Definition
Shared decision making (SDM) is a consultation process where clinician/s and individuals with cancer alongside their support person/people jointly participate in making a health decision. Discussions around treatment options and the likelihood of benefits and harms, and considerations of the patient’s values, preferences and goals is explored in this process.
Perioperative SDM focuses on decisions about surgery and alternatives – particularly where there is concern and/or where the anticipated harms may outweigh benefits1.
SDM benefits all patients contemplating surgery but is particularly useful for those patients with significantly elevated perioperative risk, where there are complex psychosocial considerations and/or there may be clinician or patient concerns expressed.
SDM should be tailored to each individual’s level of health literacy, cultural/linguistic considerations and their desired level of involvement in the decision-making process (recognising that these preferences can evolve over time).
Where possible and desired, support persons (such as family, carers, friends or significant others) should be invited to be involved in the SDM process.
- Patients sharing their values and goals that influence their decision making as well as their goals for treatment.
- Clinicians sharing best available evidence-based information about treatment options along with their expected benefits and anticipated burdens of treatment2.
- Clinician expertise to tailor and communicate the evidence to best meet the individual’s needs and also their desired level of involvement in decision making3.
- If appropriate, offering a patient-centric treatment recommendation that is based on, and reflects, their expressed values and goals.
Perioperative SDM may take place within a number of models of care.
- For low-risk patients, SDM may be most efficiently provided in the context of routine perioperative clinical encounters. All patients should receive `universal shared decision-making´ which can be described using the aide memoir INFO:
- I= individualised (type and degree of information, and how much patients wish to be involved in discussions about care)
- N= needs, preferences and goals (for the future and for treatment)
- F= facts (best available evidence to guide likelihood of benefits, harms and consequences acknowledging uncertainties where these exist)
- O= Options (which may be surgical or non-surgical treatments including watchful waiting or best supportive care)
- However, those patients with higher decisional needs – for example frail, multimorbid, those with complex psychosocial considerations – may be more efficiently provided structured decision-support by perioperative SDM services which are available in some institutions. SDM services may also be provided within high-risk pre-anaesthetic clinics.
Examples of clinicians involved in perioperative SDM forums may be:
- Surgeons
- Anaesthetists
- Perioperative clinicians
- Allied health staff (physio, nutrition, psychology)
- Intensivists
- Specialty medicine
- Specialist nurses (stoma nursing, prehabilitation)
- Primary care and rehabilitation medicine
- Geriatrician.
While there is a growing body of research on SDM, most of it focuses on settings outside of surgery. This is an evolving space in the perioperative context. There appears to be a signal for improved decisional quality and reduced decision regret in the surgical setting, however the lack of a clear, operational definition or framework for perioperative SDM has hindered its consistent implementation and subsequent evaluation. An international, multidisciplinary group has recently drafted pragmatic clinical practice guidance through a structured consensus process, to address the need for a framework to support the consistent implementation of SDM in the perioperative context4. These recommendations provide pragmatic guidance on the core components to be considered when establishing a perioperative SDM service.
Services offering structured decision support may be known by different names including:
- SDM services
- Complex Decision Making (CDM) clinics
- Perioperative care of the Older Person (POP) clinic.
These services provide patient consultations and often have access to a multidisciplinary forum to support decision making
Screening
There are currently no established criteria for identifying patients who would benefit from enhanced decisional support and referral to SDM services. It is recommended that SDM services develop locally tailored screening processes and referral criteria. However, the below criteria may provide some guidance.
- Major surgery plus one/more of the following:
- > 4% calculated 30-day perioperative mortality risk
- Objective markers indicating high perioperative risk or poor functional capacity e.g. poor peak VO2 or anaerobic threshold on CPET
- High frailty index as indicated by the Clinical Frailty Score
- High risk of cognitive decline
- Clinician concern
- Uncertainty in decision-making indicated by patient or healthcare team
- Answer “no” or “uncertain” to ‘Surprise’ question: “Would I be surprised if this patient died in the next 12 months?”5
Intervention
Patients with high decisional needs should receive enhanced decisional support through a coordinated shared decision-making service. The intervention should include:
- Prepared patients and support persons: patients should be informed about the purpose and format of the consultation, encouraged to consider what matters most to them, and invited to involve family members, carers or other support people.
- Consultations should be delivered by clinicians with effective communication skills, access to relevant clinical and contextual information, and sufficient time to explore complex decisions.
- A multidisciplinary forum with two-way communication: relevant clinicians should exchange information before the consultation to clarify the available treatment options, individualised risks, potential outcomes and uncertainties. The patient’s goals, preferences and agreed plan should then be communicated back to the multidisciplinary team, with further discussion where required. The forum should inform, but not make, the decision for the patient.
