Theroleofpatients: Shared Decision-Making
Theroleofpatients: Shared Decision-Making
Theroleofpatients: Shared Decision-Making
Shared Decision-Making
a b c,d,e,
Emily Beers, MD , Marci Lee Nilsen, PhD, RN , Jonas T. Johnson, MD *
KEYWORDS
Shared decision-making Autonomy Bioethics Patient-centered care
Head and neck cancer Physician-patient communication
KEY POINTS
Treatment priorities between patients and clinicians may not be congruent.
Most patients want to be offered choices.
Treatment options need to be explained.
Risks and benefits should be outlined and realistic.
Clinical practice guidelines may facilitate these discussions.
Decision aids, specifically patient education materials, support informed choices.
Patient preferences vary.
INTRODUCTION
Most patients with squamous cell carcinoma of the head and neck present with
advanced disease (stage III or IV).1,2 They will face many decisions about their treat-
ment, which can be very difficult for patients and their families. For many patients, the
effects of their cancer and its treatment will persist for years and impact basic function
of everyday life, such as swallowing, speech, and cosmesis. The Institute of Medicine
now recognizes that shared decision-making (SDM) is a central component to
patient-centered care and is essential to improving quality of care, especially in
oncology.3 Sharing in this process with patients helps ensure that they are educated
and informed while incorporating their values and preferences into the decision process.
The American Medical Association’s 1847 original Code of Medical Ethics advised
doctors that “the obedience of a patient to the prescriptions of his physician should
be prompt and implicit. The patient should never permit his own crude opinions as
to their fitness to influence his attention to them.”4 This antique, authoritarian model
of patients as passive recipients of doctor’s orders is fortunately becoming a thing
of the past. Despite that slow fade, however, the normative values of that paradigm
that reigned for millennia have not entirely vanished. The increased emphasis on pa-
tient autonomy has in general been good; however, autonomy is itself a complex
concept that has great bearing on the physician-patient relationship.
In the paternalistic extreme, the physician provided a plan that patients obeyed,
removing agency from patients and giving all of the power to the physician. This model
spanned from the time of Hippocrates to the 1970s. In that decade, massive culture
shifts in America forever changed the roles of women, minorities, and society’s view
of authority. This change created a reactionary backlash to the paternalistic past on
many fronts, and medical case law evolved in parallel. The 1972 case of Canterbury
v Spence transformed our health culture by drastically changing standards for
informed consent. Until that point, informed consent for a treatment included a discus-
sion that met the standard of community disclosure, that is, whatever the most physi-
cians in a community would say about such treatment. Canterbury v Spence detailed a
patient who was advised to have a laminectomy for back pain; in his case the surgeon
did not disclose the 1% risk of paralysis for fear that it would cause the patient to reject
the beneficial treatment. When the patient suffered paralysis (either from surgery or a
postoperative fall), the court ruled that the lack of disclosure was a failure on the phy-
sician’s part. The court challenged the concept of community standard on grounds
that it incentivizes physicians to protect themselves by limiting standard disclosure,
which is not a practice aligned with patients’ best interests.5 In that ruling they noted
“.the test for determining whether a particular peril must be divulged is its materiality
to the patient’s decision: all risks potentially affecting the decision must be
unmasked.”6 This ruling resulted in legal codification of a physician’s duty to fully
inform, from which all current standards of informed consent have developed.
Bioethics also had a rapid evolution in that time, and the wave of antipaternalism
caused some to advocate for a cultural reversal of power in the patient-physician
dyad: in this version, patients dictated their preferences for treatment, and the physi-
cian’s role was simply to execute a logical plan that honored those preferences. This
version was the first stirring of patient-centered medicine, a model in which “the object
of our studies is.therapy: not an isolated or specialized medical skill, but the doctor’s
whole professional activity regardless of whether he is a specialist or general practi-
tioner.”7 As the pendulum swung from paternalism to physician as passive executor
of medical possibility, the current standard has settled somewhere in the middle of
those two margins.
In modern SDM, the physician provides the medical facts and treatment options,
patients provide their values, and together they form a plan that best matches the facts
to the values.8 Although this model is far superior to either of the extremes, troubles
remain with the way it is implemented. Firstly, this model presumes facts and values
can remain completely separate. When physicians are giving facts, the data show that
it is rare that they can provide these in completely value-neutral manner. In an analysis
of 1057 audiotaped conversations of medical and surgical outpatients containing 3552
clinical decisions, only 9.0% of basic and 0.5% of complex decisions made met the
criteria for informed decision-making.9 That is, when we deliver information to patients
The Role of Patients 691
we are not just conveying facts but overlaying a complex set of our own values and
symbolism about what is important.10,11 Much of current practice in SDM evolved
from the principles of informed consent. Unfortunately, modern informed consent
has become only more informed over time, as evidenced by medication package
inserts and exhaustive forms designed to protect the physician from liability. When
Canterbury v Spence ruled that all risks must be disclosed, we accelerated disclosure
without proportional increase in patient knowledge.
