Equipoise is preference sensitive

We generally agree with issues raised by Thériault et al¹ in their article in the May issue of Canadian Family Physician 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 an SDM conversation, or at least as how equipoise was defined in this article for the following reasons.

First, clinicians might consider that a strong recommendation or grade A recommendation (this might vary, as there are many systems for grading recommendations) to do something (eg, starting a medication) might impede an SDM conversation, as there is no equipoise. Nevertheless, methods for incorporating patient preferences in recommendations were recently developed³ and they are not widely implemented. Considering that patients might value outcomes differently, the net balance of interventions is highly preference sensitive.⁴ And even if a strong recommendation includes the preferences of the general population, what happens if the preferences of our individual patients diverge from these?

Second, we understand that SDM might 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 might reduce the inadequate use of antibiotics.⁵ In these scenarios, could it be that eliciting preferences in the SDM conversation helps make a better decision?

Third, 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 well-informed patients and their right to refuse practices.⁷ This is why we believe that more often than not there are at least 2 options (doing or not doing something) where SDM could be a suitable approach for involving patients in decisions.

Finally, 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 neglects the idea that well-informed patients might refuse an intervention because they make a different judgment about the net benefit than the judgment made by their physician or a 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 could this not happen conversely (ie, a 50-year-old healthy individual who 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 medical practice and the slow and scant uptake of SDM, we believe that SDM should be the rule, not the exception, especially considering the balance of benefits and harms. Shared decision making aims to combine the best medical evidence with patients’ values and preferences. Deciding whether to use SDM only based on a biomedical component, such as the level of guideline recommendations, seems an incomplete approach to patient-centred care.

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