Shared Decision Making

In my last post, I talked about the uncertainties of medicine, and suggested that the relationship between doctor and patient must be built on trust.  (See “A Transaction Based On Trust”). I argued that this is why the consumer-driven model of medicine doesn’t work. It assumes that the doctor is a retailer selling his services and that as his customer the consumer must demand the best quality care at the lowest price. Immediately the relationship between buyer and seller begins to sound adversarial, just as it is in the commercial marketplace where “caveat emptor” always applies. 

But the health care market is not like other market places, and the doctor is not a retailer. He or she is a professional who has taken a pledge to put the patient’s interests ahead of his own interests.  For the transaction to go forward, the patient has to believe this. Who would go under the knife, or submit to any painful or invasive procedure if he didn’t trust the doctor? 

At the end of that post, I asked, “But what about the uncertainty of medicine. Does this mean that the patient must simply trust that his doctor has “the right answer?”

Not at all. The relationship between patient and doctor must be based on mutual trust. Just as the patient trusts the doctor to act as a professional, the doctor needs to trust the patient enough to be open with him about the uncertainties of the patient’s condition and the pros and cons of the treatments that they are considering.

Sometimes—but not always—the doctor must tell the patient: “In this particular case I can’t be sure what the best treatment would be. But here are the options and here are the risks and benefits of each.”    

This isn’t consumer-driven medicine, but it is “patient-centered
medicine.” The patient and doctor share in the decision making
as—together—they confront the ambiguities of medicine. What the doctor
brings to the table is his scientific knowledge, and his experience,
over the years, treating patients suffering from a similar illness.
What the patient brings to the table is his own values, priorities and
preferences.

I’ve written about shared decision making here, in an article
where I focus on doctors and patients collaborating as breast cancer
patients decide whether to have a mastectomy or a lumpectomy, while
patients who have been diagnosed with early-stage prostate cancer
decide whether they want to be treated or whether they would prefer to
wait and see how quickly the cancer progresses.

“Shared decision making” is a formal process that has been developed at
a number of hospitals around the country. Dartmouth-Hitchcock in
Lebanon, New Hampshire led the way in 1999 when it opened a Center for
Shared Decision Making where doctors and decision-making coaches
learned to use various “decision-making aids” to help patients weigh
their options. (See their website here).
These aids include pamphlets that spell out the risks and benefits of
various elective tests and procedures as well as videos featuring
patients who describe how they went about making the decision—and
whether they are happy with the outcome.

Patients take these pamphlets and videos home, and often view the
videos more than once, with their families. When they go back to the
doctor, he or she asks questions to test whether the patient fully
understands the benefits and risks. If the patient seems confused, the
doctor explains further until, as one doctor puts it—“Suddenly, the
patient’s face clears—and you know they understand.”

At that point, the doctor begins to ask the patient questions about his
own preferences, fears and priorities. Are there certain side effects
that he fears more than others? Is he a risk-taker? How does he feel
about uncertainty? Is the breast cancer patient’s first priority to try
to preserve her breast or would she prefer to “get it over with” by
having a mastectomy? The treatment that might be “right” for one
patient will not be right for another.

Here the patient becomes an active participant in the decision-making
process. In the past, we talked about patients giving “informed
consent” before any elective procedure.   At the decision-making
center, patients make an “informed choice” that takes their own values
and temperament into account.

At Dartmouth, experts in shared decision-making say that in the end,
the final decision does not have to be made by the patient. After
assimilating the information about benefits and possible
complications—and expressing his own fears and preferences—some
patients want the doctor to weigh in.  Here, strict advocates of
“patient autonomy” argue that only the patient can know what he or she
wants. If a patient asks for help, the physician is supposed to say: “I
don’t know John, I’m not you.”

But at Dartmouth, decision-making coaches recognize that while it is
important that the patient participate in the process and become fully
informed, it can be cruel to refuse to give him advice at the end of
the process.  A doctor who steps away at that point could be seen as
“abandoning” the patient.

