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Consent and shared decision-making

Dr Mark Dinwoodie, MPS Head of Member Education, looks at the term ‘shared decision-making’ and asks: what exactly does it mean and what are its benefits?

The increasing sophistication of healthcare, with an expanding number of available treatment options, set in the context of patients with rising levels of morbidity and expectations, has made decision-making more complex and challenging for both doctors and their patients. It’s perhaps not surprising that a model of decision-making that takes account of these issues, incorporates ethical and legal requirements, respects many patients’ increasing desire for involvement – while also incorporating the expertise of the clinician – has emerged.

Consent and decision-making

The requirements of the discussion process that contributes to the validity of consent have changed significantly over the last 30 years. Neither a paternalistic model of “doctor knows best” nor an informative approach of “here’s all the information, you decide” fulfil the requirements of a decision-making process outlined above. These two styles are different from making the decision in partnership with the patient, where there is an exchange of knowledge and opinion (see Box 1).

A wise decision isn’t dictated by science and clinical expertise alone, but requires consideration of the patient’s perspective
It is the discussion around the consent process that is likely to satisfy patients’ needs, enable patient autonomy and reduce the risk of medicolegal consequences. The challenge for many of us is that a wise decision isn’t dictated by science and clinical expertise alone, but requires consideration of the patient’s perspective. It also requires clinicians to move from the ‘general’, ie, what might be the right decision for the majority of patients; to the ‘individual’, ie, what the right decision is for this particular patient.
The only way to achieve the latter is to ask the patient what matters to them and involve them. Doctors contribute their expertise and experience around diagnosis, disease and evidence-based treatment while the patient contributes expertise about what matters to them as patients, such as their preferences, values, attitudes to risk, concerns and expectations reflecting past experience, and frames these in a social context.

What is shared decision-making?

“Shared decision-making is a process in which clinicians and patients work together to select tests, treatments, management or support packages, based on clinical evidence and the patient’s informed preferences. It involves the provision of evidencebased information about options, outcomes and uncertainties, together with decision support counselling and a system for recording and implementing patients’ informed preferences.”1

It is an essential component of truly patient-centred care. The goal is to arrive at a decision that is ‘right for them’, from a patient’s perspective. Some cultures and healthcare systems place less emphasis on patient involvement, with either deference to doctors as the decision-makers or to other family members. Increasing patient desire for autonomy and involvement may challenge these traditional approaches.

While many clinicians believe they practise shared decision-making, this is not always borne out in practice.2 Shared decision-making is appropriate for many decisions including those about whether to have a screening or diagnostic test, undergo a medical or surgical procedure or take medication.

Box 1:

NZ Consent-box-1

  

The patient’s preference

Resistance to shared decision-making often revolves around a perception that doctors have many patients who wish the doctor to make the decision for them: “Whatever you think best doc.” The difficulty is that just as doctors have preferences for their style of decision-making, patients also have preferences as to their desired level of involvement (see Figure 1).

Fig 1:

This is context dependent and can change with time. For example, a patient’s desire to be involved in an elective procedure is likely to be very different than if they are seriously injured in an accident, when they may be only too willing to devolve decision-making responsibility to the clinician. Should the patient experience an adverse outcome from their treatment, their preference about how much they should have been told and involved may well be different in retrospect and so can change over time.

Decision points and options

If we view a patient’s condition as a healthcare journey over time (see Figure 2), at the decision point there are a number of options. If option A is associated with an adverse outcome and they feel worse off than before treatment, the patient may well reflect as to why they had any intervention at all and that perhaps they would have been better with “no action” or conservative management (option B), a different option (option C) or even an option they weren’t told about.

An important task in the decision-making difscussion is to help the patient arrive at an appropriate understanding of the risk/benefit analysis of each option, including the option of doing nothing and to compare these in the context of their own values, preferences and expectations of treatment.

Fig 2:

Doctors’ recommendations

Consider these three approaches in the context of a 26-year-old female patient, with a young daughter, who is requesting contraception as she has started a new relationship:

Scenario A: Paternalistic

Doctor: We find that most women in your situation choose a coil and that’s what I would recommend for you. Let me tell you about the risks and benefits…

Scenario B: Informative

Doctor: There are lots of choices available. I have a comprehensive information booklet here about all the options and their risks and benefits. Why don’t you have a good look at that and let me know which you would prefer?

