Shared Decision-Making Frameworks

Shared decision-making (SDM) is a collaborative process in which clinician and patient deliberate together, combining the best available evidence with the patient's values and preferences to reach a choice. In genetic counseling, SDM frameworks complement the field's emphasis on autonomy, offering structured ways to support testing, reproductive, and management decisions when there is genuine choice and no single correct answer.

Definition

Shared decision-making is a model of clinical communication in which clinician and patient jointly deliberate over options, sharing information about evidence and about the patient's values and preferences, to arrive at a mutually agreed decision.

Scope

This topic covers the conceptual frameworks of shared decision-making and their relevance to genetic counseling: the defining features of SDM, influential process models such as the three-talk model, and how SDM relates to non-directiveness. It is a reference and educational overview of communication models, not guidance for making a specific clinical decision.

Core questions

• What defines a decision as genuinely 'shared' rather than directed or merely informed?
• What process steps do influential SDM models propose?
• How does shared decision-making relate to the genetic counseling principle of non-directiveness?
• When is shared decision-making most appropriate in genetic services?

Key concepts

• Option talk and decision talk
• Patient values and preferences
• Deliberation
• Decision support and decision aids
• Equipoise
• Relation to non-directiveness

Key theories

Charles two-way model of shared decision-making

An early conceptual framework defining shared decision-making as requiring at least two participants who both share information and both take part in deliberation and the decision, distinguishing it from paternalistic and purely informed models.

Three-talk model

A practice model that structures shared decision-making into team talk, option talk, and decision talk, supported by deliberation and decision support tools.

Mechanisms

In shared decision-making, the clinician conveys that a choice exists and that the patient's preferences matter, presents the reasonable options and their benefits and harms, supports deliberation, and then helps the patient reach and enact a decision. Charles and colleagues characterized SDM as requiring that both parties share information and both participate in the decision, distinguishing it from paternalistic and informed-choice models. Elwyn and colleagues operationalized this as the three-talk model—team talk, option talk, and decision talk—often aided by decision support tools that present options in a balanced way.

Clinical relevance

Shared decision-making frameworks describe how genuine choices in genetic services—such as whether to test, or among reproductive options—can be approached collaboratively while respecting patient autonomy. This entry explains the models for reference and education and does not direct any particular decision or recommend an option for an individual.

Evidence & guidelines

Shared decision-making is supported by a broad health-services literature and is endorsed in many clinical contexts; within genetics it is discussed as complementary to client-centered and reciprocal-engagement models. The Charles model and the Elwyn three-talk model are among the most cited conceptual references.

History

Shared decision-making was articulated in general medicine in the 1990s, with Charles and colleagues providing an influential definition that contrasted it with paternalistic and informed-choice models. Subsequent work, especially Elwyn and colleagues' three-talk model, translated the concept into practical steps and decision-support tools. Genetic counseling, already committed to autonomy through non-directiveness, increasingly drew on SDM frameworks to structure collaborative deliberation over testing and reproductive choices.

Debates

How does shared decision-making fit with non-directiveness?

Some see SDM as a natural extension of client-centered genetic counseling, while others note tension between actively deliberating with a patient and the traditional non-directive stance of not influencing the choice.

Key figures

• Cathy Charles
• Glyn Elwyn
• Amiram Gafni
• Patricia McCarthy Veach

Seminal works

• charles-1997
• elwyn-2012

Frequently asked questions

How is shared decision-making different from simply informing the patient?

In an informed-choice model the clinician supplies information and the patient decides alone, whereas in shared decision-making both parties exchange information and deliberate together to reach the decision.

Is shared decision-making compatible with non-directive genetic counseling?

They share a commitment to patient autonomy; SDM adds structured collaborative deliberation, though some commentators note a tension between actively deliberating with a patient and remaining strictly non-directive.