The SHARE Approach—Essential Steps of Shared Decisionmaking: Expanded Reference Guide with Sample Conversation Starters
|The concept of engaging patients in their health care decisionmaking to improve the quality of health care in the United States was firmly grounded in the Institute of Medicine (IOM) report: Crossing the Quality Chasm.1
The IOM defined patient-centered care as "care that is respectful of and responsive to individual patient preferences, needs, and values" and that ensures "that patient values guide all clinical decisions."
The SHARE Approach: Essential Steps of Shared Decisionmaking outlines five steps health care professionals can take to ensure that they are effectively implementing shared decisionaking with patients during clinical encounters. The steps were designed to incorporate the essential elements that have been defined for shared decisionmaking.2
Essential Steps of Shared Decisionmaking
Step 1: Seek your patient's participation.
Step 2: Help your patient explore and compare treatment options.
Step 3: Assess your patient's values and preferences.
Step 4: Reach a decision with your patient.
Step 5: Evaluate your patient's decision.
About This Tool
This tool was designed to help you incorporate the SHARE Approach from the Agency for Healthcare Research and Quality (AHRQ) into your practice. It describes each step in the SHARE Approach, and offers sample conversation starters for you to consider as you engage in meaningful discussions with your patients about their health care options.
As you begin implementing the SHARE Approach in practice, you will find that shared decisionmaking is an individualized process with your patient.
The SHARE Approach usually begins with inviting your patient to be a part of the decisionmaking process. As you implement the SHARE Approach, you may find that some of the steps overlap with one another. That is okay.
The steps are intended to serve as prompts to help ensure you are engaging your patients in their health care decisions through meaningful dialogue about the benefits, harms, and risks of their health care options, and what matters most to them. Use the checklist offered at the end of this document to check off the steps that you used with your patient.
Intended Audience for This Tool
This tool is designed for health care professionals who engage in shared decisionmaking discussions with patients.
The SHARE Approach
Step 1: Seek your patient's participation
Studies suggest that many health care professionals believe that patients are not interested in participating in their health care decisionmaking.3-5 While patients may not want to play a prominent role in problem-solving, evidence suggests that most patients want more information than they are routinely given by health care professionals, and many would like to be involved in decisionaking about their health care.3,5
Many patients are not aware that they can and should participate in their health care decisionmaking. Additionally, many patients are not aware of the uncertainty in medicine, and that the outcomes of various treatments can be unpredictable at an individual level.
Communicate that a choice exists and invite your patient to participate in the process.
- Summarize the health problem and let your patient know that there are options to consider. Describe the problem clearly and openly so that your patient understands that a decision needs to be made.
- Ask your patient to participate with the health care team in making his or her treatment decision. Help your patient understand that he or she is being invited to ask questions and discuss options with you.
- Include family and caregivers in decisions. Ask if your patient would like to have family members or caregivers participate in the discussion.
- Remind your patient that his or her participation is important. For example, say, "I would like your input."
|Try These Conversation Starters To Invite Participation|
|"Now that we have identified the problem, it's time for us to think about what to do next."|
|"There is good information about how these treatments differ that I'd like to discuss with you before we decide on an approach that is best for you."|
|"I want to go over all the options so we can find a path that works for you."|
|After being invited to participate and having the options outlined, patients may still want the health care provider to make the decision for them. In that case, the following may be useful to try:|
|"I'm happy to share my views and help you reach a good decision. Before I do, would you like more details about your options?"|
Note: Some patients may not want, or be ready, to participate.5-7 The active decision not to participate in the decisionmaking process, or to delegate the decision to the provider or a caregiver, should be respected.
Step 2: Help your patient explore and compare treatment options
Many health care decisions have multiple treatment options, including the option of no care. Often no single option is clearly superior. Use evidence-based decisionmaking resources to compare the treatment options.
Discussing options with your patient can help you build a trusting relationship.
Letting your patients know that there are options available (including watchful waiting), and guiding them through both benefits and risks of each option, can help your patients feel their views are valued and needed.
Assess what your patient already knows about his or her options
Some of your patients may gather their own information from the Internet, word of mouth, or other sources. It is important to explore what your patient may already know or understand about his or her condition and options.
|Try These Conversation Starters To Learn What Patients Know and Understand|
|"What have you heard about [condition]?"|
|"What have you read about treatments for [condition]"?|
Write down a list of the options and describe them in plain language
Before making an informed decision, your patients need to know all the options available to them.