Secondly, this still deprives the physician of much input: patients’ values are always
seen as foremost; in the era of health care consumers, we are generally taught that the
customer is always right. As drug companies, insurance providers, and clinicians all
battle in the era of cost-containment, every side is scrambling to represent themselves
as patients’ biggest advocate.12 Although it is crucial to be our patients’ best sup-
porter, it is unfair to expect doctors to act as impartial fact-delivery agents without
their own moral systems and values to uphold. Additionally, patients who are ill are
often suffering from fear, anxiety, and uncertainty amid an ocean of freely available,
and sometimes inaccurate or misleading, medical information. They should not be ex-
pected to analyze this in such a state and claim sole responsibility as preference-agent
whom the doctor obeys.
In their pioneering 1979 book Principles of Biomedical Ethics, Beauchamp and
Childress13 outlined the 4 main principles of medical ethics: autonomy, beneficence,
nonmaleficence, and justice. Beneficence and nonmaleficence relate heavily to a phy-
sician’s performance/nonperformance of various treatments for a condition, and jus-
tice is frequently a broader principle of recognizing and overcoming health care
disparities. Autonomy, however, is the elemental core in a patient-provider relation-
ship. In modern medicine, patients’ right to self-determination is rightly considered
sacrosanct. The cutting edge of truly SDM is that it fully supports patients’ autonomy
while not neglecting the physician’s autonomy either. Both parties are seen as able to
provide facts and values. In complex treatment decisions, physicians have an obliga-
tion to explore the patients’ values while presenting the facts. The things that consti-
tute value in life vary significantly from person to person: one may think it is imperative
to be able to perform high-level cognitive tasks, whereas another may find value in
simply being present and aware for one’s family. When physicians make a recommen-
dation, we automatically incorporate our own system of values about quality of life
based on our experiences, which is not a bad thing but something we must remain
aware of. For patients to benefit from our expertise, we must guide them; but in order
to do that best, we must explore their values and goals to give us both a road map and
sense of direction.
Box 1
The essential components of shared decision-making
Four steps
1. Inform
2. Explain
3. Identify
4. Make
In order to help illustrate the components of SDM, the authors would like to present
the following case study:
Ms F is a 70-year-old woman. She has a history of multiple head and neck cancers and
has undergone several surgical procedures over the past 15 years, including a partial glos-
sectomy, partial maxillectomy, and resection of the buccal mucosa squamous cell carci-
noma. Ms F returned to the authors’ head and neck clinic as a routine follow-up. In addition
to her extensive head and neck cancer history, she has multiple comorbidities, including
rheumatoid arthritis, diabetes, heart disease, macular degeneration, and advanced
vasculopathy requiring bilateral below-the-knee amputations.
During her initial physical examination, an abrasion was noted on her chin. Ms F
reported that she had fallen several days ago and was going to follow-up with her gen-
eral practitioner about the abrasion. On further examination of her chin, Ms F was
informed that this could potentially be another cancer and she agreed to have a biopsy
done in the office. The authors acknowledged that if the biopsy proves that this can-
cer, it would be advanced cancer and we would need to discuss treatment options. In
asking about her support system, she requested that her niece, who was the durable
power of attorney, be present when the treatment options were discussed.
The pathology results confirmed that the lesion was invasive squamous cell carci-
noma. A follow-up visit was scheduled with the patient, and a computed tomography
(CT) scan was ordered. The CT scan demonstrated that lesion was extensive and
included the floor of mouth with erosion through the mandible into and through the
overlying skin. With her family present during the follow-up visit, all treatment options
were outlined with the benefits and potential side effects.
When asked about her thoughts on the treatment options, Ms F acknowledged that
surgery would be extensive with a lengthy recovery that could be very difficult for her,
especially knowing that the result may not be curative. She was also aware that radi-
ation with or without biochemotherapy was not likely to be curative and may present
additional side effects. During the discussion, Ms F stated that her preference was to
remain at home. With a life expectancy of 4 to 6 months without treatment, Ms F was
referred to hospice agency that was identified by the patient and her family.
the case study, Ms F was informed via telephone that her results did demonstrate can-
cer and that treatment decisions needed to be made. She expressed her interest in
having family present, and a follow-up appointment was set up.
