Chapter 2: Shared Decision Making—the “Holy Grail” of Informed Consent? Implications for Surgical Practice

INTRODUCTION

• Informed consent is a process; the signed release is the documentation that the process took place

• Shared decision-making should take into account the patient’s interests and concerns in their care as part of the informed consent process

• Always actively assess the patient’s understanding (of the content) and capacity (to make informed decisions)

BACKGROUND

Surgeons are legally obligated to complete the informed consent process prior to proceeding with a recommended surgery. It is becoming increasingly apparent that this process is also an opportunity to engage patients in their own healthcare decision making. The many benefits to this level of patient engagement include improved safety and compliance. In this chapter, we explain how decisions are made in health care. We examine a case study typical to surgery using the shared decision making process and review how the process benefits both patients and surgeons.

THE THREE APPROACHES TO SURGICAL DECISION MAKING

Historically, physicians approach their patients using one of three approaches: paternalistic, informational, or shared decision making (SDM).¹ These general approaches are not mutually exclusive. Depending on the circumstances, aspects of each approach may be incorporated into any treatment decision (see Table 2.1).

1. Paternalistic. Traditionally, medical decisions are made using this approach in which the physician determines which treatment should be undertaken and the patient accedes. Although there may be circumstances where this approach is necessary (eg, in emergencies), this approach can be risky because it may leave the patient uninformed. This approach also assumes an alignment of physician and patient preferences without explicitly determining if alignment exists. In addition, this approach may lead to patient dissatisfaction if an unexpected outcome occurs. Paternalism has been associated with lower patient adherence with recommended treatment and less engagement in the recovery process. Patients experiencing unexpected outcomes after perceived paternalistic decisions are more likely to seek legal advice.

2. Informational. In this approach, the physician assumes a role of “information provider” and leaves all treatment decisions up to the patient. Providers using this approach make every effort to remain objective, and reveal only as much information as patients need to make their own decision. This model assumes that patients are capable of absorbing medical information and integrating this information with their own preferences and circumstances in order to make decisions. Research has shown, however, that although patients universally desire information about their condition and options for treatment, their ability to process this information and their desire to make a decision vary considerably.² If patients have a significant emotion associated with their disease or they are experiencing “information overload,” they may shut down or feel incapable of making a decision. Finally, it can ...