Intended for healthcare professionals


Importance of clarifying patients’ desired role in shared decision making to match their level of engagement with their preferences

BMJ 2013; 347 doi: (Published 02 December 2013) Cite this as: BMJ 2013;347:f7066
  1. Mary C Politi, assistant professor1,
  2. Don S Dizon, director, oncology sexual health clinic23,
  3. Dominick L Frosch, fellow456,
  4. Marie D Kuzemchak, research assistant7,
  5. Anne M Stiggelbout, professor8
  1. 1Department of Surgery, Division of Public Health Sciences, Washington University in St Louis School of Medicine, 660 South Euclid Avenue, Campus Box 8100, St Louis, MO 63112, USA
  2. 2Gillette Center for Gynecologic Oncology, Massachusetts General Hospital Cancer Center, Boston, MA, USA
  3. 3Department of Medicine, Harvard Medical School, Boston, MA, USA
  4. 4Patient Care Program, Gordon and Betty Moore Foundation, Palo Alto, CA, USA
  5. 5Department of Medicine, University of California, Los Angeles
  6. 6 Palo Alto Medical Foundation Research Institute, Palo Alto
  7. 7Department of Surgery, Division of Public Health Sciences, Washington University in St Louis School of Medicine
  8. 8Department of Medical Decision Making, Leiden University Medical Centre, Leiden, Netherlands
  1. Correspondence to: M C Politi mpoliti{at}

We should not assume that certain groups of patients don’t want to or can’t participate in decisions about their healthcare, say Mary Politi and colleagues, and they offer advice on how to determine how much patients want to be involved

Many clinicians now recognise that shared decision making can have an important role in patient care. However, in some circumstances, clinicians may assume that patients such as those with limited health literacy or low education, and older adults do not want to participate in treatment decisions and prefer physician led models of care.1 2 3 4 5 Evidence has shown that these patient characteristics are not consistent predictors of how involved patients want to be in making decisions.1 6 7 8 We discuss factors that can contribute to this misconception and the importance of clarifying how involved a patient chooses to be during decision making. We also provide recommendations about how to assess patients’ desired role in shared decision making.

From theory to practice

Shared decision making is a process during which clinicians and patients collaborate to make health decisions, considering both the best available evidence and patients’ preferences.9 It is particularly appropriate for preference sensitive decisions in which there are several options available and evidence does not point to a clear best choice, such as when choosing surgery for early stage breast cancer. It is also appropriate when patients must make difficult trade-offs between benefits and harms, such as when choosing whether to have adjuvant chemotherapy. Patients are encouraged to take an active role in their healthcare by communicating their preferences to clinicians and sharing information that influences their decision.10 11 Clinicians support patients through this process by communicating evidence and its uncertainty in understandable terms, helping patients clarify and construct preferences, and providing opportunities for patients to …

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