Step 2: Explaining the Treatment Options
The treatment options need to be explained to patients in a neutral manner, including
open and honest communication regarding their prognosis and treatment outcomes.
Discussing the treatment options, including benefits and potential side effects of treat-
ment, can help build a trusting relationship between the physician and patients. The
risk and benefits need to be outlined for each treatment options in terms that are clear
and meaningful for patients. It is also important to assess what patients already know
because they may have existing knowledge from other sources (eg, Internet, word of
mouth) and verify patients’ understanding by asking them to explain what they
perceive the treatment options to be. In terms of the authors’ case study, all potential
treatment options, including the options of no active treatment but instead palliative
and supportive care, were presented.
Step 3: Identifying Patients’ Values and Goals
Although discussion of patient preferences and goals can be incorporated into discus-
sion of the treatment options, many patients may not have clear preferences at the
onset of the discussion. It is important that physicians help guide patients in identifying
their preference through asking open-ended questions that explore what matters to
patients. When discussing pros and cons of treatment, it is imperative that we explore
the relevance of the outcome to patients. When treatment priorities are compared be-
tween patients and clinicians, they are often not congruent.22–26 Ms F was allowed
time to express her thoughts on the treatment options. With her prior treatment his-
tory, Ms F was aware of the potential effect of the treatment options and the extent
of recovery that would be involved with surgery. She acknowledged that being
home and the avoidance of further toxicities of treatment were important to her.
Step 4: Making the Decision
Once we have established the treatment options and what outcomes are important to
patients, the actual decision-making can occur. The physician should summarize what
has been addressed and ask for patients’ input or opinion. Depending on the patient
and situation, patients may need time to think about the decision or may want to
discuss it with their loved ones. If not, the physician and patients can agree on how
to proceed. In this case, Ms F and family had an extended discussion in the treatment
room before making a decision. The treatment team worked with Ms F and her family
to find a hospice agency to help continue her care and symptom management.
approach may not be patient centered. Instead, it may present a barrier to effective
SDM as patients’ values and preferences are not acknowledged during the MDT’s
treatment discussion; this has been described as health care “in absentia.”30–32
When patients’ wishes and values are not fully identified or considered during the
MDT meeting, a discordance between the MDT’s recommendations and treatment
implementation can occur.33
Decision Aids
One of the newest developments in the quest for better-informed patients in a busy
clinic is the use of decision aids (DA), specifically formulated patient education mate-
rials designed to improve patient knowledge and support informed choices. DAs for
both prevention and treatment decisions have just undergone their fifth Cochrane re-
view, which shows that the evidence continues to mount in favor of their use. Quality
evidence demonstrates DAs increase patient knowledge, reduce decisional conflict,
stimulate a more active role in SDM, and improve accuracy of risk perceptions of treat-
ments.37 Unfortunately, in the oncology world, DAs tend to be more common for pre-
vention and screening as opposed to treatment38 and DAs specific to patients with
head and neck cancer are surpassingly rare.39 The International Patient Decision
Aid Standards Collaboration has developed extensive criteria and guidelines to assist
practitioners in formulating such materials, clear information delivery, methods to elicit
patient values, providing structured guidance, peer review, and using plain language
(eighth-grade reading level).40,41 A successfully proven DA in oncology patients is the
question prompt list (QPL).42 The QPL is a booklet of questions about various dimen-
sions of care designed to assist patients when their doctor asks if they have any ques-
tions and they may struggle to respond to all of the information. The University of
Sydney has made this a printable booklet freely available online.43 New Web-based
DA platforms allow more rapid development of content that can be easily tailored to
specific patient demographics.44 The world of DAs in head and neck cancer is a
largely unexplored frontier but one that has promise to improve communication
without adding additional visit time.45,46
CHALLENGES
Patient Preferences Vary
Talking to patients about their desired role in decision-making is a critical part of treat-
ing physicians’ role to help assure patient satisfaction with the process. Over the
course of time, patients have tended to have an increasing preference for a more
The Role of Patients 695
active role in treatment decisions47–49; however, there are many factors that influence
patients’ decision-making preferences. In general, most patients want to be offered
choices and asked their opinion; none the less, a substantial portion may still prefer
to leave final treatment decisions to the physician.50–52 A critical part of the physician’s
duty is to ask about patients’ decisional preferences, which creates higher levels of
accord with patients’ goals. When patient decision-making preferences are met or
exceeded, patients have less conflict over the treatment decision, more satisfaction
