By: Donna Dubuc

EVERYTHING YOU NEED TO KNOW ABOUT SHARED DECISION MAKING YOU LEARNED IN KINDERGARTEN

This Kindergarten Lesson is Conflict Free I have no Conflict of Interest to disclose or report.

Basic principles

Values and beliefs of shared decision making

A seesaw has more than two positionsShared decision making is used for preference sensitive situations, where

there is no clear cut answer about which treatment option is best (equipoise).

Look both ways before you cross the street Shared decision making is a two-way street. You must look at both sides before moving forward. The provider identifies the medical problem and lays out reasonable options.

Patients identify and convey goals and concerns relevant to the decision.

You are not the boss of meShared decision making is based on the belief that individual self-determination should

be encouraged. Clinicians support autonomy by building good relationships and respecting patients’ competence and independence.

Sharing is caringThe responsibility for preference-sensitive decisions is shared through the creation of a partnership. With their provider’s support, patients won’t feel abandoned or like they

have to decide on their own.

Using an Options Grid Using a decision support tool in an exam room encounter

Take your turn but don’t go firstBefore offering information to patients, ask what they already know, ask “Have you

read or heard anything about lung cancer screening?” Check for understanding. Is the pre-existing knowledge accurate?

Don’t stareIn the exam room, when you offer a patient a decision aid allow for review time. Busy yourself with another task such as clinical note taking or email while the patient reads

and considers the options.

Share your crayonsWhen asking a patient to review a list of options or a decision support tool, give them a pen to make notes or circle the options they want to talk more about.

Do your homeworkKnow the options available to a patient and the risks and benefits of each.

Have decision support tools ready.

Write NeatlyWhen no existing decision tool exists, compile a list of options yourself.

Buddy up and “hold hands”Sticking together as patient and provider has psychological, social, and emotional

factors that will influence deliberation dialogue. Glyn Elwyn breaks down this dialogue into choice talk, option talk, and decision talk.

Routines are goodA three step model for routine SDM

by Glyn Elywn

Choice talk: Patients learn a choice exists, and that their personal preferences matter in making

that choice

Option talk: Patients learn about treatment options in more detail to

understand the different harms/benefits and consider the outcomes. Providers check for

understanding .

Decision talk: Providers support patients in the exploration of what

matters most to them. Providers elicit a preference. Check for certainty.

Review decision.

Ask PermissionBefore moving from choice or option talk into decision talk, ask permission. “Shall we go on?” “Do you think you know how you feel about your options?” “Do you feel ready

to make a decision?”

Tell them what you know, not what you believeOffer an objective, unbiased presentation of options to consider. Review the pros and cons of these options. Describe options in practical terms.

(+) and (-) = solutionBe clear about the pros and cons of different treatment options. Offer a neutral presentation of benefits and harms. Use easy-to-understand examples of risk.

(Absolute instead of relative risk)

Don’t use your words, use theirsUse plain language. Low literacy and numeracy are obstacles to shared decision

making. There are also cultural barriers. Make sure you meet people where they are at to form a partnership for shared decision making.

Listen when someone is talkingIt is essential to understand what matters most to patients and support the process of deliberation.

Decisions should be influenced by an exploration of preferences. Ask questions. Encourage a dialogue. Allow for pauses and silence. Listen carefully. Reflect back what is said. Confirm what you hear.

Be patientKnow that informed patients have to spend time to consider their goals and

concerns. It might not happen in one visit.

You will not always be “right”Patients are different from each other and their provider. Patients’ decisions may

surprise you and be based on priorities you do not share. Respect every decision.

When there is no right or wrong, every answer is correct

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The basic application of shared decision making is for situations when there is no “best” solution. The right answer is what best reflects the patient’s priorities and

values. It is also OK to decide not to decide.

Make it a habitIntegrate shared decision making into routine care as part of existing workflow. Check

for and resolve operational conflicts with existing systems, priorities, targets and incentives.

BE HAPPYIt is important to develop a positive attitude about involving

patients in decisions.

Say Thank YouBased on Glyn Elwyn, PhD et al. “Shared Decision Making: A Model for

Clinical Practice. Journal” J Gen Intern Med 27(10):1361-7, 2012.

ONE MORE THING YOU LEARNED IN KINDERGARTENDon’t forget to wash your hands!