Shared Decision-Making in Chronic Care

Tom G. Bartol, NP


February 10, 2015


Shared decision-making became popular in the 1990s as a form of involving and engaging patients in their healthcare. This literature review explores various theories of shared decision-making and how it can be useful for nurses working with patients with chronic diseases. It is not a "how to" for shared decision-making, but an exploration of various aspects and theories of shared decision-making.

Shared decision-making is not just giving more information to our patients, but a process that helps them to focus on key issues and evaluate relevant options for treatment.[3] It places patients at the center of their care, engaging them in using information to make decisions.

Healthcare has traditionally been a paternalistic practice. The healthcare provider has the information and makes the decision. This is often necessary in the acute/emergency care setting. When a trauma patient comes to the emergency department, the focus is on keeping that person alive, not on involving him or her in the decision-making process.

The literature acknowledges that shared decision-making is much more appropriate in the context of chronic disease care decisions.[4] Yet even in our current chronic care model, we can easily become focused on guidelines and evidence in a "cookbook approach," rather than one that incorporates the patients' desires. Diabetes, hypertension, hyperlipidemia, heart disease, obesity and many chronic conditions have guidelines for treatment that don't engage the patient or take into account the individual patient's goals, needs, and values.

When we bring our car to a mechanic, often more shared decision-making takes place than in the healthcare setting with our bodies, and our lives. We don't drop off our vehicle at the shop and pick it up later, fixed, without input into decisions based on cost, needs, goals and values. The mechanic assesses the condition of or car, contacts us with a report about what is wrong; provides an estimate of the cost to repair it; and discusses options, such as repairing it, looking for used parts, doing nothing, or replacing the car. A choice is then made—a choice that is often dependent on the relationship and trust we have with our mechanic, as well as the cost and our needs, goals, and values.

There are clearly differences between healthcare and car repair, but we may have something to learn from the decision-making process that we use in repairing and maintaining our vehicles. For patients with chronic disease, we often focus on normalizing blood glucose, cholesterol, blood pressure, or weight by simply adding medications—not engaging the patient in the process and discussing different ways in which these goals could be achieved. Does the patient want to add more medications, or would he or she prefer to try to achieve the goals through lifestyle changes? What are the risks and benefits of each? What are the patient's goals?

For many patients, when given lifestyle change as an option to avoid more medications or to reduce the medications they are currently taking, they are very motivated to make changes. If not offered the choice, they often assume that medication is the only option. If given a medication and told to make lifestyle changes, those changes don't occur, but when engaged in shared decision-making and given options and alternatives, they may be motivated to change.

We have clinical guidelines for screening and treatment, but do patients know what each means for their health? Does a patient know how much the risk is reduced for heart disease by taking a statin, or how much the risk of dying of breast cancer is reduced by having a mammogram? Do we, as healthcare professionals, know this information? If we want to engage patients, we need to do more than just follow guidelines; we need to learn and understand the information behind these guidelines so we can share it with our patients. Without information that is known and understood by the healthcare professional, shared decision-making really cannot take place.

Shared decision-making engages patients through sharing information and eliciting their input on the basis of the evidence, as well as their values, needs, and goals. Some patients may decline treatments, interventions, or medications because of their age, past experiences, or health condition, when we might traditionally recommend them. It takes more time and energy on the part of the healthcare professional because we need to understand the options, risks, and benefits of the various modalities, but the research shows that patients want to be more involved in the choices for their care.

Nurses have an opportunity to engage patients in shared decision-making. Through repeated contact with patients, nurses develop relationships with them over time, and can elicit their goals and values while sharing information to help them make shared choices about their healthcare.



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