A new report from The King’s Fund in England explores shared medical decision-making. This concept is widely promoted as a critical component for expanding patient involvement in their health and health care. (Kings Fund Report) In the United States, England and other countries, patient-centered care is believed to result in better outcomes and potentially lower spending. Shared decision-making extends across the entire spectrum of care, from major surgical procedures to lifestyle changes. It requires physician training, elucidation of general patient values and preferences, education of a patient on choices and risks and ensuring that the patient’s wishes are consistently followed.
The report contains several suggestions to ensure greater use of shared decision-making, including creating a standard set of decision aids and a standard process for engaging in shared decision-making, identifying appropriate points for joint decisions in care pathways, more training for providers, better recording in medical records of both the process and outcome of shared decision-making, incorporation of joint decision-making into accreditation standards and incentives to ensure its use by providers. The benefits of wider use of the approach include greater patient comfort with decisions, less anxiety and often, choosing less invasive and risky procedures.
It is hard to find fault with the notion of shared decision-making. It needs to be understood as a patient responsibility as well as a provider’s. Patients should not be permitted to be passive in regard to their health and health care. But one difficulty with the concept is that a lot of health care expense is for patients who are effectively unable to make decisions, either because of mental or physical limitations. For example, dementia is becoming the largest single bucket of medical spending. As much attention needs to be paid to addressing issues of surrogate decision-making as to those made directly by patients. Research has shown that often surrogates don’t know the patient’s preferences and feel a tremendous burden in making decisions. Patients should anticipate this possibility early in life and create explicit guidance for potential surrogate decision-makers. We should anticipate continuing emphasis on shared decision-making and its incorporation into performance and value-based purchasing programs.