Shared Decision-Making Model

Although health care professionals are legally obligated to inform patients about their treatment and are required to ask for informed consent (President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, 1982), there are no legal restrictions regulating the manner in which this is carried out. The paternalistic approach involves having the health care professional decide, either independently or in conjunction with other health care professionals, what is the best treatment or intervention for the patient, informing the patient of that decision, and convincing the patient to follow through with accepting that decision. The complete opposite to this is the informed approach, in which the patient is provided with information and is enabled to make a decision. Shared decision-making, on the other hand, is an approach that is considered to be somewhere in between these two extremes. Expert information is not only offered by health care professionals to the patient but also the patient shares personal information (such as patient values) with the health care professional. When the health care professional and the patient deliberate on screening, diagnostic, therapeutic, or palliative interventions (Charles et al., 2003), the decision-making process is then viewed as a shared experience (Friesen- Storms et al., 2015).

Shared decision-making is widely recommended by many professionals as a way to support patients in making health care choices (Charles et al., 1997; Elwyn et al., 2012, 1999; Stiggelbout et al., 2012). In shared decision-making, health providers together with their patients share their knowledge, values, and preferences about health care choices and explore beneficial solutions. In this manner, final decisions about treatment and management will be more compatible with patient preferences. Shared decision-making is fundamental to patient-centred care, increases patients’ and professionals’ satisfaction, improves quality of life and patient outcomes, and also creates a stronger doctor–patient relationship (Weston, 2001).

Elwyn and colleagues (2012) developed a model of shared decision-making (Figure 3), in which three phases are distinguished as follows: ‘choice talk’, involving exchanging information and announcing that a decision must be taken; ‘option talk’, involving negotiating various treatment options, including benefits and harms; and ‘decision talk’, involving

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reaching a decision together based on a patient’s informed preferences (Elwyn et al., 2012; van de Pol et al., 2016). However, many suggested refinements to this 2012 model could be made to achieve a wider understanding and conceptualisation of shared decision-making. For example, the terms ‘choice talk’ and ‘option talk’ were considered as too similar. Others found it odd that the model did not touch upon risk communication or goal-setting (Reuben and Tinetti, 2012; van de Pol et al., 2016; Vermunt et al., 2018), particularly as the idea of coproduction (Batalden et al., 2016) gains ground, and reported too little emphasis on exploring patient preferences and contexts. These critiques also reflected developments in the shared decision-making literature. One study argued that illness brings on a state of uncertainty, vulnerability, and lack of power (Gulbrandsen et al., 2016). In their study, these researchers promoted the use of shared decision-making to enhance or restore a patient’s ‘autonomous capacity’, pay more attention to the emotional and relational dimensions of care, and emphasize the need to support the patient during a process of decision-making (Gulbrandsen et al., 2016).

Figure 3. Three-talk model of shared decision-making. Taken from (Elwyn et al., 2017).

The most commonly acknowledged conceptualization of shared decision-making is that of Charles et al., who identified the main features of shared decision-making. These features are

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as follows: involvement of both the patient and physician, a sharing of information by both parties, both parties taking steps to construct a consensus about the preferred treatment, and achieving an agreement about which treatment to implement, respectively (Charles et al., 1999; Elwyn et al., 2016). Grol and colleagues described a general model for the implementation of guidelines interventions in which a systematic approach as well as good preparation and planning are central issues (Grol et al., 2013). Implementation strategies can be focused at the individual care provider (e.g., knowledge, attitude, motivation to change, personal characteristics), at the social setting (e.g., other care providers and patients), and/or at the organisational and financial system levels. Not surprisingly, the guidelines can have a major impact on the success of implementation (Grol et al., 1998; van der Weijden et al., 2010).

Satterfield et al. (2009) emphasized the importance of integrating shared decision-making with EBP because the former involves the individual patient’s values and preferences into the process of decision-making. Yet, despite this attention, there is a lack of clear guidance about how to accomplish SDM in routine practice. In this thesis, the Shared Decision-Making Model is used to inform the understanding of how a patient’s values and preferences can be integrated into decision-making within the EBP framework for people with type 2 diabetes (see Appendix B).

