[Shared decision making: an approach to strengthening patient participation in rehabilitation]

In this paper, the concept of Shared Decision Making, i. e. the participation of the patient regarding the selection of therapeutic goals and treatment options, is presented. The degree of patient participation in medical decisions varies widely across different models of the physician-patient relationship. According to the paternalistic model, the physician knows best what is in the patient's interest; patient participation is limited. This model clearly does not take into account patients' autonomy and desire for information appropriately. In contrast, the informative model claims that values are well-known to the patient while the physician's role is restricted to providing him with the necessary information. However, the assumption of fixed values may be challenged. Patients expect their doctors to be not only technical experts but also caring persons. In the interpretive model, the physician's task is to help the patient to identify and express his values. In the deliberative model, both physician and patient engage in an open discussion about the values the patient could and should pursue. The physician is allowed to present his own preferences, and conflicting values are discussed explicitly. Thus, the patient is empowered to choose between alternative preferences. This model forms the basis of shared decision making, which involves at least two participants who engage in a process of both mutual information and interactive discussion. Patient participation should result in a greater sense of personal control, more satisfaction with treatment, better compliance and transfer into the daily routine of disease management and, consequently, better outcomes. Although it is largely unknown whether these outcomes are achieved, indirect evidence may be gained from systematic reviews showing that a favourable physician-patient communication (i. e. allowing patients to express their information needs and concerns and to receive both information and emotional support) produced better outcomes regarding both mental and physical health. There are several barriers to shared decision making. No information exists regarding the degree to which physicians are interested in shared decision making. While there is ample evidence that patients' needs for information are high, patients' wishes for participation seem to vary widely, though. Both physicians and patients require the ability to make shared decisions. Structural restraints include time and institutional inflexibility. To conclude, shared decision making is a promising approach to enhance patient participation in rehabilitative care.