September 6, 2019

Purposeful SDM: Our new model of shared decision making

By Kirsten Fleming

There are many situations in which patients and clinicians need to and are making decisions together, arguably these are all instances of Shared Decision Making (SDM). The ways that patients and clinicians make decisions should change according to the problem that is the reason why decisions are being made. For example, how patients and clinicians choose whether or not to take statins to potentially reduce 10-year risk of heart attack may be different from how management decisions are made for a patient living with multiple chronic conditions who is experiencing multiple detrimental life changes. In the first instance patient and clinician might use a weighing approach to weigh the pros and cons of known alternatives (to take or not statins), while in the second they might use a problem-solving approach to uncover possible solutions and judge how they would work in the patient’s life.

In a paper published in the current issue of Patient Education and Counseling, we present the Purposeful SDM model. Purposeful SDM distinguishes different kinds of situations where patients and clinicians need to work out what to do, and different SDM methods for addressing these problems. The model suggests that there is no one way to do SDM, rather we can think of SDM as a range of methods that vary according the problem that the patient is experiencing. I.e. SDM changes according to its purpose.

Kinds of situations that require patients/family and their clinicians to make decisions together and pertinent methods of SDM.

Purposeful SDM extends the predominant focus in SDM research, practice, training, and promotion on the need to involve patients in decision making. The model draws attention to the problem that is the reason why patients and clinicians are involved in making decisions in the first place and the appropriate method of addressing these problems together. The Purposeful SDM model may help explain why many clinicians don’t see current models of SDM as being relevant to the problems that they are dealing with in their practice.

We believe that Purposeful SDM has important implications for what SDM interventions, such as decision aids, should be designed to do and what should be measured when evaluating SDM. Current measures are mostly intended for situations where SDM is used to choose between alternatives. This is only one of the situations and methods that Purposeful SDM describes.

Purposeful SDM: A problem-based approach to caring for patients with shared decision making is available through open access until October 15, 2019.

Authors: Ian G. Hargraves, Victor M. Montori, Juan P. Brito, Marleen Kunneman, Kevin Shaw, Christina LaVecchia, Michael Wilson, Laura Walker, Bjorg Thorsteinsdottir

Download the Purposeful SDM poster presented at ISDM 2019.

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I love the focus on the need to think flexibly based on the situation – the concept that there is no right way that patients and clinicians “should” do SDM given the variety of situations that can arise in care and given that the needs of the patient can vary based on the patient, an individual with unique aspects, distinct from the diagnosis/diagnoses they may be faced with. With SDM, it seems clear that clinicians and patients can both learn together how to put the unique needs of the patient first across a variety of situations. This seems to really lend itself to personalized medicine and the concept that people can share the same disease(s), but because of the unique features that give rise to an individual, treatment benefits from focusing ultimately on the patient as opposed to solely the disease(s) in question.

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