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Shared decision-making: the value of a collaborative narrative

Alliances. Partnerships. Collaborations. However we may describe them, when people work together, great things can happen. When we commit to an appreciation of what others want and need, barriers can be dismantled, and progress can be boundless.

While listening, respecting and acting upon the views of product buyers and service users have become ubiquitous in most sections of society, and reviews, driven by Trust Pilot and others, have transformed customer relationships, healthcare has been slower to adapt.

But just as we are now recognising that siloes between medical specialties run counter to delivering optimal outcomes, increasingly there has been an acknowledgement of the value of feedback and shared decision-making (SDM) between health providers and the patients they serve.

Over the past several decades, healthcare has seen a shift from paternalism (where a physician or other healthcare provider makes decisions for a patient without their explicit consent) to autonomy (a patient’s right to make decisions regarding their care). The outdated model of a largely patriarchal, doctor-knows-best approach has, in most Western democracies at least, been steadily eroded and been replaced by an environment where patients have a voice and are empowered to participate in decisions about their care.

It is, of course, not before time. The very thought that decisions about a capable individual's health and well-being can be made in the absence of any invitation to engage in those decisions seems outrageous, yet within living memory this was the norm for many seeking care. As a concept, it is, however, by no means extinct and there remain societies and communities where the voices of patients, particularly women and girls, remain silent when it comes to making autonomous decisions about what happens to their bodies.

SDM is when a health professional and a patient work together in order to decide on the best plan of action for the individual patient in their particular circumstances.

The optimum decisions are those that take into consideration the best available evidence, the knowledge and experience of the provider, and the individual needs and preferences of the patient. (For those who think this sounds familiar, yes, it’s evidence-based care.) SDM is about close collaboration, putting the patient at the heart of the decision-making process, working with the clinician, and being supported by ancillary staff, family, and/or carers.

Overwhelmingly, patients now express the view that they want to be part of the decision-making process when it comes to their health. They are undoubtedly better informed, have access to resources and information online, and are empowered by a sense of understanding the available options. They appreciate a meaningful discussion about their condition, wish to express their views and concerns and want to ask questions.

In an age of increasingly limited time resources, this can appear an insurmountable challenge. However, where shared decision making has been embraced, clear benefits have been identified.

These benefits include increased patient involvement and engagement with the process of care, improved communication between the health provider and patients, a reduction in complaints and litigation and an enhancement of recovery. Research has also shown that where patients are active partners in the care process, overall outcomes are enhanced.

Effective collaboration depends on a good relationship being developed early on in the clinical encounter. By utilising the triad of introducing choice, researching the options and exploring patient preferences, patients feel that they are actively engaged throughout the process of determining what care is best for them in their circumstances.

SDM is not just about involving the patient in decision-making but ensuring that the final decision is the right one. It therefore needs to be systematic, use reliable information and promote autonomy by giving patients the appropriate time to make an informed decision about what is best for them.

It would be dangerous not to forget that in society generally, health literacy in many communities is low. There therefore remains a need to ensure that patients’ rights to understand their treatment options are appropriately exercised so that they can make informed decisions about their care and due account can be taken of their needs and preferences.

SDM cannot happen without high quality communication. Explaining in clear, unambiguous terms what the condition entails without using medicalised terms and jargon is of critical importance. Words matter and context counts, so health providers have a duty to ensure that language is appropriate to the treatment encounter. Active listening also plays a significant role in developing trust and a sustainable relationship. Pausing, reflecting and checking understanding are also important parts of the communication exercise to ensure that the patient remains actively engaged in the SDM.

In helping to overcome deficits in health literacy, a series of stages are often recommended. These include summarising the problem clearly and unambiguously, outlining the options available for care, inviting participation and questions from the patient, and including family members or carers to help support the decision-making process. Underpinning the entire process of SDM is the need to stress the importance of bilateral engagement.

One of the best summaries of SDM has been produced by the Agency for Healthcare Research and Quality (AHRQ). By using the acronym SHARE, the AHRQ has set out five fundamental guidelines that it recommends are taken into account in every clinical encounter:

· Seek patient participation;

· Help patients explore and compare treatment options;

· Assess patient values and preferences;

· Reach a decision with the patient;

· Evaluate the patient's decision.

It is worth pausing briefly to explore the assessment of values and preferences in the SDM process. Understanding what matters most to patients is key to determining what interventions may be offered. Is it the recovery time? Are there concerns about out-of-pocket costs? Is being pain-free the absolute priority? Or is achieving a reasonable level of functionality the dominant driver?

Understanding values and preferences means encouraging the patient to talk. This is best achieved by not interrupting and by actively listening to what they are saying. The asking of open-ended questions and actively listening to the responses is key to good communication. Showing empathy and interest throughout the treatment encounter demonstrates that you are an attentive and engaged practitioner. Acknowledging values and preferences by summarising and reflecting back and agreeing on what is important to the patient helps to create a sustainable and effective patient-provider relationship.

Once the nature of the health condition has been discussed and values and preferences have been explored, an assessment of treatment options should be comprehensive and underpinned by a weighing up of the risks and the benefits of both the recommended option and of any alternative options.

An honest explanation of the limitations of care as well as the limitations of what is known or unknown about a particular condition is often appreciated. A frank discussion around what will happen if there is no treatment intervention also helps patients in the SDM process. Throughout, it is important to assess the level of understanding and to ensure that patients have the capacity to be able to make decisions about their care.

Communication can be aided by writing down a list of options, by using charts or models and by communicating numbers simply and comparatively. Assessment of understanding can be gauged using a teach back technique where the patient is asked to explain what they understand about what they have been told.

Finally, the plan of care must be agreed on the basis of scientific evidence, clinician expertise and knowledge, and the values and preferences of patients. Time must be given for patients to make an informed decision, and proceeding to care should only be in the event that the patient is ready to make a decision. Identifying barriers, scheduling follow-up and confirming their decision are all components of the process whereby the obtaining of consent can be said to be truly informed and on the basis of SDM.

Evidence-based, people-centered, interprofessional and collaborative care (the pillars of the World Federation of Chiropractic’s #BeEPIC campaign) all depend on SDM. As healthcare evolves, greater recognition will be afforded to the value of full patient engagement in the treatment encounter, and tolerance of one-way, paternalistic behaviours will dramatically reduce.

By fully investing in the process of collaboration with patients, family members and carers, SDM will be recognized for what it is: an indispensable component of the relationship between healthcare providers and their patients and a force for good in achieving the best outcomes for the unique individuals we serve.

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