with their ultimate decision, more satisfaction with the consultant’s communication,
and perceived higher levels of their oncologist’s use of SDM skills compared with
patients who were less involved than they hoped to be.53
Patients tend to fall into 3 broad categories of decision-making preference: active,
collaborative, and passive. Active patients wish to make the final decision about care
after hearing the doctor’s opinion; collaborative patients prefer to equally share re-
sponsibility for decision-making; passive patients wish the doctor to play the central
role in choosing a treatment.54 Although metrics somewhat vary, in general, approxi-
mately half of patients prefer a collaborative role, whereas the remainder are divided
fairly evenly between preference for an active or passive role.52,55–58 Patients who are
younger, more educated, and of higher income tend to prefer an active decision-
making role.51,54,59,60 Patients who are older, nonwhite, and with lower socioeconomic
status tend to have less satisfaction with decision information and are more likely to
have knowledge gaps when providing informed consent.61–65 Physicians must remain
vigilant for their own racial bias, as those with implicit bias were rated as less support-
ive, spent less time per patient, and caused less patient confidence in and adherence
to the treatment plan.65 Studies have shown inconsistent results in terms of sex trends
for SDM preferences, but it is worth noting that women are less likely to describe their
role as active despite expressing a preference for an active role.55
There has been much focus recently on active patients’ role, which is concordant
with the trend away from paternalism. Despite this movement, however, incongruity
between hoped-for and actual SDM outcomes persists. A meta-analysis of preferred
versus actual decision-making roles in patients with cancer indicated a significant de-
gree of discrepancy between the level of engagement patients preferred and what
actually occurred.66 Almost all patients in this review desired a higher level of engage-
ment than transpired. In a separate sample of oncology patients, those who described
physician-controlled decisions were less likely to report excellent quality of care,
regardless of their stated decision-making preference.67
Even as we work toward increasing concordance between patient and physician
decisional styles, there remains a substantial body of patients who still prefer passive
decision-making left to the physician’s judgment. Oncology patients who have a pas-
sive role tended to use less engagement in their coping strategies, that is, less active
coping, planning, humor, or positive reframing. In addition, they have less resilience
and higher levels of fatalism.59 Cognitive coping style is also associated with patients’
need for information, involvement, and satisfaction with SDM; importantly, even
patients with an avoidant/blunting coping mechanism still desire significant amounts
of information.45,68
burden and reduce distress without detriment to caregivers82–85 and reduce cost,86,87
and randomized controlled trials have shown increased survival.88,89 The literature in
patients with head and neck cancer is far more limited. A recent review by Liao and
colleagues90 identified some common barriers to transitioning to palliative treatment
in this group of patients, including physician’s incorrect estimation of symptom
impact, lack of investigation into patients’ desire for family in SDM, lack of knowledge
of financial impact of treatments, and physician emotion related to giving up hope. Pa-
tients with head and neck cancer often have substantial symptom burden at the end of
life, but interestingly providers may overestimate the impact of these symptoms.90,91
Given the anatomic communication difficulties that arise in these patients, it is even
more imperative that we engage in a discussion of their preferences early in the treat-
ment course. As disease progresses beyond the possibility of curative treatment, palli-
ative and hospice care must eventually be discussed. Estimates have suggested that
at least 20% of patients would qualify for hospice referral at the time of diagnosis.92
Patients with head and neck cancer have a particularly challenging set of symptoms
that test the limits of the hospice benefit.93 Although hospice is an excellent care
plan that can improve quality of life and reduce costs,94,95 these are some of the
most challenging hospice patients. Patients at risk of catastrophic bleeding or sudden
airway collapse present the greatest challenge. Inpatient hospice is an excellent
resource for this demographic, but the precipitous nature of the condition can
make it hard to use these resources appropriately. The case that follows touches on
some of the principles discussed:
Mr G initially presented at 23 years of age (1985) with a small cell carcinoma of the
left maxilla while on active duty in the military. He was treated with conventional full-
course radiation therapy and remained disease free until 2013 when he began to
develop progressive dysplasia in the oropharynx. In January 2016, biopsy showed
invasive squamous cancer (human papillomavirus negative). At that time, the area
of involvement was circumferential in the oropharynx, with involvement of the base
of tongue and all 4 walls. He declined surgery, further radiation, and chemotherapy
at that time. In September 2016, he returned with stridor, at which time he initially
declined tracheostomy. However, when told there were no good alternatives, he indi-
cated he was not ready to die and tracheostomy and a percutaneous endoscopic
gastrostomy (PEG) tube were performed.
