In the doctor’s office, words matter. The content of a conversation between doctor, patient and parent can change the course of treatment. Shared decision-making has emerged as the dominant model in medicine for these conversations. There is even evidence it can improve patient outcomes. But should doctors reconsider its constant use? Shared decision-making and its boundaries will be the subject of a discussion led by Dr. Douglas Opel at the 11th annual Pediatric Bioethics Conference, which is being held July 24-25 at the Bell Harbor International Conference Center in Seattle.
Opel, a faculty member at the Treuman Katz Center for Pediatric Bioethics at Seattle Children’s and a general pediatrician at Seattle Children’s, sat down with On the Pulse to discuss the concept of shared decision-making.
What is shared decision-making?
Shared decision-making is an approach to medical decisions that has roots in informed consent and the patient rights movement. It is meant to be a joint process of decision-making based on mutual respect and participation of the patient and the doctor. It represents a shift from a previous decision-making model where doctors made decisions independent of the patient’s preferences, a model called paternalism. Shared decision-making places a patient’s values and preferences front and center.
There is a lot about shared decision-making that is useful and valuable. It extends the principle of informed consent and improves patient involvement in decision-making. But that doesn’t mean it should be used indiscriminately. There are scenarios where shared decision-making is not the best course.
Can you give an example of when you think shared decision-making shouldn’t be used?
One scenario—a frequent one for a general pediatrician—might be the straightforward common cold. Parents often bring a child with fever, runny nose, or cough to see the doctor. Some parents expect antibiotic treatment. Most of the time, however, the child’s symptoms are caused by a virus and the treatment is supportive care with fluids and rest. Antibiotics are not indicated for treatment. When this is the case, doctors need not use shared decision-making.
Shared decision-making is appropriate when there is a true choice in the treatment. If there is only one treatment—supportive care in this case—there is no decision to share. Doctors should guide the conversation in such a way that promotes this one treatment.
So whether there are several treatment options to choose from seems to be important.
Yes, if there are two or more treatment options, shared decision-making is appropriate so that patient or parent preferences can help guide which treatment is used. But when there is only one medically-indicated treatment, shared decision-making is probably not helpful.
Identifying the boundaries of shared decision-making has become important because over the last decade, shared decision-making has become second nature and is increasingly patient-focused. It has become less about the joint process of decision-making and more patient-centric. While this has some benefits, it has also introduced problems.
For instance, it has minimized a doctor’s expertise and role in the relationship. Instead of the doctor integrating concrete medical evidence and making a recommendation with a patient’s values in mind, it has become more about the doctor simply giving patients information. I’d argue that this is a problem. We need to reorient shared decision-making so it is a joint process between doctor and patient. One way to do that is to identify what factors make shared decision-making appropriate and inappropriate.
How does shared decision-making fit into the field of bioethics?
Shared decision-making is about the interaction between doctor and patient. It forces us to think about attributes central to the doctor-patient relationship: patient values, patient autonomy, and a doctor’s obligations and role. How should each of these attributes manifest in the interaction? What conception of patient autonomy and the doctor role should dominate?
Also, one of the functions of bioethics is to challenge norms. As shared decision-making becomes the norm in medicine, it can be helpful to review its rationale and whether or not it is being used as intended. When we do this for shared decision-making, we find gaps in our understanding of when to use it and even what it means. By identifying and addressing these gaps, I think we can help shared decision-making become what it was intended to be all along: A process of mutual respect and participation for patients and doctors.
The 2015 Seattle Children’s Pediatric Bioethics Conference, The Delicate Triangle: Responsibilities and Challenges in the Provider-Patient-Parent Relationship, will take place July 24-25 at the Bell Harbor International Conference Center in Seattle. Click here for more information.