Despite the acknowledged benefits of shared decision-making—such as ensuring that client preferences and values are incorporated in care and treatment decisions, improved communication between clients and practitioners, better treatment adherence, increased satisfaction with care and fewer unwarranted variations in clinical practice—not all practitioners engage their clients in shared decision-making (Coulter and Collins, 2011). Coulter and Collins (2011) argued that shared decision-making is an ethical imperative, because it ensures information sharing and working in partnership and is associated with better outcomes.
The NHS Constitution (Department of Health and Social Care, 2015) and other policies for Scotland, Wales and Northern Ireland confirm that people have a right to be involved in decisions related to their care and treatment.The Mental Capacity Act 2005 sets out a statutory framework for decision-making for those who lack capacity in England and Wales, with the accompanying code of practice (Department of Constitutional Affairs, 2007), which provides guidance on the roles of different actors (those appointed by the courts, healthcare and other professionals and untrained staff) in decision-making. The National Institute for Health and Care Excellence (NICE) (2018) published its own guidance, which covers the overarching principles of decision-making, supporting methods, advance care planning, assessment of mental capacity and best-interest decision-making; this should be carefully read to inform practice. More recently, NICE (2019) published a draft scope for consultation for the development of ‘shared decision-making’ guidelines (expected to be published in April 2021), which will cover all clinical settings, including care in the home.
Shared decision-making is not the norm for many reasons: the mistaken beliefs that clients do not want involvement, clients will choose expensive and/or inappropriate treatments, those with low levels of health literacy are disinterested, it will make no difference, well-informed clients will demand more, there is insufficient time and, lastly, it is already embedded widely in practice (Coulter and Collins, 2011). The evidence does not support these beliefs, and Coulter and Collins (2011) made the case for co-creation in healthcare to embed shared decision-making and how it has long-term benefits, with clients becoming more engaged in self-care.
Without exception, health and social care practitioners should engage fully with their clients so that decision-making is collaborative and client preferences are respected and incorporated in care delivery. District nurses could lead the way by modelling shared decision-making with their clients by offering discussion of care and/or treatment options outlining the relative risks and benefits prior to documenting agreed decisions. Offering such a model may enable clients to be more assertive in other healthcare consultations and social care discussions, so that no decisions are made without the client's perspective being fully represented in the agreed decision. An added bonus will be improved satisfaction with the care experience (Coulter and Collins, 2011). Perhaps the falling satisfaction with the NHS in part reflects the persistence of limited shared decision-making in healthcare consultations, alongside the perception of long waiting times, staff shortages and inadequate funding (Robertson et al, 2019).
“Shared decision-making is an ethical imperative, because it ensures information sharing and working in partnership and is associated with better outcomes.”