Moreover, in the case of prostate cancer, if the patient trusts the
doctor, he may be willing to listen to the doctor who tells him that
“doing something now” may not be the best course of action.  The notion
that “more care is better care,” and that the newest, most expensive
treatment must be best is deeply ingrained in our consumer culture. And
it’s one reason why our health care costs are so high.

The goal of shared decision-making, by contrast, is to “give the right
care to the right patient at the right time.” Just because the doctor
tells the patient that he is a candidate for a particular elective
procedure–whether it’s a knee implant, angioplasty, or spine
surgery—doesn’t mean that he should have that surgery. This is where
the patient’s preferences come into play.

Perhaps it should come as no surprise that when patients have a chance
to consider the benefits, risks and uncertainties of elective
treatments—and make a choice, rather than simply “consenting”–twenty
percent of more decide not to go ahead with the procedure.  For obvious
reasons, patients just aren’t as enthusiastic about surgery as surgeons
are. A good surgeon is proud of his craft, and wants to help as many
people as possible. But the patient is also thinking about how long it
will take to convalesce, how painful it will be, whether he or she can
afford to take time off work, the possible risk that something will go
wrong . . .

Typically, the patient who decides against an elective procedure says
something like, “You know what, my knee doesn’t hurt that badly. I
think I’ll wait and see.”  Dr. John Wennberg, co-founder of Dartmouth’s
Center For Shared Decision Making, will be publishing an article about
this research in the November issue of Health Affairs.

Finally, let me suggest that while an “educated consumer” cannot bring
down health care costs, the “informed patient” could help rein in
health care spending. Let me be clear: saving money is not the goal of
shared decision-making. The goal is quality, and here I would define
high quality care as care that gives “every patient as much as he
needs—and no less” while also giving each patient “as much as he
wants—and no more.”

In other words, the goal is to avoid both under-treatment and the over-treatment that plagues our health care system.

But while the goal is not to cut costs, saving money is certainly a
welcome by-product of shared decision making. And once again, we see
that lower cost and higher quality go hand in hand.

By contrast, consumer-driven medicine is likely to push health care
spending ever higher for a number of reasons. First, the patient who
views himself as an “empowered consumer” is likely to feel that there
must always be a right answer. He is not tolerant of ambiguity.  And he
believes that, as a savvy shopper, he can find that right answer. If
his doctor doesn’t have the cure, it’s because he’s not keeping abreast
of the latest developments. But the consumer is convinced that he can
find someone who will have the answer, and who will do something now.
And chances are he will.

The patient who sees himself as a consumer also is likely to be easily
influenced by “direct-to-consumer” television ads. Unfortunately,
research shows that DTC ads tend to tout the newest, most expensive
drugs—products that the manufacturer would have a hard time selling
“direct to the doctor” because he doesn’t yet have the evidence to show
that they are effective, and that, long-term, the benefits outweigh the
risks.

The well-informed patient, on the other hand, appreciates the grey
areas of medicine. His doctor has been open in describing the
uncertainties.  As a result, this patient is more willing to accept
answers like “We don’t know.” Or, “It depends.”  And he is more likely
to listen to a doctor who tells him that the most aggressive approach
is not necessarily the best approach. He is more likely to hear a
physician who says: “Try physical therapy first. Try drug therapy. Try
a change of diet and exercise.”

This is why I think that, if doctors and patients work together, they
can contain the cost of health care, paving the way for a sustainable,
affordable, health care system that offers the right care to the right
patient at the right time.

17 thoughts on “Shared Decision Making

  1. Didn’t really need a Dartmouth study to know that “shared decision making” was the right thing to do. I disagree however with giving every patient “as much as he wants and no more” I have been literally pushed by patients to give them things they want that were dangerous or just plain not indicated, this is despite the time I spent educating, no matter how much time you spend in the education process, there are some people who do not want to hear. In some cases, in order to do no harm, I actually lost patients who went to someone who was willing to give them what they want, despite the risks. There also are people/patients that just do not have the capacity to understand much of the world of medicine, no matter how good of a teacher you are. Finally, I believe the “what you want” services, medications etc, if not indicated by good evidence based medicine should be the first things put on the “out of pocket” list for any future health plan. For instance, I performed many circumcisions, no real medical indication for it, no evidence to support it for prevention and quite expensive!!

