This type of interaction with your patients is beneficial in at least four areas. It is an ethical practice in that it treats the patient as an autonomous decision maker; it is educational in that it improves the patient’s knowledge of their condition, their options, and helps create a more realistic situation in which they can make their decisions with, hopefully, less mental and emotional conflict; it is utilitarian in that it recognizes that the best choice in any situation has to involve the patient’s personal preferences; and it can improve the interpersonal relationship between practitioner and patient, promoting patient trust and possibly enhancing their confidence.
Informed or shared decisions cannot be abandoned in favor of the informed consent process as it is practiced by many clinicians. Informed consent is a legal doctrine which requires that clinicians disclose required medical information and patients consent to or decline of the treatment; this consent or refusal is formalized with the patient’s (or patient representative’s) signature. The key factor in the informed consent process is the information dialogue, not the signature. Many clinicians have viewed the informed consent process as a quick conversation followed by a signature obtained on an appropriately worded form. This cursory approach to the informed consent process assures routine filings of informed consent claims in court.
Shared and informed decisions are intended to bring the patient into the process at whatever level they are comfortable (and able); changing these decisions to an informed consent only adds a level of paperwork to the process. Informed consent should remain necessary for procedures and other specific treatments, as determined by your practice and/or the facilities you are allied with. Appropriate informed consent must include shared decision-making dialogues, to the best of the patient or patient representative’s ability. That is what makes them truly “informed”.
Then how can you best incorporate these decision processes into your clinician/patient dialogue? It may first be appropriate to categorize the types of decisions that you ask your patients to make.
û Basic decisions such as recommending a laboratory test may only require a brief description of the test, the decision to be made (whether to have it, where to have it, etc.) and a request for the patient’s preference.
û Intermediate decisions such as recommending a new medication would require a little more dialogue about the medication (what it is for, how it acts, its side effects, etc.) and its alternatives (other medications, available alternative therapies, and the possible outcome of not taking the medication at all); once again, you would elicit the patient’s feedback in the form of questions or a decision.
û Complex decisions such as procedures, of course, require the most detailed interactive discussion and often become part of the informed consent process; that is, the discussion may end with a signed consent or refusal form.
Understanding these three levels of decisions can help each clinician evaluate the nature of patient decisions made routinely in their office and the frequency with which each level of decision is made. An approach can be tailored to address the practice’s needs to upgrade and/or change current practices. For example, practices which are very busy and have a great deal of basic level decision-making requirements may consider involving supporting clinical staff in patient education and discussions.
Clinicians who are required to do more intermediate and complex decision discussions with their patients may find that decision aids are helpful in some situations. These aids can be pamphlets, videotapes, web-based tools, and other unbiased material which can augment the information that the clinician has provided. In 1999 O’Conner, et al. published their research which showed that these tools could be effective in helping patients make decisions on their treatment when they were faced with a multitude of choices in a very difficult situation.