3.2 Shared Decision-Making, Goal-Concordant Care & Decision Aids

Shared Decision-Making, Goal-Concordant Care & Decision Aids

CPXP Exam Focus: The CPXP exam evaluates Shared Decision-Making (SDM) not merely as patient education, but as a formal deliberative partnership model. Key tested concepts include Elwyn's 3-Talk Model, the International Patient Decision Aid Standards (IPDAS), the distinction between preference-sensitive care vs. effective care, and structured serious illness conversational tools (VitalTalk SPIKES/REMAP and Ariadne Labs Serious Illness Conversation Guide).

Modern healthcare ethics has evolved from historical paternalism ("doctor knows best") through informative/consumerist care ("here is the menu of options, you decide") to Shared Decision-Making (SDM). In SDM, clinicians bring clinical evidence, diagnostic expertise, and probability estimates, while patients bring expertise in their own values, lifestyle preferences, risk tolerance, and life goals.

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The Spectrum of Clinical Decisions

Not all clinical decisions require shared decision-making. CPXPs must distinguish between:

1. Effective Care (High Evidence / Clear Benefit):

   • Interventions where clinical evidence overwhelmingly demonstrates benefit over harm (e.g., prescribing antibiotics for bacterial meningitis, emergent PCI for acute ST-elevation myocardial infarction).
   • Communication Goal: Persuasive recommendation, informed consent, and adherence support.

2. Preference-Sensitive Care (Equipoise / Trade-Off Decisions):

   • Scenarios where two or more medically reasonable options exist, or where the trade-off between benefits and harms depends entirely on personal values (e.g., lumpectomy with radiation vs. mastectomy for early breast cancer; surgical prostatectomy vs. active surveillance for low-risk prostate cancer; starting a biologic with immunosuppressive risks for rheumatoid arthritis).
   • Communication Goal: Formal Shared Decision-Making (SDM).

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Glyn Elwyn's 3-Talk Model of Shared Decision-Making

Developed by Professor Glyn Elwyn and colleagues, the 3-Talk Model provides a practical, step-by-step clinical roadmap for operationalizing shared decision-making during clinical encounters.

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|                       ELWYN'S 3-TALK MODEL OF SDM                              |
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| 1. CHOICE TALK:   "Step back: A choice exists, and your opinion matters."     |
|                   - Justify choice (equipoise, no single right answer)        |
|                   - Check reaction & offer reassurance                        |
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| 2. OPTION TALK:   "Compare: Here are the options, benefits, and trade-offs."  |
|                   - Check existing knowledge & present balanced alternatives  |
|                   - Use validated PtDAs & convey absolute risk numbers        |
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| 3. DECISION TALK: "Deliberate: Given your values, what matters most to you?"  |
|                   - Elicit preferences & guide trade-off deliberation         |
|                   - Make, defer, or schedule decision review                  |
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Step 1: Choice Talk (Creating Awareness of Choice)

• Objective: Establish that a decision needs to be made, that multiple legitimate paths exist, and that the patient's preferences are essential to deciding.
• Core Actions:
  1. Summarize the situation: Acknowledge that the patient faces a health crossroad.
  2. State the choice explicitly: State clearly that there is more than one reasonable option.
  3. Offer partnership: Reassure the patient that you will support them throughout the decision process.
  4. Check reaction: Elicit immediate thoughts ("How does it feel to hear that you have a choice here?").

Step 2: Option Talk (Comparing Alternatives with Evidence)

• Objective: Provide clear, balanced information on the practical alternatives, including their distinct pros, cons, and uncertainties.
• Core Actions:
  1. Check prior knowledge: Ascertain what the patient already knows or has researched.
  2. List options clearly: Include the option of active surveillance or "doing nothing" when clinically appropriate.
  3. Describe trade-offs in plain language: Present benefits and side effects using natural frequencies (e.g., "5 out of 100 people" rather than relative percentages like "a 30% reduction").
  4. Deploy Patient Decision Aids (PtDAs): Introduce visual decision aids to facilitate cognitive processing.
  5. Check understanding: Use the teach-back method to verify that risks and trade-offs are grasped.