  2. Dr. Matt–
    The “as much as you want and no more” formula isn’t meant to suggest that patients should receive anything they want—including unncessary care.
    Rather, it’s meant to do precisely the opposite–to guard against overtreatment.
    The emphasis is on “no more” not on “want”
    Similarly, the “as much as they need–and no less” is meant to guard against undertreatment.
    The formula is Dartmouth’s, and they have spent years working on the problem of over-treatment.
    Also, I wouldn’t dismiss the Dartmouth research on shared decision-making as simply another study showing something obvious.
    The whole process of getting patients involved in decision-making is complicated. For one, patients need to understand that going into elective surgery is a “wager” as Dr. Jack Wennberg puts it.
    Few patients like to think that they’re gambling when they choose an elective treatment, but they are.
    Secondly the Dartmouth coaches work hard to get patients to understand “odds”–something that many have a hard time grasping.
    If you say that with treatment the number of survivors that died was cut in half, that sounds pretty promising.
    But then, if you tell the patient–“in other words, instead of 2 out of 100 patients dying, only one out of 100 died”–that doesn’t sound so exciting.
    In the meantime, 20% of those who chose the treatment became permanently incontinent . .
    Now the patient is confused. . . How is he suppposed to weigh that against the fact without treatment 2 out of 100 died . . .
    Meanwhile, the doctor is talking to someone who has recently found out that he or she has cancer. “First, you have to get them down off the chandelier,” one woman doctor who works with breast-cancer patients at Dartmouth explained. .
    The psychology of decision-making is pretty interesting, and I think it’s something doctors need to study. Letting the patient realize that he is in fact “making a wager” without scaring him to death is both an art and a science.

  3. Maggie,
    Pardon me, I don’t mean to sound cavalier about shared decision making, I am fully aware of the effects of bad news on what the patient actually hears and the need for follow up and repetition, further I am aware of the changing perspective that happens when you present statistics in different ways (wrote a whole chapter on it in my book). what you are detecting here is a bit of bitterness, it is lovely to see these very important issues gain scholastic recognition, but how is this going to give any practing doctor the time to follow through. Unfortunately, in the current system it is unrealistic. I have done these things, in my office, literally hours of repetition to make sure people understood what they were doing/about to do. Look where it got me. Again, my apology, I look forward to reading the outcome research.

  4. Maggie,
    Shared decision making as you describe it sounds all well and good. I wonder about a couple of things, though.
    For example, suppose I tell my doctor that I want him to treat me as though I were a member of his own family (provide competent and compassionate care) and as though he were paying the bill out of his own pocket (no unnecessary tests). I could tell him in no uncertain terms that the probability that I will sue over an adverse outcome is zero, short of something egregious like wrong site surgery. He tell me that all tests he orders are necessary. However, he may well tell his colleagues that many of them are ordered to protect against lawsuits such as sending everyone who presents with a headache for an MRI because that’s the community standard. He may also benefit financially from ordering the tests, especially if he owns the equipment.
    What about medical encounters that occur in a hospital ER or as an inpatient after being admitted through the ER? The patient and doctor(s) often don’t know each other. In the case of complex patients with multiple co-morbidities being treated by several doctors, the doctors themselves often don’t know what each other is doing leading to duplicate testing and possibly adverse drug interactions. How do you share decision making under those circumstances?
    On consumerism, I think price transparency is potentially quite useful in the commodity-like areas of medicine such as drugs, imaging services, blood tests, simple primary care procedures such as those offered in retail clinics and the price of a doctor’s time for consults, etc. With the exception of care delivered under emergency conditions, I don’t think it is asking too much to be able to find out what services cost before they are rendered even if insurance is ultimately paying for most of it.
    Finally, on paying for healthcare as a society, I think there are really three different models that apply depending on what we are talking about. The first is well care and routine primary care. Costs are not especially high, many people could probably afford to pay largely out of pocket, and normal market forces including price transparency can work quite well. Insurance also has its role to play for the poor who cannot afford out of pocket payments beyond a nominal sum at best and the middle class who want to pay for what is essentially prepaid healthcare rather than insurance. The second segment is catastrophic care. This is care related to serious accidents, heart attacks, cancer, etc. This is the piece that insurance is meant to cover. Few of us can afford to pay out of pocket, not that many of us will suffer such an event in any given year, but, if we do, we need insurance to help us pay for it. The final segment is end of life care. This includes advanced Alzheimer’s, severe dementia, and costly care needed by those who have already lived a normal life span and then some – say, age 85 and older. In a world of high costs and finite resources, rationing needs to be applied here, at least eventually, even though Americans don’t want to hear that word.
    I think people who reach this stage really need to have a living will which is probably the ultimate in shared decision making. Such a document can speak to not only medical issues like feeding tubes and ventilators but the patient’s values like quality of life, maintaining dignity, and being kept comfortable. If no living will exists, I think we need to change our laws to allow doctors and hospitals to apply common sense depending on circumstances without having to worry about being sued. As it stands now, they feel they have no choice but to do everything technically possible to keep these people “alive.” If Europe and Canada don’t have these train wrecks filling their ICU’s, why the heck do we?

