Many problems. Many forms of shared decision making (SDM)
Purposeful SDM is a problem-based perspective of SDM. From this perspective:
- SDM is foremost a method of care
- The purpose of SDM is to create care that best responds medically, practically, emotionally, and existentially to each patient’s problems
- How patients and clinicians work together to figure out how to respond depends on the problematic situation that they’re working through
- Because there are many kinds of problems, many kinds of SDM are used to care for patients
This perspective grew out of KER Unit researchers observing thousands of real-world patient-clinician encounters over more than 15 years and a developing sense that what they saw only partially aligned with models of SDM.
In 2019, Ian Hargraves PhD led his KER Unit colleagues in giving voice to the Purposeful SDM perspective and describing four different kinds of SDM, addressing four kinds of patient problems, and each with its own distinct collaborative deliberative method.
Examples of different ways shared decisions are made in different situations
Mode 1: Weighing treatment options Patient and clinician meet to discuss adding a second-line medication for type 2 diabetes. The clinician invites the patient to join in selecting the new medication and presents options. Together they weigh pros, cons, preferences and decide to start a GLP-1 receptor antagonist.
Mode 2: Negotiating inter or intrapersonal conflict A patient is conflicted because he has resisted taking an antidepressant, viewing it as a sign of weakness. One the other hand, he now sees that his worsening depression is harming his relationship with his wife. He talks with his clinician. As they negotiate this internal conflict, the patient finds a new perspective as he recognizes that he doesn’t think of others who take medicines as weak. As a result, they are able to decide to start an antidepressant.
Mode 3: Problem-solving multiple competing demands A patient with formerly well-controlled diabetes, hypertension and other chronic conditions is struggling to maintain her health now that her spouse is undergoing treatment for cancer and she has assumed the caregiver role. As cooking smells nauseated her spouse, the patient can no longer cook at home and hence eats at cheap fast-food restaurants. The burden of medical bills means that the patient cannot afford her current insulin regimen. Stress is affecting her sleep and work. Together, patient and clinician problem solve. They create and configure possible options—perhaps Meals-on-Wheels, eating at a friend’s house, alternate caregivers, counselling, or changing to a more affordable insulin type. Collaboratively, they develop a plan.
Mode 4: Developing existential insight A primary care clinician sits with an elderly woman receiving dialysis for end-stage renal disease and her daughter. As they talk, it tearfully emerges how life-diminishing dialysis is becoming, and they all develop an understanding that it might be time to step away from dialysis and consider palliative approaches. They ultimately decide to adopt these approaches.
The evolution of this thinking is perhaps best represented by this sequence of papers. In this page, we will be adding these as we work to explore this conceptual framework empirically.
SDM is not about information but conversations, not about empowerment or choice, but to respond well to patient problems – commentary on the challenges of SDM as usually understood
Hargraves I, Montori VM. Decision aids, empowerment, and shared decision
making. BMJ. 2014 Sep 25;349:g5811. doi: 10.1136/bmj.g5811. PMID: 25255800. Full text
Hargraves I, LeBlanc A, Shah ND, Montori VM. Shared Decision Making: The
Need For Patient-Clinician Conversation, Not Just Information. Health Aff
(Millwood). 2016 Apr;35(4):627-9. doi: 10.1377/hlthaff.2015.1354. PMID:
27044962. Full text
Hargraves I, Kunneman M, Brito JP, Montori VM. Caring with evidence based
medicine. BMJ. 2016 Jun 28;353:i3530. doi: 10.1136/bmj.i3530. PMID: 27353312. Full text
Hargraves IG, Montori VM. Aligning Care With Patient Values and Priorities.
JAMA Intern Med. 2019 Dec 1;179(12):1697-1698. doi:
10.1001/jamainternmed.2019.4230. PMID: 31589248. Full text
Barton JL, Kunneman M, Hargraves I, LeBlanc A, Brito JP, Scholl I, Montori
VM. Envisioning Shared Decision Making: A Reflection for the Next Decade. MDM
Policy Pract. 2020 Oct 20;5(2):2381468320963781. doi: 10.1177/2381468320963781.
PMID: 35187247; PMCID: PMC8855401. Full text
Purposeful Shared Decision Making
Hargraves IG, Montori VM, Brito JP, Kunneman M, Shaw K, LaVecchia C, Wilson
M, Walker L, Thorsteinsdottir B. Purposeful SDM: A problem-based approach to
caring for patients with shared decision making. Patient Educ Couns. 2019
Oct;102(10):1786-1792. doi: 10.1016/j.pec.2019.07.020. Epub 2019 Jul 19. PMID:
31353170; PMCID: PMC6717012. Full text
Relating a problem-based perspective to an established involvement-based SDM approach
Hargraves IG, Fournier AK, Montori VM, Bierman AS. Generalized shared
decision making approaches and patient problems. Adapting AHRQ’s SHARE Approach
for Purposeful SDM. Patient Educ Couns. 2020 Oct;103(10):2192-2199. doi:
10.1016/j.pec.2020.06.022. Epub 2020 Jun 27. PMID: 32636085; PMCID: PMC8142549. Full text
How well do current measures of SDM capture all forms of Purposeful SDM
Hartasanchez SA, Grande SW, Montori VM, Kunneman M, Brito JP, McCarthy S,
Hargraves IG. Shared decision making process measures and patient problems.
Patient Educ Couns. 2022 Jul;105(7):2457-2465. doi: 10.1016/j.pec.2021.11.001.
Epub 2021 Nov 8. PMID: 34802881; PMCID: PMC9079183. Full text
SDM as a method of care (a guide for clinicians)
Montori VM, Ruissen MM, Hargraves IG, Brito JP, Kunneman M. Shared decision-
making as a method of care. BMJ Evid Based Med. 2022 Dec 2:bmjebm-2022-112068.
doi: 10.1136/bmjebm-2022-112068. Epub ahead of print. PMID: 36460328. Full text
Montori V, Kunneman M. Caring without boundaries: delimiting shared decision-making. BMJ Evidence-Based Medicine Published Online First: 15 December 2022. doi: 10.1136/bmjebm-2022-112184. Full text
Observations of Purposeful of SDM in practice
Montori VM, Ruissen MM, Branda ME, Hargraves IG, Kunneman M. Problem-based
shared decision making: The role of canonical SDM steps. Health Expect. 2022 Nov 29. doi: 10.1111/hex.13654. Epub ahead of print. PMID: 36448245. Full text