Shared decision-making as a method of care

To cite: Montori VM, Ruissen MM, Hargraves IG, et al. BMJ EvidenceBased Medicine Epub ahead of print: [please include Day Month Year]. doi:10.1136/ bmjebm-2022-112068 © Author(s) (or their employer(s)) 2022. Reuse permitted under CC BYNC. No commercial reuse. See rights and permissions. Published by BMJ. Care happens in interaction between the patient and the clinician, in conversation where the patient and clinician uncover or develop a shared understanding of the problematic situation of the patient and identify, discover, or invent ways to make that situation better, given what each patient prioritises and seeks. Thus, to get the right care for each patient, patient and clinician collaborate and deliberate together to figure out what to do. Shared decisionmaking (SDM) has been traditionally defined as a collaborative approach by which, in partnership with their clinician, patients are encouraged to think about the available care options and the likely benefits and harms of each, to communicate their preferences, and help select the best course of action that fits these. This definition is limited to situations in which the problem and the pertinent options to address it can be defined a priori, and the main task is to find the option that best matches the patient’s preferences. Thought in this way, SDM may involve distributing decision aids for patients to come prepared for the consultation and using tools to elicit and document patient preferences. This practice has been proposed as an expression of patientcentred care, a way of involving patients, an antidote to medical paternalism, and as a way to promote highvalue care. But anytime, a patient and clinician figure out together what to do about the patient’s situation, they are doing SDM. Although there are multiple models and accounts of what SDM is and is not, 4 5 in practice, SDM starts by determining the nature of the problematic situation the patient is experiencing. This often requires considering insights that only the patient and perhaps their family can share, insights about both the patient’s biology and biography. Then clinicians must mobilise their competence and compassion to work with patients to develop a sensible care plan that responds to the situation as understood, is based on relevant evidence, attends to the emotional aspects of the problem, and is feasible and sustainable for the patient. 7 Therefore, we believe SDM is not ‘another thing clinicians must do’, that is, to help patients select the best evidencebased option given their preferences, but that it is a method of care, as central to the clinician’s art as history taking, the physical examination, the selection and interpretation of diagnostic tests, and patient education and counselling. The practical method to implement SDM as a method of care proposed below seeks to make as few demands as possible of both patients, who are taxed by the demands of selfcare and of navigating a labyrinthine healthcare system while responding to the demands of living, and of clinicians, who, despite some evidence of the contrary, often express their worries about SDM adding time to their encounters.