  5. Barry–
    Thanks for your comment. Let me take your points one by one, beginning with the last one.
    Regarding end-of-life care, it’s not clear what you are suggesting that we do with 85-year-old Alzheimer’s patients.
    Many people in this country would not feel comfortable with the idea that once they reach 85, Alzheimer’s patients should be “put down.”
    How else do we reduce the cost of caring for them? Bathe them less often? No nursing care at night?
    While you could ask everyone to make a living will, you should keep in mind that many people would make out a will saying that they do want extraordinary measures taken up to the last possible moment. For religious reasons many feel that we do no have a right to decide when we die. (I don’t happen to share that view, I personally don’t want extraordinary measures used to keep me alive, but I’m just pointing out that cutting the cost of end-of-life care is not so simple.)
    When it comes to who should pay for preventive care, while some preventive care is quite inexpensive it is also the type of care that people are most likely to skip–especially if they have to pay out of pocket. When you’re not in pain, you’re less likely to go to the doctor.
    If we rely on indivdiuals paying for their own preventive care many simply won’t get it. And this is not just because human beings often are foolish (though we are).
    Keep in mind that the average household in this coutnry has a joint income of roughly $54,000–before taxes. Half of the people in this country earn less than that. If you were supporting 3.5 people in a household where you and your spouse earned, say $35,000–before taxes. I imagine you’d think twice before spending, say $75, to go to a doctor for preventive care (a Pap smear, a mammogram, counseling on how to lose weight, counseling on how to stop smoking, a blood sugar check, a cholesterol check, blood pressure check, etc.)
    In addition, some of the most important “preventive care” involves managing chronic diseases. Most people think that the bulk of our heatlh care dollars are spent on “acute” diseaes like cancer because these are the most visible expenses.
    But it just isn’t true. As Kaiser Permanent president George Halverson points out in his new book, Health Care Reform Now! most of our health care dollars are spent on five chronic diseases: diabetes, congestive heart failure, cornorary artery diseae, asthams and depression.
    These are not catatrophic events, but these are the diseases that insurance needs to cover because unless they are continuously “managed”–with many doctor’s visits, drugs, etc.” they will lead to unncessary hospitalizations, surgeries, etc.
    On price transparency–it does you little good to know the price of a blood test if you don’t know whether you really need the blood test. Without knowing anything about the quality of the product (which includes whether you need the product), you can’t comparison shop.
    Finally, on shared decision-making–this applies to decisions about elective tests and procedures, decisions that take place before you are in the hospital.

