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Chapter 27: Decision Making and the Patient

Victor M. Montori; Glyn Elwyn; PJ Devereaux; Sharon E. Straus; R. Brian Haynes; Gordon Guyatt

Introduction

One of the 3 key principles of evidence-based medicine (EBM) is that the evidence alone is never sufficient to make a clinical decision (see Chapter 2, What Is Evidence-Based Medicine?). Clinicians require expertise in interpreting the patient dilemma (in its clinical, social, and economic contexts) and in identifying the body of evidence that bears on optimal patient treatment. These considerations, however, are not enough. Evidence-based medicine requires that clinical decisions be consistent with the informed values and preferences of the patient.

We use values and preferences as an overarching term that includes patients' perspectives, priorities, beliefs, expectations, values, and goals for health and life. We also use this phrase, more precisely, to mean the processes that individuals use in considering the potential benefits, harms, costs, and inconveniences of the management options in relation to one another.

Consideration of patient values and preferences often enables clinicians to understand the patient who declines lifesaving treatment and the patient who seeks active treatment even when, from a clinician's perspective, the hope of any gain is lost and palliation may seem a wiser path. Differences in values and preferences also may explain policy decisions and practice guidelines that, despite relying on the same evidence, differ across settings and contexts. Patient values and preferences become more crucial when confidence in the estimates of a beneficial effect is low and when the balance is close between important benefits and similarly important downsides.

What Approaches to Decision Making Are Available?

Box 27-1 summarizes decision-making approaches theoretically available to the clinician and patient facing an important decision.

BOX 27-1

Decision-Making Approaches

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BOX 27-1

Decision-Making Approaches

Minimal or no attempt to ensure decision consistent with patient values and preferences

  • Paternalistic or parental approaches: Clinician makes minimal effort to establish patient values and preferences, makes decision on behalf of patient

Approaches that attempt to ensure decision consistent with patient values and preferences

  • Clinician-as-perfect-agent approach: Clinician ascertains patient's values and preferences, makes decision on behalf of patient

  • Informed decision making: Clinician provides patient with the information; patient makes the decision

  • Shared decision making: Patient and clinician both bring information/evidence and values and preferences to the decision

Paternalistic Approach

When clinicians offer patients minimal information about the options and make the decision without patient input, a style commonly referred to as a paternalistic or parental approach, they are not considering patient values and preferences. This does not mean that patients do not have an opportunity to express their wishes, but they may do so in a delayed fashion and through actions. For instance, if the treatment choice is not consistent with their values and preferences, patients may not act on the decision or may abandon the plan shortly after the visit with the clinician. Evidence-based medicine requires ...

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