NICE Shared Decision Making Guidance, June 2021
Questions this post addresses: What can be done to implement shared decision making in routine clinical practice?
Shared decision making, particularly about consequential decisions that involve preference-based tradeoffs, is widely considered a key component of good health care. It is also widely recognized that shared decision making is not carried out nearly as often as it should be.
To improve this situation in the UK, in 2021 the National Institute for Health and Care Excellence (NICE) issued a Guidance containing recommendations to foster shared decision making. Like all NICE recommendations, the Guidance is based on published evidence supplemented with the opinions of the guideline committee members when limited trial data are available.
The Guidance defined shared decision making as “a collaborative process that involves a person and their healthcare professional working together to reach a joint decision about care.
The Guidance includes the following recommendations:
A. Top level organizational support and training for both patients and staff is essential to successfully implement shared decision making:
The Guideline Committee was aware that implementing shared decision-making is a complex task that needs to be led from the highest levels of the organisation, supporting practitioners to facilitate shared decision-making in every clinical encounter.
B. The Guidance recommends steps to implement shared decision making before, during, and after a consultation. Prior to the visit, patients should be alerted that there will be an important decision discussed, given relevant information, and encouraged to bring a friend or relative with them to their appointment. After the visit, patients should be given a summary of the discussion and the decision(s) that were made, links to high quality sources of information, and the name of whom they should contact if they have additional questions.
During the visit, providers are encouraged to establish a collaborative atmosphere and:
• Discuss risks, benefits, and consequences in the context of each person’s life and what matters to them.
• Personalise information on risks, benefits, and consequences as much as possible.
• Make it clear to people how the information they are providing applies to that person personally and how much uncertainty is associated with it.
• Have a good understanding of the information and how to apply and explain it clearly.
C. To help practitioners accomplish these tasks, the Guidance includes updated guidelines for communicating information about risks and benefits. They include providing quantitative data whenever possible rather than using qualitative descriptors such as “rare” or “uncommon”, and presenting it using a mixture of pictures and numbers. The data should focus on absolute as opposed to relative risks, and be framed in both positive and negative frames using a constant denominator.
D. The use of patient decision aids is endorsed but only if they are relevant to both the decision being made and the clinical context, up to date, and reflect “evidence-based best practice”.
The full Guidance document is freely available on the Internet at: https://www.nice.org.uk/guidance/ng197. The information above is based on short summary of the Guidance recommendations published by Carmona and colleagues. 1 Unfortunately it appears to be behind the journal paywall.
Comments and Musings
This Guidance clearly recognizes that high level organizational support is essential for clinical implementation of shared decision making. A key question then is what would make shared decision making an important enough aim for an organization to be worth the costs of implementing it. My impression is that little attention has paid to the organizational benefits of routine shared decision making. Wouldn’t it be terrific if someone could demonstrate that the benefits of routine shared decision making more than outweigh the costs involved?
I think it is unfortunate that although the Guidance conceives shared decision making as a collaborative decision making process involving both patient and practitioner, there is no mention of how the provider should engage in the decision making process other than providing information and assessing the patient’s decision-related preferences.
While endorsing the idea of patient decision aids, the Guidance does so with a number of caveats. Particularly important to me are the cautions that decision aids should be relevant not only to the decision being made but also the individual patient and clinical circumstances. I wonder how many decision aids currently available would meet these criteria.
Finally, the Guidance does not refer to any particular shared decision making model, though it seems quite consistent with the one proposed by Charles and colleagues. Does the model adopted affect the likelihood of implementation? My guess is that it probably does. Whether it should or not is an interesting question.
Carmona C, Crutwell J, Burnham M, Polak L. Shared decision-making: summary of NICE guidance BMJ 2021; 373 :n1430 doi:10.1136/bmj.n1430.