Shared Decision Making: The Limits

Shared decision-making (SDM) ensures that individuals are supported to make decisions that are right for them. It is a collaborative process through which a clinician supports a patient to reach a decision about their treatment.

In the Sri Lankan culture, the majority of patients take a paternalistic view in looking towards the option that is recommended by the doctor.

However, even in Sri Lanka, with access to health information using the Internet, the younger, educated and even the elderly may want more clarifications and ask more questions about treatment options they have. Therefore, SDM will be increasingly important even in Sri Lankan settings and should be more applied widely, perhaps more widely than many health professionals think possible.

It’s not routine for us to discuss limitations to a a well accepted process. we use. Therefore it s important to know that SDM has its limitations where wider interests can override the priority given to individual preferences.

Limits on SDM will occur when:

  • Wider interests override individual wishes
  • Evidence of benefit is insufficient or absent
  • Lowered decisional capacity is present
  • Profound existential uncertainty exists.

Wider interests override individual wishes

When the safety of the wider population is a concern, SDM can be limited. some examples are: (a) requests for antibiotics in a self limiting viral infections such as URTI (b) vaccine hesitancy -where for the wider benefit for the population, taking a pro-vaccine view that may be different from the individual patient

Evidence of benefit is insufficient or absent.

Due to strong personal belief when a patient requests a test or a drug, may be augmented by media hype and you know that is no evidence for the beneficial effects and may have harmful effects

Lowered decisional capacity is present

Although an obvious reason, proxies (most often children) may represent the persons view. Even for the ‘normal’ child who is under stress because of the parents illness, when we present the facts it must be in very simple terms. Its usual for health professional to overestimate the capacity of the individual.

Profound existential uncertainty

An example is for a incurable lung cancer there may be novel treatment that may delay the progression (without having an effect of the end result) but with painful side effects and huge cost. Patient in these circumstances of uncertainty may trust the opinion of the doctor.

Many interventions in medicine do not have strong evidence of effectiveness, and states that more research to determine clinical effectiveness. In addition, evidence from randomised trials cannot be easily applied to individuals with different characteristics, and such evidence definitely lacks information about the context, priorities and preferences of individuals. The need for SDM is increasing given the increasing complexity of therapeutic potential coupled with comorbidity.

However even with the increasing importance of SDM, are situations that limit when decisions can, or should, be shared. Clinicians have a duty of care to the people they advise, and, in our view, to involve them carefully in decisions: they also have obligations to their profession, to society and to science. It helps to be clear when those other obligations take precedence and therefore limit the use of SDM.

Elwyn et al. – 2022 – The limits of shared decision making





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