Shared Decision Making Q&A

Shared Decision Making (SDM) is a client-centered health care model in which clients are active participants in their own medical care and their own health.^1,2 With the support of the health care provider (HCP), who gives adequate and accurate information when engaging with the client, the client can make better informed decisions based on his or her issues, goals, preferences, values and treatment options. The client and HCP maintain open and respectful dialogue with each other in order to improve clinical care and health outcomes for the patient.^1,2,3,4

Drs. Nicole Lassiter, Amy Marowitz, Jane Houston, and Megan Garland offer insight on the Shared Decision Making model and the health care provider and client relationship.

Q: Are there any guidelines for HCPs? 

A: There are many. For example, the Agency for Healthcare Research and Quality provides the SHARE approach.⁵ A humanistic approach to communication is also encouraged, whereby the HCP sincerely strives to convey compassion, and empathy with the client.⁶

Q: What are three basic components of SDM?

A: Collaboration between provider and client, education on care options based on the evidence, and incorporation of the client’s values and preferences in the collaborative process.^1,2,3

Q: What is the HCP’s role in making medically indicated recommendations in the SDM model? 

A: When there is clear evidence that one care option would result in better outcomes, it is the HCP’s duty to explain such recommendations. This is often referred to as “directive counseling,” which is an integral component of informed consent. “Directive counseling” is not forced or coercive. When multiple, reasonable options seem equivalent in terms of outcomes, the HCP should offer those reasonable options.⁷

Q: What are some risks of strained communication between the HCP and the client? 

A: Strained communication between the client and HCP may arise when the client refuses or decides against a recommended treatment, or chooses a treatment not recommended.⁷ The evidence indicates that poor communication between client and HCP can lead to suboptimal clinical care and poor health care outcomes. Thus, striving to maintain a respectful, supportive relationship with the client improves clinical care and improved health care outcomes.^3,4,7

Q: What if the evidence and the HCP’s clinical experience strongly support the recommendation, then shouldn’t the HCP do everything reasonable to lead the client to that choice? 

A:  When the HCP believes that the choice will help the client and decrease risks, it is essential that the HCP make strong recommendations and provide necessary information for the client to understand the risks and benefits. Yet, it is ultimately the client’s decision.^2,7 It is the HCP’s duty to continue to provide informative, respectful, professional care. According to current professional guidelines, true SDM and informed consent must still occur when an adult client, who is capable of making a decision, maintains the right to make their own decisions about their own health.^2,7

Q: Are there ever any situations in which coercion is acceptable? 

A: No. The HCP should not coerce, threaten, or force the client.^2,7

Q: Isn’t the HCP at legal and professional risk if the client refuses a recommended treatment or intervention? 

A: Without attempting to provide legal advice, it seems reasonable that if the client is not incapacitated, it is the HCP’s duty to recognize the client as an autonomous individual. When an honest, trusting, and supportive relationship is maintained with the client, much literature indicates that this may reduce litigious situations.^2,3,7

Q: How should the HCP collaborate with a client who is refusing a medically indicated treatment?

A: The HCP should strive to sincerely listen to and take into consideration the following: The client’s concerns, life experience, history, thoughts and feelings, and her value system.^1,2,3,7 The HCP should also integrate the strength of the evidence, the level of maternal and fetal risk, the acuteness of the situation, and the client’s level of understanding of the factors. Under these circumstances, the HCP’s efforts to give the best result will hopefully have maximum chance of success.^2,7

Q: What if an adverse outcome occurs after client refusal of a recommended treatment? 

A: All supportive means should be taken and resources made available for both the HCP and the client including but not limited to debriefing and counseling support.^2,7 A contemporaneous record of all the relevant details should be made and carefully preserved. 

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Disclaimer: The statements in this blog are not intended to be legal advice.  We also note that laws may be different from state to state.

References

1. ACNM Position Statement. [ACNM]. (2016, December). Shared decision-making in midwifery care. 

2. Kotaska, A. (2017). Informed consent and refusal in obstetrics: A practical ethical guide. Birth (Berkeley, Calif.), 44(3), 195-199. doi:10.1111/birt.12281 

3. American Congress of Obstetricians and Gynecologists (2019). “Partnering with patients to improve safety.” ACOG Committee Opinion Number 490.

4. ACNM Position Statement. [ACNM]. (2016, February). Creating a culture of safety inmidwifery care. 

5. Agency for Healthcare Research and Quality (2016). The SHARE Approach: Essential steps of shared decisionmaking. AHRQ Pub. No. 14-0026-2-EF. https://www.ahrq.gov/health-literacy/curriculum-tools/shareddecisionmaking/tools/shareposter/index.html

6. Kunneman, M., Gionfriddo, M. R., Toloza, F. J. K., Gärtner, F. R., Spencer-Bonilla, G., Hargraves, I. G., . . . Montori, V. M. (2019). Humanistic communication in the evaluation of shared decision making: A systematic reviewdoi:https://doi-org.frontier.idm.oclc.org/10.1016/j.pec.2018.11.003

7. American Congress of Obstetricians and Gynecologists (2016). “Refusal of medically indicated treatment during pregnancy.” ACOG Committee Opinion Number 664.