Scenario C: Shared decision-making

Doctor: What matters to you most about the choice of contraception? Is it reliability, minimal side effects, impact on your bleeding pattern or something else?

Patient: The most important thing for me, doctor, is not to get pregnant so early in a new relationship, so I would like the most reliable method.

Doctor: There are several options, including… Given that not becoming pregnant is your most important consideration, I would probably recommend the combined pill, assuming there aren’t any contraindications. What do you know about the pill?

I’m sure most doctors with this type of request would share knowledge and opinion as in scenario C and it would seem bizarre not to arrive at a decision that reflected and incorporated the values of the patient. The doctor’s recommendation is a vital ingredient to help arrive at the decision but may be invalid unless based on patient preferences, concerns, values and expectations.

Patient dissatisfaction

Most dissatisfaction with clinical decision-making relates to:

  • The amount and quality of information received
  • Level of involvement in the decision-making process.

Numerous studies have shown that doctors’ assumptions of patient values on which they may base their recommendations regarding investigation or treatment can be inaccurate,3 eg, women with abnormal menstrual bleeding who are more informed through a decision aid elect to have surgery less frequently.4 Better-informed patients often make different choices, eg, more conservative treatment, and are more risk averse. What patients want is often different from what doctors think their patients want.1,3,5

Shared decision-making has significant benefits and should be an integral part of interactions with patients if we are to fully embrace patient-centred care

Often we decide what we think is in the patient’s best interest from a clinical perspective, eg, whether to undergo an elective operation or take lifelong preventative medication, inform them as to why we have arrived at that decision and then give them details of the risks and benefits. This represents more persuasion than collaboration, acquiescence rather than concordance or making decisions for rather than with the patient. The danger is that we could subject patients to operations, investigations or medications that they don’t want.5

Shared decision-making has significant benefits (see Box 2 below) and should be an integral part of interactions with patients if we are to fully embrace patient-centred care. The initial consultation may take a little longer but less than the time spent dealing with uncertain or unhappy patients.1,4

Box 2: Benefits of shared decision-making1-3

  • Increases patient involvement in the decision-making process
  • Increased patient knowledge and understanding
  • Patients share some responsibility for the decision
  • More realistic expectations from treatment
  • Decisions and choices that align with patients’ preferences and values
  • In some cases better health outcomes
  • Helps reduce geographical variations in care
  • Improves patient satisfaction
  • Better adherence to treatment
  • Patients are better informed with more accurate risk perceptions
  • Helps identify the high-risk decision.

AT A GLANCE: The official guidance

In paragraphs 1 and 2 of Information, choice of treatment and informed consent, the Medical Council of New Zealand says:

  1. Trust is a vital element in the patient-doctor relationship and for trust to exist, patients and doctors must believe that the other party is honest and willing to provide all necessary information that may influence the treatment or advice. The doctor needs to inform the patient about the potential risks and benefits of the options available and support the patient to make an informed choice.
  2. Informed consent is an interactive process between a doctor and patient where the patient gains an understanding of his or her condition and receives an explanation of the options available including an assessment of the expected risks, side effects, benefits and costs of each option and thus is able to make an informed choice and give their informed consent.

Furthermore, under Right 5 of the Code of Health and Disability Services Consumers’ Rights, “…you must convey information to the patient in a form, language and manner that enables the patient understands the treatment or advice. This means you should do your best to help your patient to understand any information you provide to them.”

For more information on Mastering Shared Decision Making, a workshop run by MPS in New Zealand, visit our workshops page.

References

  1. Coulter A, Collins A, Making shared decision making a reality, No decision about me, without me. London: King’s Fund (2011)
  2. The Health Foundation, Helping people share decision making. London: The Health Foundation (2012)
  3. Stacey D et al, Decision aids for people facing health treatment or screening options. Cochrane Database Syst Rev 10: CD001431 (2011)
  4. Kennedy A et al, Effect of decision aids for menorrhagia on treatment choices, health outcomes and cost: a randomised controlled trial, JAMA 288:2701-8 (2002)
  5. Mulley et al, Patient preferences matter: stop the silent misdiagnosis. King’s Fund (2012)
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