Shared decision making is the progressive way of making medical decisions and is a collaborative process between the physician and the patient, weighing the choices in an informed manner.
Some medical decisions are straightforward, and do require informed consent, but not necessarily a value judgment. E.g. if an appendix is inflamed and needs to be removed, it is a straightforward recommendation. Bacterial infections need to be treated with antibiotics, hypertension with medications; glaucoma needs eye drops or surgery. Some decisions are based on “value judgment”, where the benefit of the treatment is weighed against the cost. The perceived cost to the physician may be quite different from the perceived cost to the patient. This discrepancy has been established by many studies. Recommendations are often based on the value judgment of the treating physician.
Especially in the realm of Cancer, the decisions are not so straightforward. In other cultures, and in previous times, decisions were much more paternalistic (the choice of gender is deliberate, as most physicians were male), and sometimes, elderly patients were “sheltered” from the harsh facts.
Patients are now better informed, and do their own research. The NCCN guidelines give direction to what are the medical facts. But undergoing treatment for a 2% recurrence benefit at the cost of 6% risk of permanent damage of some nature requires a much more nuanced discussion. The decision will be different depending on life stage and personal choices.
One of our children was diagnosed with a blood condition at a very early age. We did our own research and were well equipped to evaluate the data, which did not give clear guidelines. After a couple of unsuccessful treatments, we had the choice to continue on with stronger treatments or not to do so. With both parents being medically and scientifically literate, we came to our own decision, and we decided observation was a more suitable option. Fortunately, the treating consultants at The Children’s Hospital in Boston were supportive of our decision. I did do a curbside consultation with someone at another institution where I worked, who came to an entirely different recommendation. This did cause us some consternation, whether we were making the right choice. We reviewed the data, and were happy with our original decision. If we had been referred to Institution #2, we may have been advised to follow a different course.
Many patients are not equipped to make these choices, and often defer to the physician. Our discussions often end with the question, “what would you do?” That question cannot be answered without inserting our own value judgment. That answer needs to be both nuanced and honest. An ideal outcome is when both physician and patient are satisfied with the decision.
We did not ask our child’s doctor what they would do, as we needed to live with our decision. We were happy they were comfortable with it as well.
Ref: Medical Facts versus Value Judgments — Toward Preference-Sensitive Guidelines Peter A. Ubel, M.D. :N Engl J Med 2015; 372:2475-2477June 25, 2015DOI: 10.1056/NEJMp1504245