How could the authors have improved this patient’s care? He understood in January
that he had untreatable, incurable cancer and yet returned to the emergency depart-
ment 9 months later in distress. Introducing the topic of palliative surgery further
upstream in the discussion can help obviate emergency department admissions for
patients with no curative treatment available. When we know that patients are likely
to have airway compromise or terminal dysphagia, open and honest discussion of
the possibility of tracheostomy and PEG before they occur allows patients to consider
them in a nondistressed state. It also important to remember that patients will almost
always fluctuate in their level of acceptance of their illness. Although we tend to see
denial and acceptance as binary states, patients tend to fluctuate between them
and use each in various circumstances as a coping mechanism.96
Another major barrier to pursuing palliative treatment is intervention bias or the pro-
pensity to think that doing something is better than doing nothing. Intervention bias is a
complex phenomenon involving portions of self-interest, confirmation, and publication
biases.97 Physicians wrap up their moral identities in the curing of disease and triumph
over illness, and American physicians in particular are more apt to choose intervention
over observation in a broad variety of circumstances.98 This bias runs deep through
the heart of our existence as professionals and is not easily reconciled. The financial
698 Beers et al
incentives of the American health care system are deeply biased toward intervention;
although we all strive to provide just, responsible care, it is impossible to eradicate this
feature in the current health care environment. Increasing premiums and deductibles
attempt to increase cost-sharing incentives for patients but in fact can lead to poorer
compliance99,100: the model assumes that patients use health care services in the
same way they do traditional consumer goods. Even our much-vaunted evidence-
based medicine structure arises from a foundation of human researchers who spend
lifetimes invested in their work and whose very sense of self is bound up in success of
their work in a publication environment predisposed to report significant treatment
results. Studies with positive results of the intervention can be 2 to 3 times more likely
to be published,101 and positive-outcome studies were more favorably reviewed and
suggested for publication in the peer-review setting.102 Intervention bias is a hydra-
headed enemy that the treating clinician will confront in many arenas, and as we
look back to the core of medical ethics we must remember that the irreducible princi-
ple of nonmaleficence dictates that before all other things we “first do no harm.”13
Consequences of Treatment
There is a vast array of data published about head and neck cancer treatment compli-
cations and quality-of-life outcomes. Although dysphagia, xerostomia, dysphonia,
mucositis, fistula, and fatigue can all plague these patients,103 most of these symp-
toms have clinical algorithms for treatment. However, there is one silent symptom
that is often underreported unless specifically queried by the physician: depression.
Although patients generally feel comfortable talking about their physical symptoms,
depression and anxiety often carry stigma.104 In the context of SDM and improving
our communication with patients, being attentive to depression in this group can
substantially improve trust and influence treatment outcomes.
We know depression among the head and neck cancer population is a known
concern. Some studies have shown a risk as high as 20% to 40%, with depression
serving as a detriment to treatment adherence and functional outcome.105–107 There
are not enough data to definitively know if depression is linked to overall survival,
but the high incidence of pretreatment and posttreatment depression should make
clinicians watchful.108,109 The most frightening complication of unrecognized or un-
treated depression is suicide, which has been shown to be present at a substantially
higher incidence in this population. A general study of patients with cancer in Europe
revealed that patients with head and neck cancer were at highest risk of cancer sub-
types and were almost 5 times as likely to commit suicide as controls.110 A more
recent follow-up review of data from greater than 350,000 patients with head and
neck cancer showed an overall suicide risk of 3 times, with laryngeal and oropharyn-
geal at 5 times, and patients with hypopharyngeal cancer at a stunning 14 times in-
crease in risk.111 There are multiple different depression screening instruments,
many of which have been validated in the head and neck cancer population.112
Although far from perfect, even asking patients the single question of whether they
are depressed has a reasonable sensitivity and specificity in advanced illness.113 In
whatever fashion, the critical task of the clinician is to ask patients about depression
and aggressively pursue treatment if it is discovered.
If I Do Not Offer Treatment, Will They Just Find Someone Who Will?
