Shared Decision-Making

Shared decision-making (SDM) is an approach in which clinicians and patients work together to make health decisions, combining the best available evidence with the patient's values, preferences, and circumstances. It is most relevant for preference-sensitive decisions, where more than one reasonable option exists and the right choice depends on what matters to the patient.

Definition

Shared decision-making is a collaborative process in which clinician and patient jointly deliberate over options, exchanging information about evidence and about the patient's values, to reach a mutually agreed decision.

Scope

This topic covers the concept and models of shared decision-making, the role of decision aids, and the evidence on its effects on patient knowledge and decisional conflict. It is treated as a communication and counseling competency within primary care, framed for reference and education rather than as clinical instruction.

Core questions

• What distinguishes shared decision-making from informed choice and from paternalistic decision-making?
• Which decisions are most preference-sensitive and therefore best suited to SDM?
• How do decision aids affect knowledge, decisional conflict, and choice?
• What organizational and communication barriers limit SDM in practice?

Key concepts

• Preference-sensitive decisions
• Option talk and decision talk
• Decision aids
• Decisional conflict
• Equipoise
• Patient-centered care

Key theories

Charles three-stage framework

Charles, Gafni, and Whelan characterized shared decision-making by contrasting it with paternalistic and informed models, requiring at least two participants who both share information and both take steps to build consensus on the preferred treatment.

Three-talk model

Elwyn and colleagues described SDM as a sequence of team talk, option talk, and decision talk, providing a practical model for clinical encounters.

Mechanisms

Shared decision-making operates by making options and their trade-offs explicit, eliciting the patient's informed preferences, and integrating both into a deliberated choice. Decision aids support this by presenting probabilities and outcomes in accessible formats and by helping patients clarify values. A Cochrane review of decision aids reports improved knowledge, more accurate risk perceptions, and reduced decisional conflict for people facing treatment or screening decisions.

Clinical relevance

SDM is presented as a model for preference-sensitive decisions in primary and specialty care; it describes how clinicians and patients can deliberate together. This entry characterizes the approach and its evidence base and does not prescribe how any specific decision should be made for an individual.

Evidence & guidelines

The strongest evidence concerns decision aids: a Cochrane systematic review finds they increase knowledge and reduce decisional conflict, with more variable effects on which option is chosen and on downstream outcomes. SDM is endorsed in many patient-centered care frameworks, though implementation in routine practice remains incomplete.

History

Shared decision-making emerged in the 1980s and 1990s as a counterpoint to both paternalism and pure informed choice. Charles, Gafni, and Whelan's 1997 conceptual analysis gave the field a working definition, and later work on decision aids and the three-talk model translated the concept into practical clinical tools and evidence.

Debates

Does shared decision-making improve clinical outcomes or mainly the decision process?

Decision aids reliably improve knowledge and reduce decisional conflict, but effects on hard clinical outcomes and on actual choices are smaller and more variable, so the primary benefit may lie in decision quality rather than outcome change.

Key figures

• Cathy Charles
• Amiram Gafni
• Glyn Elwyn
• Michael Barry
• Dawn Stacey

Seminal works

• charles-1997
• elwyn-2012
• stacey-2017

Frequently asked questions

How is shared decision-making different from informed consent?

Informed consent is a process and standard for authorizing a specific intervention; shared decision-making is a broader collaborative process of choosing among options, which may precede and inform consent but is not limited to it.

When is shared decision-making most appropriate?

It is most appropriate for preference-sensitive decisions, where there is genuine equipoise between reasonable options and the best choice depends on the patient's values and priorities.