Shared decision making: what do clinicians need to know and why should they bother?

To the Editor: The ideas expressed by Hoffman and colleagues1 are laudable. In an ideal situation, shared care as described can offer benefits to patients and doctors in choosing patient-centred appropriate care.

However, for older patients with multiple morbidities and complex acute health care problems, the evidence to guide investigations and treatments is often lacking or not directly applicable. The basic knowledge of health care that patients need to possess in order to understand the risks and side effects of interventions — and even their knowledge about the natural history and processes of disease — is often absent or inadequate.2 Further, many older people have cognitive impairment that does not allow a sufficiently sophisticated assessment of risk and benefit.

In the clinical scenario provided in Hoffman et al, there was a single-system problem with good evidence. Even in this situation, I suspect that shared decision making would be challenging with a tired, distressed mother and a screaming child.

We should also be mindful that shared decision making should not result in doctors abdicating responsibility for making difficult decisions.3