In reply: We thank Picone and Levinson for their comments on our article. Levinson raises concerns about situations involving clinical decisions in which evidence is lacking (eg, for patients with complex multiple morbidities), urgent and emotional consultations, and management of patients with cognitive impairment. Certainly, such situations make clinical care encounters more difficult. We acknowledge that shared decision making may not always be possible, and that sometimes the process may need to extend to family or a health care proxy. Nor will it always be desired by every patient or for every health care decision. Nevertheless, it should at least be offered. When there are multiple morbidities, with each needing a decision, one approach is to address each in turn, dealing with interactions between them, as we do for other clinical modalities.
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