Step 3: Decision Talk (Deciding Based on Values)

• Objective: Elicit the patient's personal goals and guide them toward a decision that matches what matters most to them.
• Core Actions:
  1. Focus on values: Ask explicit value-elicitation questions ("When you think about the recovery time versus the risk of side effects, what worries you most?").
  2. Assess decision readiness: Gauge whether the patient is ready to decide or needs more time/family deliberation.
  3. Agree on a plan or next review: Formulate the agreed-upon clinical path or schedule a follow-up conversation.

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Patient Decision Aids (PtDAs) & IPDAS Standards

Patient Decision Aids (PtDAs) are evidence-based tools (interactive web tools, booklets, video modules, grid sheets) designed to help patients make specific, deliberated choices among healthcare options. Unlike generic educational materials that describe disease pathophysiology, PtDAs explicitly present options, balance benefits vs. harms, and guide value clarification.

International Patient Decision Aid Standards (IPDAS) Collaboration

The IPDAS Collaboration establishes international quality criteria across three essential dimensions:

Cochrane Review Evidence: Cochrane Systematic Reviews of over 105 randomized controlled trials confirm that patients exposed to validated PtDAs achieve higher knowledge scores, more accurate risk perceptions, reduced decisional conflict, lower rates of choosing major elective surgery (often choosing less invasive alternatives), and greater satisfaction without increasing anxiety.

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Goal-Concordant Care & Serious Illness Conversations

In serious, life-limiting illnesses (advanced cancer, end-stage heart failure, neurodegenerative disease), clinical success is defined not by physiological metrics alone, but by goal-concordant care—ensuring that every diagnostic and therapeutic intervention strictly aligns with the patient's authentic values and definitions of quality of life.

Ariadne Labs Serious Illness Conversation Guide

Developed by Dr. Atul Gawande and Ariadne Labs, the Serious Illness Conversation Guide (SICG) provides clinicians with a structured, compassionate conversational framework:

1. Set Up:       Introduce the conversation and seek permission to discuss the future.
2. Understand:   Assess patient's current understanding of their illness and prognosis.
3. Share:        Share prognosis as a range or time horizon with tailored information.
4. Explore:      Elicit key goals, critical abilities, fears, and trade-offs.
5. Close:        Summarize what was heard, make recommendations, and document in the EHR.

Core Value-Elicitation Questions from the SICG:

• "What are your most important goals or hopes if your health worsens?"
• "What are your biggest fears and worries about your illness and treatment?"
• "What abilities or activities are so crucial to your life that you cannot imagine living without them?"
• "If you become sicker, how much are you willing to go through for the possibility of gaining more time?"
• "How much do your family members know about your priorities and wishes?"

VitalTalk: SPIKES and REMAP Frameworks

• SPIKES Protocol for Delivering Difficult News:

  • Setting (Privacy, seating, tissues)
  • Perception (Assess what the patient already knows)
  • Invitation (Ask how much detail they want)
  • Knowledge (Deliver clear news with a warning shot: "I have some serious results to share")
  • Empathy (Respond to emotions using NURSE statements)
  • Strategy and Summary (Outline next steps clearly)

• REMAP Protocol for Goals of Care Re-framing:

  • R — Reframe: "We are in a different place with your disease today."
  • E — Expect Emotion: Validate distress with NURSE statements.
  • M — Map the Future: "Given where things are, what is most important to you?"
  • A — Align with Values: "As I listen to what matters most, it sounds like being home and comfortable is top priority."
  • P — Propose a Plan: Recommend a clinical plan (e.g., palliative care/hospice) that matches their articulated values.

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Advance Care Planning (ACP) & Healthcare Proxies

Advance Care Planning (ACP) is an iterative communication process wherein individuals identify their values, appoint trusted surrogate decision-makers, and document treatment preferences for future medical incapacity.

Legal & Clinical ACP Instruments

Legal Standards for Surrogate Decision-Making

Surrogates must apply decision criteria in strict hierarchical order:

1. Substituted Judgment Standard: The surrogate must make the decision that the patient would have made if they were currently capable of speaking for themselves, based on their known values, prior statements, and life history.
2. Best Interests Standard: Used only when the patient's authentic wishes are completely unknown and cannot be deduced. The surrogate and clinical team decide what would produce the best overall outcome for the patient.