  6. Barry–
    Thanks for your comment. Let me take your points one by one, beginning with the last one.
    Regarding end-of-life care, it’s not clear what you are suggesting that we do with 85-year-old Alzheimer’s patients.
    Many people in this country would not feel comfortable with the idea that once they reach 85, Alzheimer’s patients should be “put down.”
    How else do we reduce the cost of caring for them? Bathe them less often? No nursing care at night?
    While you could ask everyone to make a living will, you should keep in mind that many people would make out a will saying that they do want extraordinary measures taken up to the last possible moment. For religious reasons many feel that we do no have a right to decide when we die. (I don’t happen to share that view, I personally don’t want extraordinary measures used to keep me alive, but I’m just pointing out that cutting the cost of end-of-life care is not so simple.)
    When it comes to who should pay for preventive care, while some preventive care is quite inexpensive it is also the type of care that people are most likely to skip–especially if they have to pay out of pocket. When you’re not in pain, you’re less likely to go to the doctor.
    If we rely on indivdiuals paying for their own preventive care many simply won’t get it. And this is not just because human beings often are foolish (though we are).
    Keep in mind that the average household in this coutnry has a joint income of roughly $54,000–before taxes. Half of the people in this country earn less than that. If you were supporting 3.5 people in a household where you and your spouse earned, say $35,000–before taxes. I imagine you’d think twice before spending, say $75, to go to a doctor for preventive care (a Pap smear, a mammogram, counseling on how to lose weight, counseling on how to stop smoking, a blood sugar check, a cholesterol check, blood pressure check, etc.)
    In addition, some of the most important “preventive care” involves managing chronic diseases. Most people think that the bulk of our heatlh care dollars are spent on “acute” diseaes like cancer because these are the most visible expenses.
    But it just isn’t true. As Kaiser Permanent president George Halverson points out in his new book, Health Care Reform Now! most of our health care dollars are spent on five chronic diseases: diabetes, congestive heart failure, cornorary artery diseae, asthams and depression.
    These are not catatrophic events, but these are the diseases that insurance needs to cover because unless they are continuously “managed”–with many doctor’s visits, drugs, etc.” they will lead to unncessary hospitalizations, surgeries, etc.
    On price transparency–it does you little good to know the price of a blood test if you don’t know whether you really need the blood test. Without knowing anything about the quality of the product (which includes whether you need the product), you can’t comparison shop.
    Finally, on shared decision-making–this applies to decisions about elective tests and procedures, decisions that take place before you are in the hospital.

  7. Maggie,
    Regarding end of life care, I know that some people want everything possible done to keep them alive as long as possible and express that view in a living will. That’s fine, though I suppose we could debate, through our political system, whether people who want the medical system to “do everything” for them should pay more for their insurance than those of us who just want comfort care and pain management under similar conditions. For those that have neither a living will nor a family member or other advocate to speak for them, doctors and hospitals should be able to apply comment sense depending on circumstances without having to worry about being sued rather than automatically feel compelled to “do everything.”
    What I’m suggesting we do in end of life situations is to fully understand what they do in Europe and Canada with respect to how they define and apply good, sound medical practice. Do they provide kidney dialysis or bypass surgery or chemotherapy to 85 or 90 year old people whose quality of life is gone? How about otherwise healthy people in that age range? I don’t know, but I would like to know why they don’t have the train wrecks filling their ICU beds like we do. Just because we have the technical capability to do an intervention doesn’t necessarily mean that we should, especially when resources are finite and we are already spending far more than any other country on healthcare. Perhaps the difference in approach to end of life care among countries is part of the reason.
    On preventive care, you and I have gone back and forth numerous times on the appropriate role of personal responsibility. Lots of people in the income range that you cited in your last comment have no trouble spending $100 per month for cable TV or cell phone service. They even seem to be able to maintain their cars by paying for oil changes and other routine maintenance with after tax dollars. Yet, somehow, flu shots and other routine preventive care are unaffordable. Personal responsibility also includes compliance with medical instructions including taking drugs that your doctor prescribed and following other instructions related to smoking, weight control, etc. Even gold plated insurance can’t guarantee compliance.
    Finally, on price transparency, if I need an MRI or blood test or whatever, and there are five different places I can get it in my area, it would be helpful if my PCP knew which imaging centers or labs offered the best rate for good quality work and could send me there instead of just sending me to the facility he usually refers to without any clue as to how much it charges compared to its competitors.

