Implementing shared decision making in the NHS: lessons from the MAGIC programmeBMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j1744 (Published 18 April 2017) Cite this as: BMJ 2017;357:j1744
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It is problematic that clinicians are still slowly journeying towards the murky halfway house of ‘shared decision-making’ when our law has already travelled further and arrived at the clearer destination of genuine informed consent.
I very much agree with the overall thrust of this paper, so my comments here should be taken as being ‘supportive’, but I would point out that
‘Clinicians’ long held commitment to doing what they perceive to be the best for their patients is a key barrier to attitudinal change. This is well intended, but fails to recognise that patients’ values, opinions, or preferences are important and might differ from their own.’
encompasses ‘a deep technical issue’ rather well. I write ‘technical’ because I am avoiding using ‘ethical’ or a similar term. I would not want my doctors to have a commitment to doing the worst for their patients – but while the second sentence is correct, it is also misleading in a ‘technical’ sense. Here, for ‘technical’ the word ‘legal’ can be substituted.
All of England’s ‘consent law’ is contained within the Mental Capacity Act: and ‘shared decision-making’ is an unhelpful term if the MCA is being described. The consent process if the patient is mentally capable, is correctly described as Supported Decision-Making: the clinician explains clinical options and outcomes, after which the patient accepts or refuses an offered intervention. As we can read on page 2 of the paper:
‘These [decision support tools] provide short (one to three pages) summaries of the treatment choices, the likely outcomes, and the factors that patients might consider when making their decision, including risk and benefit data.’
Challenge 3 raises the issue of whether or not patients actually want to make their own decisions, which I feel sure is a major issue: but, it is clear that English law is now firmly based on a requirement for Informed Consent, and it becomes ‘messy and problematic’ if patients are treated in the absence of genuine informed consent. Patients are not required to express a ‘preference’ at the conclusion of the process of informed consent: the patient is required to express the decision. Not to express ‘a good, or wise, decision’ but to express ‘an informed decision’ - which takes us back to the barrier of clinicians ‘doing what they perceive as the best for their patient’, when our law limits the clinical role to the provision of information.
Challenge 4 starts with ‘Clinicians and managers implementing shared decision making want to know what difference it makes to their patients and to clinical practice’ and that is also problematic for informed consent: the difference in outcomes, good or bad, is not the metric for informed consent. It will never be a satisfactory situation if our judges and law are examining whether consent was informed, while our clinicians [and perhaps patients] are more interested in comparing ‘outcomes’.
Challenge 5 develops the same theme - ‘For example, the Quality and Outcomes Framework rewards general practitioners for behaviours that are evidence based but not necessarily about what matters most to patients’ - and that is the foundation of informed consent: ‘what matters most to the individual patient’. What matters to the patient will often be ‘the best clinical outcome’, although this is not so true in end-of-life, which I write about, and it is not necessarily true in other situations.
So, in ‘Recommendations for implementation’, when I read the following, all I can say is ‘well, your shared decision-making is not an accurate description of our law’:
‘Shared decision making may not necessarily result in, or depend on, complete agreement between a clinician and a patient. Instead, it is about bringing both types of expertise together, and weighing up the available options in light of both of these perspectives; it makes it more likely that the final decision is informed by what the clinician knows (medical evidence, clinical experience) and by what the patient knows (what matters to them, the outcomes they are prepared to accept).’
There is no ‘melded mind’ involved in Informed Consent: it is not a combination of the clinician’s mind and the patient’s mind that ‘weighs up the available options’ - the patient’s mind weighs up the options, so it would be, to fit English law:
‘the final decision is informed by what the clinician knows (medical evidence, clinical experience) but made by the patient, who also considers what matters to him and which outcomes he prefers’
FOOTNOTE: the paper does not seem to address mentally-incapable patients. But the MCA does not describe ‘shared decision-making’ there, either: it describes ‘defensible decision-making’ (which requires consultation and information sharing) and it also describes whether decision-making authority exists or not (what typically exists, is a legal duty – not a legal authority).
It is problematic when ‘ethics’ and ‘law’ do not easily fit:
Mike Stone Contact email@example.com
Competing interests: No competing interests