed preferences in making a determination about the best course of action which respects patient autonomy, as well as ethical and legal norms.

One of the first instances where the term shared decision-making was employed was in a report entitled the "President's Commission for the Study of Ethical Problems in Medicine and Biomedical Research." This work built on the increasing interest in patient-centredness and an increasing emphasis on recognising patient autonomy in health care interactions since the 1970s.

Charles described a set of principles for shared decision-making, stating “that at least two participants, the clinician and patient be involved; that both parties share information; that both parties take steps to build a consensus about the preferred treatment; and that an agreement is reached on the treatment to implement". These principles rely on an eventual arrival at an agreement but this final principle is not fully accepted by others in the field. The view that it is acceptable to agree to disagree is also regarded as an acceptable outcome of shared decision-making.

Elwyn described a set of competences for shared decision-making, which are composed of the steps of defining the problem which requires a decision, the portrayal of equipoise and the uncertainty about the best course of action, thereby leading to the requirement to provide information about the attributes of available options and support a deliberation process. An assessment scale to measure the extent to which clinicians involve patients in decision-making has been developed and translated into Dutch, Chinese, French, German, Spanish and Italian. A talk model has been recently proposed, composed of three different phases: team, option and decision talk. In the first of these phases, clinicians' work to create a supportive relationship with the patient as they introduce the idea of recognizing the existence of alternative actions (options) - this is to form a team with the patient and their family. In the second phase, the work is to introduce the options in a clear way, describing and explaining the probabilities of benefits and harms that might be likely - this is option talk. In the last phase, patients' preferences are constructed, elicited and integrated - this is decision talk. A shorter 5-item version of the Observer OPTION measure has been published based on this model.

With funding bodies emphasizing knowledge translation, i.e. making sure that scientific research results in changes in practice, researchers in shared decision-making have focussed on implementing SDM, or making it happen. Based on studies of barriers to shared decision-making as perceived by health professionals and patients, many researchers are developing sound, theory-based training programs and decision aids, and evaluating their results. Canada has established a research chair that focusses on practical methods for promoting and implementing shared decision-making across the healthcare continuum.


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