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To share or not to share

When is shared decision making the best option?

Guylène Thériault, Roland Grad, James A. Dickinson, Pascale Breault, Harminder Singh, Neil R. Bell and Olga Szafran
Canadian Family Physician May 2020; 66 (5) 327-331;

Article Figures & Data

Figures

  • Figure 1.
    Figure 1.

    Three-step model of shared decision making

    Data from Elwyn et al.5

  • Figure 2.
    Figure 2.

    Determining if SDM is the right approach: Tables 1 and 2 offer examples.

    SDM—shared decision making.

  • Figure 3.
    Figure 3.

    Approach for when patients’ requests seem unreasonable

    Inspired by a tool in progress from the Canadian Task Force on Preventive Health Care. Used with permission.

Tables

  • Table 1.

    When SDM should be considered

    CARE OPTIONS*CATEGORIESEXAMPLES
    There are at least 2 medically valid options with a balance between benefits and harms

    • If the recommendation is in favour of action, SDM should precede ordering the test or treatment

    • Mammography in women 50–74 y10

    • Screening for abdominal aortic aneurysm in men 65–80 y11

    • Statins for primary prevention of CVD in people at moderate risk

    Many weak or conditional recommendations12

    • If the recommendation is against action, SDM is useful when the patient wants to know more about the option

    • PSA screening in men 55–70 y13

    • Mammography in women in their 40s10

    In specific circumstances even if the balance between benefit and harms is usually not in equipoise

    • The balance between benefits and risks is different for a particular patient

    • A potentially lifesaving surgery in a patient with multiple comorbidities in whom potential harms are important

    Some strong recommendations in favour of action12

    • A patient who expresses the desire to discuss a specific recommendation

    • Colon cancer screening in adults 60–74 y14

    • CVD—cardiovascular disease, PSA—prostate-specific antigen, SDM—shared decision making.

    • ↵* When there is a decision to be made and the patient can collaborate.

  • Table 2.

    When SDM should probably not be considered

    SITUATION*EXAMPLES
    There is no decision to be made

    • There is no valid indication for a diagnostic or therapeutic maneuver (eg, you should not offer imaging in patients with acute low back pain and no red flags)

    • There is a clear urgency to act in a patient for whom benefits clearly outweigh possible harms (eg, unstablechest pain with elevated cardiac enzymes in a 50-year-old man in otherwise good health)

    • There is only one therapeutic option and the option of doing nothing would be detrimental (eg, reduction and immobilization of a fracture)

    • The patient has already clearly expressed he or she does not want an intervention

    The patient cannot collaborate in the process

    • Unable to participate in the decision† (eg, dementia)

    • Emotional overload (eg, at the time we announce a life-changing diagnosis)

    • Under the effect of substances that can alter judgment

    • Emotional crisis (eg, suicidal)

    The balance between benefits and harms is not in equipoise

    • Most strong recommendations in favour12 (eg, screening for hypertension in middle-aged people15)

    • Strong recommendation against12(eg, screening for dementia16; screening for thyroid dysfunction in nonpregnant adults17)

    • Some weak or conditional recommendations in favour12(eg, screening for tobacco smoking in children and adolescents18)

    • SDM—shared decision making.

    • ↵* Sharing information is always helpful and should be part of practice. Each clinical situation is different. Obtaining consent should not be confused with SDM.

    • ↵† At times, SDM can be used with families or alternate decision makers rather than with patients themselves.19

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To share or not to share
Guylène Thériault, Roland Grad, James A. Dickinson, Pascale Breault, Harminder Singh, Neil R. Bell, Olga Szafran
Canadian Family Physician May 2020, 66 (5) 327-331;
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