To share or not to share

We generally agree with issues raised by Thériault et al. (1 )in their article in terms of the importance of thinking about when shared decision making (SDM) is of greatest value. As a matter of fact, the first step of SDM involves talking about the decision to be made (2). However, we disagree with the concept that equipoise is a prerequisite to establishing a SDM conversation, or at least as how equipoise was defined in this article for the following reasons:

a) Clinicians may consider that a strong recommendation or grade A recommendation (this may vary as there are many systems for grading recommendations co-exist) to do something (e.g. starting a medication) may impede a SDM conversation since there is no equipoise. Nevertheless, methods for incorporating patients preferences in recommendations were recently developed (3) and they are not widely implemented. Considering that patients may value outcomes differently, the net balance of interventions are highly preference-sensitive (4). And even if a strong recommendation includes the preferences of the general population, what happens if the preference of our individual patients diverges from the majority?

b) We understand that SDM may be inadequate when there is a strong suggestion that harms outweigh the benefits, which is highlighted in the article example of the use of antibiotics for an upper respiratory tract infection in which benefits are negligible and harms (including antibiotic resistance) are important. Even so, there is evidence that interventions that enhance SDM may reduce the inadequate use of antibiotics (5). Maybe in these scenarios, could it be that eliciting preferences in the SDM conversation help make a better decision?

c) SDM intends to share the best evidence with the patient, including evidence about the consequences of doing nothing (6). That option will always be valid if we respect the autonomy of a well-informed patient and their right to refuse practices (7). This is why we believe that more often than not, there are at least two options to consider (doing or not doing something) where SDM could be a suitable approach for involving patients in decisions.

d) The statement “Some patients want a test or treatment where the recommendation is strongly against it or will refuse an intervention where the benefits clearly seem to outweigh the harms” (1) is in itself neglecting the idea that well-informed patients may refuse an intervention because they make a different judgement about the net benefit than the judgement made by his/her physician or clinical practice guideline. The example of the consideration of colon cancer screening in elderly but fit individuals paradoxically considers that patient preferences can reverse a recommendation against a potentially harmful practice, why couldn’t this happen conversely (i.e. a 50-year-old healthy individual that does not want to undergo screening)?

This does not imply that practices that offer net harm should be validated but considering the long tradition of paternalistic communication models in the medical practice and the slow and little uptake of SDM, we believe that SDM should be the rule, not the exception, especially considering the balance of benefits and harms. SDM aims at combining the best medical evidence with patients’ values and preferences. Deciding whether to use or not to use SDM only based on a biomedical component such as the level of guidelines recommendations seems an incomplete approach to patient-centred care.

References

1. Thériault G, Grad R, Dickinson JA, et al. To share or not to share. Can Fam Physician. 2020;66(5):327-331.
2. Elwyn G, Durand MA, Song J, et al. A three-talk model for shared decision making: multistage consultation process. BMJ. 2017;359. doi:10.1136/bmj.j4891
3. Zhang Y, Coello PA, Brożek J, et al. Using patient values and preferences to inform the importance of health outcomes in practice guideline development following the GRADE approach. Health Qual Life Outcomes. 2017;15(1):1-10.
4. Alper BS, Oettgen P, Kunnamo I, et al. Defining certainty of net benefit: a GRADE concept paper. BMJ Open. 2019;9(6):e027445.
5. Coxeter P, Del Mar CB, McGregor L, Beller EM, Hoffmann TC. Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care. Cochrane Database Syst Rev. 2015;(11):CD010907.
6. Légaré F, Shemilt M, Stacey D. Can shared decision making increase the uptake of evidence in clinical practice? Frontline Gastroenterol. 2011;2(3):176-181.
7. Health Care Consent Act, 1996. SO 1996, c 2, Sched A. July 2014. https://www.ontario.ca/laws/view. Accessed May 21, 2020.