  8. Barry– and Everyone–
    On the whole question of personal responsibilty and what insurance should pay for–I just listened to a speech that Berkley profesosr James Robinson (the new editor of Health Affairs) gave last week.
    Here’s the link: http://icvclients.com/ehcca/consumer_2007/day1_115/.
    You may need to download something to hear it but it should be free.
    Listen carefully–it’s a tricky speech. At first, it sounds as if he’s endorsing “consumer-driven care” but in fact he’s recommending a very new, very diffrent version of healthcare.
    Instead of endorsing personal responsibility, he believes that medicine needs to be somewhat paternalistic.
    As he puts it: “People make lousy decisions. They need help” (in making healthcare decisions. They need help from a doctor.) This is why he says “High-deductibles and choices for consumers won’t solve the problem.”
    Patients, he says, need to be able to see that doctor and this means they need “first dollar coverage” (with no co-pay) to encourage them to see that doctor.
    Otherwise,Robinson realizes, they won’t go for the effective care and preventive care that they need. (And if they don’t, we’ll all end up paying for it when they get sicker.)
    When I interviewed Robinson for my book a few years ago, he was much more enthusiastic about giving consumers choices–though he acknowledged that he was worried about the many people who just aren’t in a position to make good choices.
    It’s interesting to see how his position has changed over the last few years.
    I plan to write about his speech in the near future.

  9. I listened to Dr. Robinson’s speech and heard a lot that I could agree with. For example, first dollar coverage for clearly cost-effective care such as a beta blocker following a heart attack is fine. It is also appropriate for clearly medically necessary emergency procedures like an appendectomy. On the other hand, tiered co-pays to steer patients toward generic drugs instead of brands are also appropriate as are differential copays to incentivize use of the most cost-effective doctors and hospitals.
    I am also in full agreement with the need for interoperable electronic medical records, especially in hospitals. The medical home concept to encourage care coordination also makes good sense. The interest in pricing for a full episode of care, which I like to call package pricing, is also encouraging, though this will require much more teamwork and coordination between doctors and hospitals to gain traction.
    Interestingly, he did not speak about end of life care or malpractice reform and defensive medicine. Perhaps he could address those issues in a subsequent speech or article.

  10. Maggie,
    I enjoyed the post. Having read Herzlinger’s book recently, my sense is she would respond by saying that with integrated, soup to nuts pods (aka focused factories, etc), as well as advances in outcomes measurement, John and Jane Q public would have the ability to make the choices you outline in your post. I also find those generalizations specious at best given our primitive abilities to measure quality at this time, but she can make a compelling case. Her typical “renal failure” serves as the illustrative example.
    However, those of her ilk, and others in the CDHC-oid camp (Porter, etc) are quite articulate and compelling in their views, and I would love to see an invited response to your post to get an alternative perspective. They could easily question the “trust” issue with the breakdown of the doctor-patient covenant of recent years, the power of the internet, and cost of care to drive (key word) change in how patients get their services, etc. While diabetes care is not a muffler change, the public can get better at these activities. A few Oprah moments and I think all of us might be surprised how things can transform.
    Anyway, just a thought. I am not saying I agree with these folks (I dont believe I do), but some contrast would be inviting. What you blogged about here is so very important.
    Brad

  11. Bradley and Barry–
    I would love to get Herzlinger to respond here.
    I could certainly e-mail her and see what happens . . .
    I also plan to write about James Robinson’s recent speech where he talks about a “new form of consumer-driven care–which turns out not to be consumer-driven care at all, but something very much like what I call “patient-centered medicine” where patient and doctor collaborate to try to help the patient make better choices. Perhaps she would be interested in responding to what Robinson has to say.(See my response to Barry abover for a link to Robinson’s speech.)
    Barry– Yes, I thought you would like much of Robinson’s speech. He has just become the new editor of Health Affairs–which is far and away the most important journal about health care policy published in this country.
    So I was very glad to read his speech–it integrates some of the very best ideas out there today.

