{"id":2909,"date":"2015-05-22T09:37:10","date_gmt":"2015-05-22T08:37:10","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=2909"},"modified":"2015-05-22T09:37:10","modified_gmt":"2015-05-22T08:37:10","slug":"re-engineering-shared-decision-making","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2015\/05\/22\/re-engineering-shared-decision-making\/","title":{"rendered":"Re-Engineering Shared Decision-Making"},"content":{"rendered":"<p><strong><em>Guest post by\u00a0Muriel R. Gillick<\/em><\/strong><\/p>\n<p>When physician-law-professor, Jay Katz, published <em>The Silent World of Doctor and Patient<\/em> in 1984, shortly after I completed my medical residency, I felt he was speaking directly to me. \u00a0He was telling me what kind of physician to be\u00a0&#8211; not\u00a0the old-school, paternalistic physician who told patients what treatment was best, but rather a physician who participated in shared decision-making. \u00a0For the next few\u00a0decades, I aspired to cultivate patient autonomy by engaging my patients in deciding, with my input, how to approach their medical care.<\/p>\n<p>There were substantial obstacles. \u00a0There were cognitive barriers to shared decision-making, as Twerksy and Kahneman brilliantly revealed: whether you spoke of a 60% success rate or a 40% failure rate seemed to matter, even though they were mathematically equivalent, as did the patient or doctor\u2019s most recent experiences. \u00a0Then there was the problem of innumeracy, of patients lacking the tools needed to understand probabilities. \u00a0There was the challenge of limited health literacy, or inadequate knowledge of the vocabulary and concepts of health and disease. \u00a0And there were cultural biases, because patients of various ethnic backgrounds had a world view radically different from the physician\u2019s biomedical model. \u00a0But each of those barriers could be surmounted with careful choice of words, better graphs, or cultural sensitivity. \u00a0I continued to strive to be a physician who practiced shared decision-making.<\/p>\n<p>But more and more often, I found that patients wanted me to make a treatment recommendation. \u00a0It wasn\u2019t that they didn\u2019t want to be involved in the decision-making, or that they couldn\u2019t understand medical jargon, or that they didn\u2019t know what odds ratios were &#8211; although sometimes those were issues. The main issue was that the purpose of the prevailing model of shared decision-making was to figure out, when multiple treatment options existed, which one to choose. \u00a0It seemed to me that this focus on what was essentially a technical outcome was misplaced.<!--more--><\/p>\n<p>What if, instead, the objective of the dialogue between physician and patient was to ascertain the patient\u2019s goals of care? \u00a0Goals, after all, are the values-based part of decision-making; they are what is unique to a given patient. \u00a0But much of the decision-making literature has assumed that patients know their goals, and that goals follow directly and inevitably from one\u2019s culture or religious beliefs. \u00a0In fact, people\u2019s goals change depending on their position in the life cycle and on their overall health as well as on their background and personal philosophy. \u00a0Patients are often unclear on their goals and benefit from a conversation with their physician to elucidate their beliefs. \u00a0But once patients have articulated and prioritised their goals of care, it is a technical matter for the physician to figure out how to translate those goals into practice.<\/p>\n<p>\u201c<span style=\"text-decoration: underline\"><span style=\"color: #0000ff\"><a style=\"color: #0000ff;text-decoration: underline\" href=\"http:\/\/jme.bmj.com\/content\/early\/2015\/04\/29\/medethics-2014-102618.full.pdf\">Re-Engineering Shared Decision-Making<\/a><\/span><\/span>\u201d makes the case for this perspective. \u00a0I argue that the conceptual foundation of shared decision-making is strong, but implementation is problematic. \u00a0If after thirty years of tweaking, we haven\u2019t figured out how to go about the process in a way that the vast majority of patients and physicians find acceptable, then maybe it\u2019s time to re-examine the approach. \u00a0Instead of adding more fixes &#8211; better language, better framing, better graphics\u00a0&#8211; we should\u00a0focus on goals of care instead of treatment options. \u00a0Fundamentally, this shifts the process from one that addresses physician\u2019s needs (to know what to do) to one that addresses patient\u2019s needs (to know how to achieve their interests).