It is necessary to note that skills of SDM are unlikely to be developed, let alone demonstrated, unless the clinician agrees with the underpinning ethical principles. At its core, SDM rests on accepting the idea that individual self-determination is a desirable goal and that clinicians need to support their patients to achieve this goal wherever possible. Self-determination theory is a broad-based theory of human motivation that emphasizes the extent to which behaviours are relatively autonomous (i.e., the extent to which behaviours originate from the self) as opposed to relatively controlled (i.e., the extent to which behaviours are pressured or coerces by external forces) (Patrick and Williams, 2012). It explicitly identifies autonomy as a human need that, when supported, facilitates more autonomous forms of behavioural regulation. Self-determination theory research accordingly focuses on patients’ perceptions and views of providers’ support for their autonomy (Vansteenkiste and Sheldon, 2006). Self- determination theory suggests that autonomously regulated individuals experience greater life satisfaction and, in the long-term, show greater persistence and adherence (Williams et

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al., 2009). Support for self-determination theory comes from studies demonstrating that people who are autonomously self-regulated tend to show higher levels of satisfaction, confidence, and trust (Deci et al., 1989); greater initiative and persistence (Ryan and Deci, 2019); better physical and psychological health (Langer and Rodin, 1976); and better adherence to medication regimens (Williams et al., 1998) than do people who feel controlled by external agents or internal pressure (Patrick & Williams, 2012).

Self-determination theory posits that people are oriented towards achieving good physical and psychological health (Ryan and Deci, 2000). Additionally, self-determination theory posits that people are more likely to adopt healthy behaviours or to terminate unhealthy ones when their basic psychological needs for autonomy, competence, and relatedness are promoted. For patients with type 2 diabetes, the concepts of autonomous self-regulation and perceived competence for healthy behaviour engagement are of central importance in the initiation and maintenance of healthy behaviours (e.g., taking medication as directed to improve glucose control) or to the change of unhealthy ones (e.g., smoking cessation). People feel autonomous when they regulate their behaviour volitionally in a way in which they experience choice and reflective self-endorsement. To illustrate, patients with diabetes would feel autonomous if they took their medication as directed because doing so was personally significant to them rather than if they did it because of pressure from either health care providers or family members (Williams et al., 2009). Supplementary to this, people feel competent when they are capable and effective in attaining desired outcomes. Most importantly, previous research using self-determination theory found that people are more likely to feel competent to achieve desired outcomes when they feel autonomous (Williams et al., 2004, 1998; Williams and Deci, 1996). Therefore, patients are more likely to establish the skills needed to manage their health once they volitionally sustain those behaviours (Williams et al., 2009).

Williams et al. (2009) applied the self-determination theory to predict medication adherence, quality of life, and physiological outcomes among patients with type 2 diabetes. The results support those hypothesized relations and suggest that self-determination theory of health behaviours provides a useful framework for understanding quality of life and medication adherence among patients with diabetes.

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Self-determination in the context of shared decision-making does not mean that individuals are abandoned to make decisions alone (Quill et al., 1996). However, shared decision-making is the solution to this concern, not the cause of it (Elwyn et al., 2017). Done well, shared decision-making combines different types of expertise, both from the world of medicine as well as that from the patient’s personal lifeworld where priorities exist (Freeman et al., 2004). Shared decision-making recognizes the need to support autonomy by building good relationships, respecting both individual competence and interdependence on others. These are the key tenets of self-determination theory (Ryan and Deci, 2000). As discussed earlier, self-determination theory is concerned with individuals’ intrinsic tendencies to protect and preserve their wellbeing (Ryan and Deci, 2019). Therefore, as King and Moulton (2006) stated, these principles extend the concept of informed consent beyond that of a simple information transfer towards honouring informed preferences.

However, some health providers express doubts, believing that patients don’t want to be involved in decisions, lack the capacity or ability, or might make wrong decisions or worry that SDM is time-consuming and just not practical. Others claim that they are already adopting SDM into their day-to-day practice, though data from patient experience surveys indicate that this is generally not the case (Zikmund-Fisher et al., 2010).

Nevertheless, it is also important to note the challenges that clinicians might face when implementing SDM. For example, low health literacy could pose barriers to SDM, while some patients might come from cultural backgrounds that lack a tradition of people making autonomous decisions (Elwyn et al., 2016). Having said that, shared decision-making takes into account, among other things, the extent to which patients want to be involved in the decision-making process (Politi et al., 2013). It could be that patients want to be informed about options without necessarily wanting to hold the entire responsibility for making decisions; SDM accommodates this method of approaching decisions (Elwyn et al., 2016; Landmark et al., 2015).

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