Shared Decision-Making in Everyday Practice

Shared decisions are not delegated decisions

Shared decision-making is sometimes misunderstood as handing the decision to the patient.

That is not the goal.

The clinician still contributes medical expertise: diagnosis, prognosis, evidence, likely benefits, harms, uncertainty and professional recommendation.

The patient contributes knowledge that the clinician cannot supply: goals, fears, prior experiences, practical constraints, acceptable burdens and the outcomes that matter most in daily life.

A good decision uses both.

First, make it clear that there is a decision

Patients cannot participate in a choice they do not know exists.

A consultation may move quickly from diagnosis to recommendation:

“I think we should start medication X.”

That may be clinically reasonable, but if more than one reasonable option exists, the patient may hear that the decision has already been made.

A simple choice-awareness statement can change the conversation:

“There are two reasonable ways we could approach this, and which one fits best depends partly on what matters most to you.”

Not every clinical situation has several options. Sometimes the medically appropriate course is narrow or urgent.

Shared decision-making does not require pretending that every option is equally good.

It requires being honest about where genuine choice exists.

Compare options in a way that can be used

When presenting options, organise information around the comparison the patient needs to make.

For each reasonable option, consider:

• likely benefit;
• important harms or side effects;
• treatment burden;
• what happens if no treatment or no change is chosen, when that is a relevant option;
• uncertainty;
• reversibility;
• and what would make the option more or less suitable.

Avoid presenting one option in vivid detail and the alternative in a dismissive sentence.

The wording should not silently decide the choice before the patient has entered it.

Ask what matters before assuming what matters

Two patients with the same diagnosis can reasonably make different choices.

One person may prioritise the greatest possible reduction in future risk.

Another may prioritise avoiding fatigue that would interfere with work or caring responsibilities.

Another may be willing to accept treatment burden for a small potential benefit because the feared outcome matters enormously to them.

Useful questions include:

• “What matters most to you when you think about these options?”
• “Which downside worries you most?”
• “What would make this treatment difficult to live with?”
• “Is there an outcome you especially want to preserve or avoid?”

The answers are clinical information.

A recommendation can still be appropriate

Shared decision-making does not require the clinician to become neutral when they have a professional view.

It can be helpful to say:

“Given what you have told me matters most to you, I would lean toward option A because…”

That is different from:

“This is what we are doing.”

The first makes the reasoning visible and keeps room for the patient's priorities.

The second closes the decision before collaboration has occurred.

Patients differ in how much responsibility they want

Some patients want to analyse every option.

Others want a clear recommendation.

Some say:

“Doctor, you decide.”

That preference can itself be valid.

But it is worth checking what the statement means.

Does the patient genuinely prefer to delegate?

Or do they believe there is no real choice?

Or are they overwhelmed by information?

A useful response is:

“I’m happy to give you my recommendation. Before I do, is there anything especially important to you that I should take into account?”

A patient may ask the clinician to take a stronger role in recommending an option. The patient’s preferences and informed consent, or the applicable decision-making process when capacity is in question, still matter; asking for guidance does not by itself transfer legal decision-making authority.

Use teach-back for the decision, not only the facts

Understanding options is part of informed choice.

After explaining, avoid relying on:

“Does that make sense?”

Instead:

“Just so I know I explained the choices clearly, can you tell me how you see the difference between the two options?”

If the answer shows that one option was misunderstood, repair the explanation before asking for a decision.

Do not force immediacy when time exists

Some decisions need to be made now.

Many do not.

When clinically safe, tell the patient how much time they have.

A patient who receives difficult information and is then asked to make a preference-sensitive decision immediately may not be able to use the information well.

Questions such as:

• “Do I need to decide today?”
• “What would change if I waited a week?”
• “Can I discuss this with my family and come back to it?”

can be legitimate parts of shared decision-making.

Decisions can be revisited

A decision is not always permanent.

Trials, review points and changing circumstances can make a plan revisable.

For example:

“We can try [the agreed option] for [a clinically appropriate period] and review whether the benefits and burdens make it worth continuing for you.”

That can make uncertainty more manageable and reduce the sense that choosing means being trapped.

Caregivers can support the decision when the patient wants that

Family members, friends and caregivers may help a patient remember information, articulate priorities, or explain practical realities that affect a plan.

Their involvement should be invited according to the patient's wishes and the clinical context.

A caregiver can contribute.

They should not automatically become the decision-maker simply because they are present or highly involved.

A compact sequence

A practical shared-decision conversation can be remembered as:

Name the choice.

Compare the reasonable options.

Ask what matters.

Give a recommendation when appropriate.

Check understanding.

Agree what happens next.

This is close to the logic of AHRQ's SHARE Approach: seek participation, help compare options, assess values and preferences, reach a decision together, and evaluate the decision.

The central idea

Shared decision-making is not a ritual phrase at the end of a consultation.

It is a way of making three things visible at the same time:

the evidence, the clinician's reasoning, and the patient's priorities.

When those remain hidden from one another, decisions can look agreed while remaining poorly understood.

When they are made explicit, even a difficult choice becomes more genuinely shared.

Selected evidence and guidance

Agency for Healthcare Research and Quality. The SHARE Approach: Shared Decisionmaking Tools and Training.

Agency for Healthcare Research and Quality. The SHARE Approach — Putting Shared Decisionmaking Into Practice: A User's Guide for Clinical Teams.

National Institute for Health and Care Excellence (NICE). Shared decision making. NICE guideline NG197.

National Institute for Health and Care Excellence (NICE). Patient experience in adult NHS services. Clinical guideline CG138.