These will vary depending on the health service
- Patient involvement in decision-making to the extent that they wish to be
- Formulation of a goal-congruent collaborative care plan that takes into account (potentially dynamic) personal values and preferences at the time the decision is made
- Satisfaction with decisions
- Reduced decision regret
- Minimising decisional conflict
- Optimising decisional quality
- Where appropriate, discussion about limitations of medical treatment
- Advance care planning and nomination of a medical decision treatment maker (MDTM)
Within the shared decision-making consultation, clinicians should:
- establish the patient’s preferred level of involvement and how they would like to be supported;
- explore their goals, values, expectations, concerns and understanding of their illness;
- clarify what outcomes would represent a successful treatment and which outcomes or losses of function may be unacceptable;
- discuss all reasonable options, including surgery, alternative treatments, watchful waiting, symptom-focused care or best supportive care;
- communicate the individualised likelihood of benefits, harms, consequences and functional outcomes, while acknowledging uncertainty;
- explain the practical trade-offs associated with each option, including recovery, treatment burden and possible limitations or escalation of care;
- support the patient to deliberate over time and, where appropriate, provide a patient-centred recommendation based on what they have said matters most;
- agree on and clearly document the decision, its rationale and the next steps.
The consultation should be underpinned by relational skills that build trust, rapport and empathy. Clinicians should use partnership language, listen without judgement, recognise the influence of emotions and previous experiences, avoid rushing to closure, and tailor communication to the patient’s cultural, linguistic and health-literacy needs. The aim is not simply to transfer information, but to create a psychologically safe relationship in which the patient feels heard, supported and able to participate in the decision to the extent they wish.
Clinicians conducting SDM consultations should have experiential skills training to gain the necessary knowledge and skills. Commonly adopted SDM communication frameworks from outside the surgical setting include:
- The 3 Talk Model6
- The 5 question model7
Assessment tools (of the patient)
At present, there are no agreed-upon best methods for measuring either the process or outcomes of perioperative SDM. In the absence of robust evidence, services are nonetheless encouraged to evaluate both:
- A measure of the SDM process itself
- Outcomes that matter to patients, clinicians, and the healthcare system.
This dual approach can help build local insight and support continuous improvement while the evidence base continues to evolve.
Evaluation tools
- CollaboRATE score – Patient reported experience measure for SDM8
- OPTION score – observation instrument for assessing the extent to which clinicians actively involve patients in decision making9
- Decisional regret – Download here
- Decisional support on a Likert scale.
- Decisional conflict scale – Download here
- Quality of life measures e.g. Eq5d
- Utilisation of SDM services
- Postoperative complication rates
- Unexpected readmission rates
- 30/90 day mortality
Resources
- NHS (UK) SDM implementation checklist
- Australian commission on safety and quality in healthcare: Shared decision making
- SDM video by Australia and New Zealand college of anaesthetists
- Finding your way (Australia)
Shared decision making model created with mob, for mob. It is a holistic, two-way process where Aboriginal people and their healthcare professionals make decisions together.
- Leung. The Role of Perioperative Shared Decision Making: When Risk Is Non‐modifiable. Current Anesthesiology Reports. Nov 2021. https://doi.org/10.1007/s40140-021-00492-z
- Kruser, J. M. et al. “Best Case/Worst Case”: Training Surgeons to Use a Novel Communication Tool for High-Risk Acute Surgical Problems. Journal of pain and symptom management 53, 711-719.e5 (2017).
- Pham, C. et al. Strategies for implementing shared decision making in elective surgery by health care practitioners: A systematic review. J Eval Clin Pract 26, 582–601 (2020).
- Leung, D., Collins, A., Philip, J., Grocott, M.P.W., Riedel, B., Levett, D.Z.H. and the PeriOperative Quality Initiative XVIII (POQI XVIII) Workgroup (2026), PeriOperative Quality Initiative consensus statement recommendations on the definitions, aims and delivery of shared decision-making for major surgery. Anaesthesia, 81: 1100-1115. https://doi.org/10.1111/anae.70205
- van Lummel ETVJ, Ietswaard L, Zuithoff NPA et al. The utility of the surprise question: A useful tool for identifying patients nearing the last phase of life? A systematic review and meta-analysis. Palliative Medicine 2022, Vol. 36(7) 1023–1046 | doi: 10.1177/02692163221099116
- Elwyn G, Durand MA, Song J, et al. A three-talk model for shared decision making: multistage consultation process. Bmj. 2017;359:j4891. doi:10.1136/bmj.j4891
- Hoffmann TC, Légaré F, Simmons MB, et al. Shared decision making: what do clinicians need to know and why should they bother? The Medical Journal of Australia. 2014;201(1):35-39. doi:10.5694/mja14.00002
- Barr, P. J. et al. The Psychometric Properties of CollaboRATE: A Fast and Frugal Patient-Reported Measure of the Shared Decision-Making Process. J. Méd. Internet Res. 16, e2 (2014).
- Elwyn, G. et al. The OPTION scale: measuring the extent that clinicians involve patients in decision‐making tasks. Heal. Expect. 8, 34–42 (2005).