One thing many academic surgeons fear is the complexities of the second opinion. This
role can come in many forms, from an elective office referral from a colleague to a patient
being helicoptered to your facility after being told “they will fix you there” by the outside
hospital emergency department. There is a small body of literature on the outcomes of
The Role of Patients 699
second opinions in cancer care. The number of patients who seek a second opinion after
cancer diagnosis can vary from 7% to 35%.114 Patients who were female, more
educated, or with more advanced disease at diagnosis were more likely to seek a second
opinion.115–117 Although many surgeons fear that if they do not operate someone else
will, variance in treatment plan is less common than we may fear. In patients with
head and neck cancer referred for a second opinion to a comprehensive center for
MDT evaluation, the treatment plan was modified only 10% of the time.118 Broader
studies of general surgical oncology patients confirmed a 12% to 16% rate of treatment
discrepancy and that, even when a second opinion was sought, 93% received surgery
from the first surgeon consulted.117,119 These data translate at the policy level: historical-
ly some states required mandatory surgical second opinions for elective Medicaid cases.
Review of the policy revealed the low discrepancy of opinion and minimal change in cost
to the system, leading to a program shift toward voluntary second opinions only.120
They may wish to proceed alone or may wish to have another person present to sup-
port them and help talk about options. Third, and perhaps most importantly, it gives
them a measure of control in a situation that has suddenly become frightening and un-
controlled.127 After delivering the news, at the close of the discussion, there is a final
ask, which is to clarify understanding. Questions like the following can help guarantee
that patients understood the information correctly: Does that make sense? Just so I’m
sure I explained that well enough, could you tell me what you understand about what
we discussed?
The second major hazard in clinical communication is emotion. Dealing with bad
news brings up emotion in both patients and the physician.128 Physicians are trained
to deal with data and algorithms and procedures: emotion tends to feel disruptive and
unpredictable. All people process information in both an emotional channel and a
cognitive channel.129 These two channels relate to each other in complex ways, and
both are highly activated during the patient interview. When bad news about patients’
cancer is conveyed, one must expect emotion and be able to respond. When deliv-
ering bad news, it is best to keep the news to a few short sentences and then pause,
because emotional reactions happen almost instantaneously and irrespective of
cognitive input.130 The next reaction should be from patients; the physician tendency
to fill uncomfortable-seeming silence with more clinical information should be avoided,
as this activates the penchant of generating false optimism.131–133 Another thing to
remember is that highly emotional data can override the cognitive channel. When pa-
tients hear emotionally negative news, the negative affective experience can impair
working memory.134 This impairment leads to a decoupling of cognition after
emotional stimulus and poorer recall of the very data we try to use to console our pa-
tients and ourselves. VitalTalk, an organization devoted to improving physician-patient
communication, has created the acronym NURSE to give clinicians tools to help
respond to emotion (Table 1).135
And lastly when dealing with emotion, it is important for clinicians to pay attention to
body language. Maintaining eye contact and an open body posture (avoiding crossing
Table 1
Statements to help deal with and support emotion
From VitalTalk. NURSE statements for articulating empathy. Available at: http://www.vitaltalk.org/
sites/default/files/quick-guides/NURSEforVitaltalkV1.0.pdf. Accessed March 28, 2017; with permission.
The Role of Patients 701
arms or placing computer screens between you and patients) are shown to improve
patient ratings of providers and foster empathy.136,137
The good news when considering all of the high-stakes components of patient
communication and emotion is that training programs can help providers learn to
manage this more expertly. Communication training interventions have been shown
to improve confidence, increase response to emotion, increase patient engagement
and trust,138–141 and in some cases even improve Hospital Consumer Assessment of
Healthcare Providers and Systems scores for doctor communication.142 Fortunately,
access to training programs is expanding as hospital systems and national organiza-
tions recognize the foundational nature of communication in our role as physicians.
SUMMARY
The evolution of SDM has been a gradual one, with a recent acceleration fueled by
massive cultural changes and an exponentially expanding volume of scientific knowl-
edge. Patients with head and neck cancer face a unique and steep set of challenges
spanning physical, social, emotional, and cultural dimensions. As clinicians, we are obli-
gated to provide the best care possible. Newer tools, such as DAs and multidisciplinary
conferences, are first steps toward improving the breadth of our care; but there are still far
more questions than answers about how to implement these best for patients with head
and neck cancer. Increasing access to palliative care services and using them earlier in
patients’ trajectory will help improve symptom management, decrease cost, and in-
crease the odds that patients’ time is spent the way they desire. As providers, we will
also have increasing access to continuing education opportunities to improve our
communication skills, which will be critical to hone as more of our performance evalua-
tion is linked to patient satisfaction. In total, the legal, ethical, and moral domains of SDM
represent our most current understanding of “the pinnacle of patient-centered care.”143
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