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  Informed consent is a process; the signed release is the documentation that the process took place

  
  
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  Shared decision-making should take into account the patient’s interests and concerns in their care as part of the informed consent process

  
  
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  Always actively assess the patient’s understanding (of the content) and capacity (to make informed decisions)

Surgeons are legally obligated to complete the informed consent process prior to proceeding with a recommended surgery. It is becoming increasingly apparent that this process is also an opportunity to engage patients in their own healthcare decision making. The many benefits to this level of patient engagement include improved safety and compliance. In this chapter, we explain how decisions are made in health care. We examine a case study typical to surgery using the shared decision making process and review how the process benefits both patients and surgeons.

Historically, physicians approach their patients using one of three approaches: paternalistic, informational, or shared decision making (SDM).¹ These general approaches are not mutually exclusive. Depending on the circumstances, aspects of each approach may be incorporated into any treatment decision (see Table 2.1).

1. 
   

   Paternalistic. Traditionally, medical decisions are made using this approach in which the physician determines which treatment should be undertaken and the patient accedes. Although there may be circumstances where this approach is necessary (eg, in emergencies), this approach can be risky because it may leave the patient uninformed. This approach also assumes an alignment of physician and patient preferences without explicitly determining if alignment exists. In addition, this approach may lead to patient dissatisfaction if an unexpected outcome occurs. Paternalism has been associated with lower patient adherence with recommended treatment and less engagement in the recovery process. Patients experiencing unexpected outcomes after perceived paternalistic decisions are more likely to seek legal advice.

   
   
2. 
   

   Informational. In this approach, the physician assumes a role of “information provider” and leaves all treatment decisions up to the patient. Providers using this approach make every effort to remain objective, and reveal only as much information as patients need to make their own decision. This model assumes that patients are capable of absorbing medical information and integrating this information with their own preferences and circumstances in order to make decisions. Research has shown, however, that although patients universally desire information about their condition and options for treatment, their ability to process this information and their desire to make a decision vary considerably.² If patients have a significant emotion associated with their disease or they are experiencing “information overload,” they may shut down or feel incapable of making a decision. Finally, it can be difficult for providers to remain completely unbiased, and they may unintentionally frame the information provided in a way that expresses their own preferences. Again, this model may be appropriate for some patients, particularly those who are prepared to absorb the information and take into account their own desires. But, it can be difficult for physicians to ascertain which patients are capable of this level of independent decision making.

   
   
3. 
   

   Shared decision making. The third model of treatment determination is called shared decision making. This incorporates features of the two previous models, with explicit elicitation of patient involvement. This approach requires two parties to participate, share information, and make a mutual decision. Decision aids such as pamphlets, videos, interactive activities, and time with allied health providers may lead to greater information absorption, lower anxiety, and increased patient satisfaction.³ Shared decision making may be made more effective during the clinical encounter through the use of electronic decision aids, which link directly to trustworthy summaries of evidence from systematic reviews and guidelines.⁴ Finally, patient activation measures have been developed to determine the patient’s level of engagement, and these have also correlated with greater levels of involvement in the recovery process.⁵ In actuality, several parties may participate in the process, including people the physician may never meet. Patient decision making may be influenced by family members and friends, as well as previous experiences with the medical profession, biases from the media, or misinformation from various sources. Physician decision making may be influenced by information elicited from other providers or recommendations the physician made previously that may not be applicable in the current patient’s circumstances. Certain patient personality types may emerge as a barrier to implementing shared decision making. Some may prefer receiving minimal information and have the physician decide how to proceed (inferring the paternalistic approach) whereas others wish for “information only” and will not be swayed by further discussion (informational approach). Physicians may create barriers to this exchange by being unable to create an atmosphere conducive to information transfer, which may occur when physicians discount patient concerns or preferences. The most common barriers include time constraints and perceived lack of applicability, in which a surgeon doesn’t recognize how shared decision making could benefit a particular situation, either due to patient characteristics or clinical situations.⁶ Providers must ensure that the information provided is reasonable in quantity (ie, not overwhelming) and quality (ie, stated in terms the patient can understand, which varies based on patient capacity). Overcoming these barriers in the real world may require more than just a conversation.

When a patient is making a decision about treatment, one of several scenarios may emerge:

1. 
   

   The decision may be obvious and can be made immediately.

   
   
2. 
   

   The patient may feel overwhelmed and want to defer the decision to someone else, either another expert or trusted source.

   
   
3. 
   

   The patient may need further time to process the consequences and/or information.

   
   
4. 
   

   The patient may feel that more information is needed in order to proceed.

The provider should respect this process and work with the patient until the decision becomes obvious and can be made immediately.

Understandably, a surgeon’s first reaction to the shared decision making process might be “I don’t have time for this” or “I don’t have the skills to get this done.” You will need to invest time and effort into learning this approach. Fortunately, research has shown that once the shared decision making process has been implemented, it doesn’t take much more time. And, if there is more time associated with the process, it is outweighed by the rewards of greater patient and physician satisfaction and improved outcomes.⁷

Case Study 2.1

The story: John Smith presents to his primary care physician (PCP) for a routine physical examination. The PCP performs a prostate examination, and the exam reveals a possible nodule. A subsequent PSA blood test reveals elevated levels of 6.8, and the PCP refers Mr. Smith to Dr. Jones, a urologist, for a consultation. After confirming the findings, Dr. Jones began a conversation with Mr. Smith. This is when the shared decision making process begins, as it includes the process of taking the patient’s history and performing an examination. During this time, Dr. Jones gets to know the patient, including his interests, preferences, and life plans. Dr. Jones incorporates this knowledge into subsequent discussions about choices for medical treatment.

On the surface, this case example may seem to illustrate what would be a perfunctory decision regarding the necessity of performing a biopsy to determine the nature of the palpable nodule. However, Dr. Jones needs to consider the characteristics of the patient. This includes Mr. Smith’s age, physical condition, and whether he would be able to undergo the treatment based on the results of the biopsy. Equally important would be whether Mr. Smith would want any treatment if the biopsy revealed a malignancy.