Beyond shared decision making: an expanded typology of medical decisions

The most popular current models of medical decision making, identified by names such as shared decision making, informed decision making, and evidence-based patient choice, portray an empowered patient actively involved in his or her medical choices and generally assume that patient and physician reach agreement. These models are limited to a specific type of decision (in which there is more than one choice) and a specific process (in which agreement is reached). The authors extend the model of medical decision making beyond shared decisions in 2 dimensions. First, the authors incorporate a class of medical decisions in which there is only one medically reasonable treatment option, such as the removal of a primary melanoma. Patient preferences are irrelevant to whether or not the melanoma should be removed, so there is no treatment choice in which the patient can share. When there is only one realistic treatment option, the clinician's job is not to offer alternatives but to explain why there is only one viable choice and move the decision-making process forward. The physician does not thereby abridge the patient's autonomy; rather, the disease process itself constrains both patient and physician. Second, the authors include decisions in which patient and physician do not reach agreement. Sometimes the patient insists on a particular treatment and the physician reluctantly yields, sometimes it is the other way around, but disagreement is commonplace in clinical medicine and its presence deserves inclusion in the way we think about medical decisions. Conflict resolution requires acknowledging the potential for conflict.