Shared clinical decision making. A phrase I hear myself saying regularly; a concept I encourage, a principle I endorse, the backbone of my clinical practice. Or so I like to think. But in the last few weeks a couple of events have led me to question my principles, and as I write this I still haven’t really worked out what I now understand of this phrase; whether I have ever really understood the concept at all. And the more I think about this the more it unsettles me.
I’ve written before about decision fatigue; the mental exhaustion that comes from a day of constant decision making, and how by the end of these days even the simplest of life’s decisions; what to have for dinner or what I want to drink, seem impossible to contemplate.
Decision making in clinical practice is constant. Which analgesia would be best for the patient in front of me? Does this E.C.G. show anything concerning that needs immediate action? Does this patient with an ankle injury need an X-ray? What ceiling of care is appropriate for my patient in the resuscitation room? Is it safe to send this patient home?
Sometimes clinical decision making in medicine is black and white; the right course is clear and the path laid out before both patient and clinician. Often a protocol exists that is peer reviewed, generic, and even if not risk free is still considered to be the right course of action. Little ‘thought’ is needed; the response almost an autopilot reaction. If x condition is diagnosed then you need to do y and z. If the E.C.G. shows ST elevation in a specific pattern then the next step is clear and rehearsed. If the patient’s ankle is tender in certain areas an x-ray is ordered. Simple. That’s just the way it is; but should it be? How often do we stop and think how our patients feel about these decisions; decisions we are making about them. Decisions that seem easy to us are often far from easy for our patients and their relatives. I wonder how often we acknowledge this, take the time to explain our thought process and by doing so really involve our patients, and their families, in the decisions we are making. In the last month I’ve spent quite a lot of time working in the paediatric area of our A&E department. I’ve seen multiple children with head injuries; minor knocks and bangs presenting in a variety of ways and with varying degrees of severity. These cases for me are generally easy to deal with and take up little of my cerebral ‘band width’. Clear guidance exists that I have been using clinically for a number of years. Pattern recognition has been built up. The concerning cases are concerning for a reason. I know fairly quickly on assessing these kids which need a head scan, which need a period of observation and re-evaluation and which can be discharged straight home with a sticker and an advice sheet. Easy.
But the Mum and Dad of the toddler jumping around the room in front of me, or maybe still a little subdued and pale, probably don’t have the benefit of the years of pattern recognition I have been fortunate to have built up in looking after kids with head injuries. They came because they have concerns about their child. If I was to just dismiss these concerns, or even acknowledge them but with seemingly scripted platitudes then I would feel I had failed them. So I try to take time; to share my thought processes, to discuss the ways in which I am making the decisions I am making and the guidance I am using to do so. I’m still not sure this is really shared decision making; after all, I’m still the one making the decision, but I like to think I’m sharing the ‘how’ and the ‘why’ behind my thinking. And I like to think that, having shared my thoughts, if the parents seem unhappy or disagree then I would stop and re-evaluate my decision. I always caution strongly against ignoring parental instinct,making sure to advise trainees at induction that to do so is perilous!
The other day I made a decision about a patient that to me seemed to be the obvious choice. As with the decisions about head injured kids, it didn’t require much band width, and I relayed my decision to my patient. I thought that was the end of it. But then my patient, an elderly lady well into to her ninth decade, turned her face towards me and questioned me; Questioned the decision I had unilaterally made about her care, her life, without any discussion as to the risks and benefits; without any attempt at the shared decision making principles I felt were embedded in my clinical practice. This made me stop and think, to question my values and beliefs and the way I work. Was this concept of shared decision making just a nice sounding idea, a phrase that looks good when written and spoken aloud but bearslittle resemblance to reality. How many decisions about my patients am I making each day without properly engaging in open and honest discussions, and how often do these just pass me by because my patients accept my decisions without question. Is this necessarily a bad thing? Are there some decisions that are right and proper for me just to make and take responsibility for; after all, isn’t that what my training has been for? Is it indeed wrong for me to potentially burden my patients with a feeling of responsibility for decisions about their care?
Often the clinical picture in front of us is not that clear cut, with multiple confounding factors and personal circumstances playing their part.Sometimes the decisions we need to make are difficult -really difficult. This ismore so when decisions need to be made without all the information that is needed immediately to hand, or when tired, or stressed, or feeling overwhelmed, or when we feel torn in two directions, or when we feel personally involved. Maybe this is when the concept of shared decision making should really be focused and encouraged. But then I think that maybe in these really difficult situations it is even more burdensomefor me to encourage patients, or their families, to help me make these difficult decisions. And what happens if we don’t agree on the next steps and course of action that should be taken? I found myself on the other side of one of these ‘shared decision making’ conversations not that long ago in an outpatient clinic I attended as a patient. On the other side of the desk was a competent, but relatively inexperienced doctor in training, and the consultation was professional, not rushed and conducted with empathy. But there was a difficult decision to make; should I or should I not be listed for a surgical procedure? As a doctor myself this is a decision I had been weighing up in my mind for a few weeks already, and was really struggling to answer. What I needed, as the patient that day, was guidance; a professional opinion as to what the next steps should be. I know from the language used that the doctor was really doing her best in trying to involve me in the decision making process, encouraging me to voice my opinion and actively listening to what I had to say. She had clearly explained the risks and benefits of surgery. But I didn’t know what I wanted. I needed someone with specialist knowledge to guide me or, even better, make the decision for me. To take that responsibility.
Working in acute care, some of the most challenging, but also some of the most rewarding shared decision making conversations I have had relate to ceilings of care and resuscitation statuses. Reflecting now I wonder if the reason I find these conversations both difficult and fulfillingin equal measure is that often I am more prepared in these clinical scenarios to take control, to be the professional,to exert authority; to spell out clearly what I really think is the right course of action. Yes, I still take time to share my thought processes, to spend time listening and discussing concerns and ideas. But fundamentally, the decision to fill in a DNAR form, or not, is mine to make; one that I need to take full responsibility for, as an advocate for my patient. This weighs heavily on my shoulders. But I am trying to make the burden of the decision mine to bear,and not burdensome on my patient or their family.
So, I’m still unsure. Exactly what is shared clinical decision making?
Is it a good thing or a bad thing? Or both?
Is it a myth? An excuse for clinicians to shirk the burden of difficult decisions onto their patients? Or a way for patients to exert control?
Or is it all of the above?
For me the answer is still well and truly uncertain.