Implementing shared treatment decision making and treatment decision aids: a cautionary tale

Abstract

Clinical and research interest in shared treatment decision making (STDM) and decision aids (DA) evolved in the 1980’s and 1990’s with an initial focus on patients with cancer, and particularly, women with breast cancer. This interest has undergone a shift in emphasis over time from curiosity about the meaning of these concepts and their potential to improve patient participation in treatment decision making to wide scale endorsement, attempts to expand implementation in a variety of clinical settings, measurement of multiple outcomes at the clinical and public policy level, and the development of standardized criteria for evaluating DA. In this chapter we raise the question: are we moving too fast to promote implementation of STDM and DA before resolving important challenges that still exist about the meaning and merits of these initiatives? We discuss four such challenges: i) ambiguity and inconsistency in the definition of STDM, ii) variations in patient and physician preferences for STDM, iii) the increase in the number and range of goals defined for STDM and /or DA to achieve, and iv) the lack of well documented theoretical and empirical support for criteria to be used in evaluating DA quality, and potentially for purposes of DA certification. These findings suggest the need for caution, for more thoughtful analysis, and additional research on the challenges raised above prior to wide scale endorsement of STDM and DA in routine clinical practice.