Sharing Decisions

It’s ubiquitous . . . the admonition to “utilize a process of shared decision making.” With each new guideline, treatment option, or vaccine, clinicians are confronted with data supporting the action, as well as the various risks and benefits. That litany of objective data is followed by the exhortation to share the decision making process with patients when considering implementing the recommendations.  

Sharing decision making is something we do daily in our lives outside of patient care. We share decisions with family, friends, and coworkers, usually without a thought about the process. Where should we have lunch? What color to paint the nursery? Where should we vacation? Do we need the gigantic air fryer at Costco? These decision trees are typically based on personal biases and opinions: “I can’t say why I like baby-blue better . . . I just do.” These conversations typically don’t involve one discussant acknowledged to be an “expert” in the field. For such decisions, multiple answers can often be correct (although the default choice for the king-sized wholesale club item should likely be “don’t get it.”)  

When decisions are made in concert with patients, there’s often the tacit understanding that the clinician is the expert in the room. On so many occasions, I’ve had “the discussion” in which I present the rationale for a treatment, the “attendant risks and benefits,” considerations of the patient’s finances and insurance coverage, social situation, and burdens the proposed action might impose. I’ll typically then ask the patient: a) Do you have any other questions? and b) well, what do you think? And, on so many of those occasions, the patient will look at me and say: “That’s great, doc. But you’re the one I trust, the one whose opinion I value. So tell me what do do.” Of course, there are variations on this theme, typically taking the form of “If it was you, what would you do?” But in the end, the patient is asking for the same thing: guidance from us, direction, reassurance, confidence, and expertise. And often, we can’t give them those things with the clarity they desire or deserve. When that happens, patients may perceive that we’re “passing the buck,” abdicating our role and allowing us to dodge responsibility (and in the view of some, avoid litigation.)  

Clinicians, burdened by so many demands during each encounter, can be frustrated by the need for all of this sharing. It may be seen as an extra two minutes spent on an encounter that’s already encroaching on the next patient’s visit time. Shared decision making becomes another task, another checkmark in the EHR (and, oh yes, is it covered by a procedure code that can justify a charge?)  

When sharing decision making with our patients, we should be guided by several principles: We need to respect the autonomy of our patients. This includes the right of a patient to make a bad decision (because “bad” may be a perception rather than an objective reality.) We have an obligation to educate and to provide the best possible information for patients to enable them to make the best decisions with our guidance. 

Just because we can do something, doesn’t mean we should necessarily do it, or perhaps even offer it. We should practice humility; we can’t and don’t know everything. But we can reassure our patients that we’ll help find answers to questions that remain. 

“Do no harm” should remain a core principle. We need to acknowledge that we can cause harm by commission (administering the treatment) or omission (advising against an intervention that may be beneficial and that aligns with the patient’s goals and beliefs.)

We should leverage our relationship with a patient, especially if we have a long history of caring for them (as I do as a primary care doctor and have often gotten to know patients over years and decades.) We may have insights into a patient’s values and goals better than other members of the care team.

And finally, we must remember that a patient may value things we don’t, and that doesn’t make them wrong. After all, you may actually need that extra large air fryer. 

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.