<\/p>\n<p>Instead of dwelling on whether a patient wants to be intubated for respiratory failure, or to undergo dialysis for kidney failure, patients should lay out their goals: do they want to live longer, no matter what the consequences to their ability to function or their ability to interact with others? \u00a0Or is what they prize most their independence, their ability to talk and walk and think and listen, or whatever it is that gives them a sense of meaning and satisfaction in their lives? \u00a0Or is comfort what is most important to them, even if maximising comfort entails forgoing potentially life-prolonging but assuredly painful procedures? \u00a0Depending on the answer, the physician tells the patient what treatment makes most sense.<\/p>\n<p>Surely only the most extreme libertarians would argue that promoting patient self-determination requires that patients decide for themselves which antibiotic should be used to treat their pneumonia or which anti-hypertensive they should take for their high blood pressure. \u00a0So why are we so intent on asking patients to choose between medical and surgical management of coronary artery disease or between chemotherapy and radiation therapy for cancer? \u00a0Truly promoting autonomy requires a physician to recommend treatment in accordance with a patient\u2019s values and goals. \u00a0My job\u00a0and that\u00a0of physicians everywhere who try to incorporate the principles of ethical decision-making into practice\u00a0&#8211; is to\u00a0suggest what treatment makes most sense for this particular patient, in light of this patient\u2019s values and goals.<\/p>\n<p><em>Read the full paper <span style=\"text-decoration: underline\"><span style=\"color: #0000ff;text-decoration: underline\"><a href=\"http:\/\/jme.bmj.com\/content\/early\/2015\/04\/29\/medethics-2014-102618.full.pdf\">here<\/a><\/span><\/span>.<\/em><!--TrendMD v2.4.8--><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Guest post by\u00a0Muriel R. Gillick When physician-law-professor, Jay Katz, published The Silent World of Doctor and Patient in 1984, shortly after I completed my medical residency, I felt he was speaking directly to me. \u00a0He was telling me what kind of physician to be\u00a0&#8211; not\u00a0the old-school, paternalistic physician who told patients what treatment was best, [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2015\/05\/22\/re-engineering-shared-decision-making\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[968,2153,443,576],"tags":[],"class_list":["post-2909","post","type-post","status-publish","format-standard","hentry","category-clinical-ethics","category-guest-post","category-jme","category-the-art-of-medicine"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Re-Engineering Shared Decision-Making - Journal of Medical Ethics blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2015\/05\/22\/re-engineering-shared-decision-making\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Re-Engineering Shared Decision-Making - Journal of Medical Ethics blog\" \/>\n<meta property=\"og:description\" content=\"Guest post by\u00a0Muriel R. Gillick When physician-law-professor, Jay Katz, published The Silent World of Doctor and Patient in 1984, shortly after I completed my medical residency, I felt he was speaking directly to me. \u00a0He was telling me what kind of physician to be\u00a0&#8211; not\u00a0the old-school, paternalistic physician who told patients what treatment was best, [...]Read More...\" \/>\n<meta property=\"og:url\" content=\"https:\/\/blogs.bmj.com\/medical-ethics\/2015\/05\/22\/re-engineering-shared-decision-making\/\" \/>\n<meta property=\"og:site_name\" content=\"Journal of Medical Ethics blog\" \/>\n<meta property=\"article:published_time\" content=\"2015-05-22T08:37:10+00:00\" \/>\n<meta name=\"author\" content=\"BMJ\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"BMJ\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"4 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2015\\\/05\\\/22\\\/re-engineering-shared-decision-making\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2015\\\/05\\\/22\\\/re-engineering-shared-decision-making\\\/\"},\"author\":{\"name\":\"BMJ\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/#\\\/schema\\\/person\\\/ba3da426ed20e8f1d933ca367d8216fe\"},\"headline\":\"Re-Engineering Shared Decision-Making\",\"datePublished\":\"2015-05-22T08:37:10+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2015\\\/05\\\/22\\\/re-engineering-shared-decision-making\\\/\"},\"wordCount\":836,\"commentCount\":0,\"publisher\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/#organization\"},\"articleSection\":[\"clinical ethics\",\"Guest Post\",\"JME\",\"The Art of Medicine\"],\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"CommentAction\",\"name\":\"Comment\",\"target\":[\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2015\\\/05\\\/22\\\/re-engineering-shared-decision-making\\\/#respond\"]}]},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2015\\\/05\\\/22\\\/re-engineering-shared-decision-making\\\/\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2015\\\/05\\\/22\\\/re-engineering-shared-decision-making\\\/\",\"name\":\"Re-Engineering Shared Decision-Making - 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