Donna Dubuc

By: Donna Dubuc
This Kindergarten Lesson is Conflict Free
I have no Conflict of Interest to disclose or report.
Basic principles
Values and beliefs of shared decision making
A seesaw has more than two
Shared decision making is used for preference sensitive situations, where there is no
clear cut answer about which treatment option is best (equipoise).
Look both ways before you cross the
Shared decision making is a two-way street. You must look at both sides before moving
forward. The provider identifies the medical problem and lays out reasonable options.
Patients identify and convey goals and concerns relevant to the decision.
You are not the boss of me
Shared decision making is based on the belief that individual selfdetermination should be encouraged. Clinicians support autonomy by building
good relationships and respecting patients’ competence and independence.
Sharing is caring
The responsibility for preference-sensitive decisions is shared through the
creation of a partnership. With their provider’s support, patients won’t feel
abandoned or like they have to decide on their own.
Using an Options Grid
Using a decision support tool in an exam room encounter
Take your turn but don’t go first
Before offering information to patients, ask what they already know, ask “Have
you read or heard anything about lung cancer screening?” Check for
understanding. Is the pre-existing knowledge accurate?
Don’t stare
In the exam room, when you offer a patient a decision aid allow for review
time. Busy yourself with another task such as clinical note taking or email while
the patient reads and considers the options.
Share your crayons
When asking a patient to review a list of options or a decision support tool, give
them a pen to make notes or circle the options they want to talk more about.
Do your homework
Know the options available to a patient and the risks and benefits of each.
Have decision support tools ready.
Write Neatly
When no existing decision tool exists, compile a list of options yourself.
Buddy up and “hold hands”
Sticking together as patient and provider has psychological, social, and
emotional factors that will influence deliberation dialogue. Glyn Elwyn breaks
down this dialogue into choice talk, option talk, and decision talk.
Routines are good
A three step model for routine SDM
by Glyn Elywn
Choice talk: Patients learn a choice
exists, and that their personal
preferences matter in making
that choice
Option talk: Patients learn about
treatment options in more detail to
understand the different
harms/benefits and consider the
outcomes. Providers check for
understanding .
Decision talk: Providers support
patients in the exploration of what
matters most to them. Providers elicit
a preference. Check for certainty.
Review decision.
Ask Permission
Before moving from choice or option talk into decision talk, ask permission.
“Shall we go on?” “Do you think you know how you feel about your options?”
“Do you feel ready to make a decision?”
Tell them what you know, not what
you believe
Offer an objective, unbiased presentation of options to consider. Review
the pros and cons of these options. Describe options in practical terms.
(+) and (-) = solution
Be clear about the pros and cons of different treatment options. Offer a neutral
presentation of benefits and harms. Use easy-to-understand examples of risk.
(Absolute instead of relative risk)
Don’t use your words, use theirs
Use plain language. Low literacy and numeracy are obstacles to shared
decision making. There are also cultural barriers. Make sure you meet people
where they are at to form a partnership for shared decision making.
Listen when someone is talking
It is essential to understand what matters most to patients and support the process of
deliberation. Decisions should be influenced by an exploration of preferences. Ask questions.
Encourage a dialogue. Allow for pauses and silence. Listen carefully. Reflect back what is said.
Confirm what you hear.
Be patient
Know that informed patients have to spend time to consider their goals and
concerns. It might not happen in one visit.
You will not always be “right”
Patients are different from each other and their provider. Patients’ decisions
may surprise you and be based on priorities you do not share.
Respect every decision.
When there is no right or wrong,
every answer is correct
The basic application of shared decision making is for situations when there is
no “best” solution. The right answer is what best reflects the patient’s priorities
and values. It is also OK to decide not to decide.
Make it a habit
Integrate shared decision making into routine care as part of existing workflow.
Check for and resolve operational conflicts with existing systems, priorities,
targets and incentives.
It is important to develop a positive attitude about involving
patients in decisions.
Say Thank You
Based on Glyn Elwyn, PhD et al. “Shared Decision Making: A Model for
Clinical Practice. Journal” J Gen Intern Med 27(10):1361-7, 2012.
Don’t forget to wash your hands!
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