  12. The final segment is end of life care. This includes advanced Alzheimer’s, severe dementia, and costly care needed by those who have already lived a normal life span and then some – say, age 85 and older. In a world of high costs and finite resources, rationing needs to be applied here, at least eventually, even though Americans don’t want to hear that word.
    Well the trouble is when it comes down to individuals.
    I’m not American. My grandmother is 85. She’s had a good innings, and I want her around for a couple more decades yet. Or longer. I really don’t want her to die at all. I still miss grandma sometimes who died hears ago in her ’70s.
    I don’t think I would want to keep grandmother alive if her mind was gone, my cousins’ grandfather developed Alzheimers and that’s a totally different situation, and I understand why when he no longer knew any of them that they wanted pallative care so he didn’t suffer and nothing else. But I still have my grandma in a way they didn’t have their granddad by that stage.
    And that said, their grandfather’s care cost a lot as he was not only incapable of caring for himself, but violent towards other people by the end.
    Sorry, just this year I’ve started to really confront that my grandmother is getting slowly and slowly worse, and what that means, and I’m really not at all happy about it.

  13. Tracy,
    End of life care must be adressed. When I talk to people about end of life care I specifically direct them not to do what it seems you are doing. Do not make the decisions based on what you want. I know grandma has been around and a huge part of your life, but, what would she want at this point. This is one of the most difficult parts, I have personally always been good a letting my family members go, but the closer the member, the harder it is. I imagine if my daughter was on a vent I would have an impossible time removing what “I want” from what was the right decision. I always talked to my patient’s about having these conversations with thier family ahead of time, so family would know what they want. Difficult though, if I bring up end of life care with a healthy patient they are often suspicious that I am not telling them something.

  14. I have no problem with shared decision making if all the practioner does is give me the options and then let me make my own decision. However knowing the intent of the health care reform bill, I am sure that the government controled health care will pressure me to take the cheapest way out.

  15. Dr. Matt & Ernest
    Dr. Matt– I agree. It is often very difficult for the family to separate what they want from what is best for the patient.
    This is why palliative care specialists put the emphasis on what the patient wants. Of course, if the patient is not conscious, then the family makes decisioons–and sometimes doctors have a hard time getting the family to focus on the patient . . .
    Earnest– What you thin you “know” about health reform is, I’m afraid, based on misinformatoin spread by conservatives who oppose reform–and prefer the status quo.
    The truth is that very often, no one knows what will prove less expensive in the long run.
    Consider a woman deciding between a lumpectomy and a mastectomy– the lumpectomy is easier, and won’t require breast reconstuction –which means that initially, it is less expensive
    But there is the risk that she will have to come back later and have the mastectomy–and reconstruction ( if she wants it) making the whole treatment much more expensive.
    Mortality rates are the same, either way.
    The same applies to a man diagnose with early-stage prostate cancer choosing between “watchful waiting” (which costs very little) and surgery or radiation (which can be extremely expensive–and lead to side effects (incontinence and impotence.)
    AT first glance, watchful waiting seems less expensive– but down the road, the cancer may spread, and he may require very expensive treatment . . .
    Then there is the person considering a knee replacement. No knee replacement costs nothing in term of surgery–though he probably will need pain medication and physical therarpy.
    And again in two or three years, he may decide to have the knee replacement . ..
    I could go on. There is always so much amibuity in medicine . ..it’s hard to predict what will happen down the road, so it’s hard to predict expense over the long term.
    But we do know that if patients particpate in the shared-decision-making protocol, they experience fewer regrets and lawsuits are much less likely.
    This does save money–and much emotional wear and tear.

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  17. Shared decision making for me is the best way for both doctors & patients to obtain the best quality of health care, however giving everything the patients wants is a little over the top.