Two to Tango: Shared Decision Making

Often patients or their parents can place an expectation on our shoulders to always have a plan and answers as their physician. The shaking truth of the medical field is that this is not always possible. While the expectation is seen as a privilege by most physicians, it can also lead to significant stress and pressure. When asked specific questions that are either unanswerable or unknown at that time, a physician may find it difficult. Shared decision making is fundamental for patient care as an effective tool for a physician to use when addressing such situations with patients and their parents.

The idea of shared decision making is more recent in the field, compared to the centuries of the practice of medicine (Veatch). It is a hallmark in patient-centered care because it relies heavily on patient and/or parental input into treatment decisions. Glyn Ewlyn, et al. described a practical way to implement shared decision making using:

  • Choices: making sure that patients/parents know different, reasonable options are available to them,
  • Options: providing detailed information about all options, and
  • Decision talk: supporting and allowing for time for the patients/parents to deliberate over the available options.

While shared decision making is an important part of patient care, its use can be limited in some situations, such as in emergencies that require immediate action or conditions that require extensive use of medical knowledge to make a decision. Other limitations to shared decision making include inadequate health literacy and cultural differences in autonomy (Glyn Ewlyn et al). Even in these situations, using shared decision making as much as possible at the patient/parent’s level of understanding can help. It can be employed as a tool to help move forward in difficult situations, or even to create an open dialogue and invite parents to share their input. 

Even in pediatrics, we can involve our patients in shared decision making to empower them to actively participate in their own health. One small example includes asking them the form of medication they like (e.g.pill, liquid, or chewable) (Furman). Although we are not asking them what treatment plan they want, offering even a small choice can help empower them in their own healthcare. 

While shared decision making can be used in a positive way to forge a bond between parents and pediatricians, a one-sided relationship, whether on the parent or physician side, can be detrimental to this balance. With the advent of the internet, parents have numerous different resources to use as they deliberate their options. This should be supported and encouraged within reasonable limits by pediatricians. The balance lies within the decision talk portion of shared decision making. Pediatricians should listen to parent’s wishes and informed decisions, and parents should work with the pediatricians and trust them to make decisions for their child’s well-being. With unbalanced power on either side, friction and erosion of patients’ care can occur.

Many questions still exist as to how to best integrate and implement shared decision making from both the parent’s and the pediatrician’s role in a child’s medical care. By implementing these three steps into each patient encounter, both with a patient and their parents, pediatricians can create an optimal balance in unknown or difficult situations. 

Chelsea Burroughs, M.D.

References:

Elwyn, Glyn et al. “Shared decision making: a model for clinical practice.” Journal of general internal medicine vol. 27,10 (2012): 1361-7. doi:10.1007/s11606-012-2077-6

Furman, Lydia. “Shared Decision Making – Harnessing Trainee Enthusiasm.” American Academy of Pediatrics (2017). 

Veatch, Robert. “Models for Ethical Medicine in a Revolutionary Age.” The Hastings Center Report vol. 2, 3 (1972): pp 5-7. 

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