Annals of Long Term Care

The approach to decision making in patient care has increasingly emphasized the need to involve the patient in the decision-making process, using such rubrics as shared decision making and patient-centered decision making. The practical difficulties of achieving this goal have often received less attention. Shared decision making involves significant time costs, and, in at least some cases, the time required to make a shared decision about a proposed intervention may well exceed the amount of time required to actually make the intervention. Respect for patient autonomy can often be achieved by means other than shared decision making.

The issue of shared decision making has often arisen in the context of making decisions about screening tests. Screening tests are usually not emergent, so there is generally ample time to involve the patient in the decision-making process. Shared decision making has been discussed in the context of breast cancer screening,1 noting a lack of clarity about what information is to be shared. It has been speculated that electronic mail between patient and physician can facilitate shared decision making.2

It has been argued that the decision-making process necessitates an interaction with a patient that goes well beyond describing the risks and benefits of a proposed procedure to the patient, and requires that the clinician inquire about and understand the patient’s objectives in terms of his or her individualized life situation.3 In a parallel trend, as clinical guidelines have been promulgated to deal with a variety of complex decisions about patient care, such guidelines, in many cases, do not make specific recommendations, and instead indicate that clinicians should discuss the issue with their patients. The core values being served by this process are not always made explicit, but typically embrace two different goals. The first goal is respecting patient autonomy by following the course that is chosen by the patient. The second goal is practicing beneficence by following the course that produces the best outcome. The weight of these two goals may vary considerably in the particular clinical context.

There is, however, a fair amount of complexity about how best to translate these notions into practice. It has been argued, for example, that shared decision making is different from informed consent; some situations call for both informed consent and shared decision making, while other situations may require only one of these tasks.4 At one extreme, where the single best clinical course is clear, the patient is primarily being asked to give assent to the one best option, such as accepting antibiotic therapy for a bacterial pneumonia. In such situations, in fact, the patient may not even be asked to consent specifically to receipt of antibiotics, but consent will be taken from their general implicit or explicit consent to receive medical care and treatment.

The other extreme is manifested by a situation where the clinical decision is more closely balanced, either because the evidence is approximately equal for choice A versus choice B, or because the evidence is too poor to make any strong recommendation. This is often a situation where some professional groups may recommend one or the other course of action, but where other groups may only state that the physician should discuss the matter with his or her patient. A recent report from the U.S. Preventive Services Task Force, for example, looked at the question of screening for family and intimate partner violence, and concluded that it “could not determine the balance between the benefits and harms of screening….”5

As mentioned, the time needed to make a shared decision about a proposed intervention can exceed the time needed to make the intervention.