Confronting Evidence : Patient-Centred Care and the Case for Shared Decision-Making

In many clinical scenarios there are two or more appropriate therapeutic options. When these involve subjective trade-offs between potential benefits and harm, patients’ preferences should guide the intervention strategy. The preferences of fully-informed patients often diverge from clinicians. A response to this is shared decision-making, whereby clinicians use evidence to systematically inform patients of an intervention’s risks and benefits, and in turn patients’ preferences inform clinical decision-making. In practice, decision-making often fails to meet this standard. Shared decision-making is relevant for conditions such as stable coronary artery disease, benign enlargement of the prostate, end-of-life care, and the many small decisions of chronic disease management. There is evidence of improvement in patients’ understanding, sense of empowerment, and decision quality. Moreover, many trials reported a 20% reduction in major surgery in favour of conservative treatment, suggesting a potential for cost reductions, although demand tends to increase for some interventions. Implementation may involve “decision aids,” tools that objectively inform patients on the risks and benefits of diagnostic and treatment strategies. Caution is warranted to limit this to clinically appropriate contexts, and to avoid cognitive biases in decision-making. The generalizability of international evidence to Ireland is unclear. Considering its numerous potential benefits, it may be sensible to implement and carefully evaluate pilot projects of shared decision-making in Ireland