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