- Explain each option clearly, using plain language.
- Avoid using technical or medical jargon (for example, say, "both sides" instead of "bilateral" or "high blood pressure" instead of "hypertension" or "not cancer" instead of "benign."
- Point out when there are clear differences between specific options (e.g., having surgery vs. taking a medication).
- Talk about important unasked questions. Your patient may not know the appropriate questions to ask or may be hesitant to ask. You should anticipate critical unasked questions and suggest discussing them.
|Try These Conversation Starters To Start Discussion About Options|
|"Let me list the options before we get into more detail about each of them."|
|"Here are some choices we can consider."|
|"Let's go over your options."|
Clearly communicate the risks and benefits of each option
Explain the limitations of what is known and unknown about the treatment options, and what would happen with no treatment. A balanced discussion allows patients to make more informed decisions.
It is critical to present both the benefits and risks of each option. These can be presented in the form of trade-offs. For example, "Medicine [xxx] is more expensive than the one you are currently taking, but you will only have to take it once a day."
|Try These Conversation Starters To Explore Pros and Cons|
|"Let me tell you what the research says about the benefits and risks of the medicines you are considering."|
|"These options may have different effects for you compared with other people, so I want to describe them."|
|"The treatments I just described are not always effective for everyone, and the chances of having side effects can vary from one person to another."|
Communicate numbers in a way that your patient can understand
Numbers can be a big part of discussing risk and communicating information about the potential benefits and harms of treatments. Communicating numbers can be challenging because even people with high health literacy can have low health numeracy. Refer to Communicating Numbers to Your Patients: A Reference Guide for Health Care Providers (Tool 5) for more information.
- Avoid descriptive terms (such as "low risk"). Instead, provide estimated numbers.
- Express the odds of possible outcomes with a consistent denominator (for example, 1 in 100 compared with 5 in 100, rather than 1 in 100 compared with 1 in 20).
- Offer positive and negative outcomes. For example, provide both the chance of experiencing side effects and of remaining free of side effects.
- Whenever possible, use absolute numbers—not relative risks. Patients can easily misinterpret statements such as “three times as many people found lowered symptoms with medicine A as compared with medicine B.”
- Use and explain appropriate visual aids (graphs, charts, pictographs) to help patients understand your explanations.
|Try These Conversation Starters When Introducing Numbers|
|"Here are two graphs with pictograms that compare what can happen if you take this medicine or if you choose not to take the medicine. In 10 years, six women who were not on medicine broke a bone. Only three women on the medicine broke a bone in that 10-year period. So, taking the medicine lowered their chance of breaking a bone by half."|
|"The red area on this pie chart shows the number of people who developed a blood clot after getting a stent. The blue area shows the number of people who developed a blood clot…."|
Offer evidence-based decision aid tools whenever possible
Research has demonstrated that using decision aids in shared decisionmaking with patients has several benefits:8
- Improves patients' knowledge of their options.
- Results in patients having more accurate expectations of possible benefits and harms.
- Leads to patients making choices that are more consistent with their values.
- Increases patients' participation in decisionmaking.
Use evidence-based decision aids and other decision resources to facilitate patient decisionmaking. Decision resources can be presented to your patient in advance of the visit, during the visit, or sent home with your patient to review and consider after his or her visit.
Roles for Other Members of the Interdisciplinary Health Care Team
Along with prescribing clinicians, other members of the interdisciplinary health care team may be tasked with helping patients and their caregivers in a shared decisionmaking process. They may provide decision tools and resources to help facilitate patient decisionmaking.
|Try These Conversation Starters When Introducing Decision Aids|
|"These tools have been designed to help you understand your options in more detail."|
|"I have some booklets I want to give you that have information about your condition and the treatment options. They will be able to help you in your decisionmaking process."|
|"This online tool offers a handout as well as a video. The video highlights the pros and cons of each treatment option. Let's discuss your options and go over the benefits and risks at our next visit."|
|"These online resources provide information to patients about the importance of exploring your treatment options. They compare the benefits and risks of each and offer information on options that you may want to discuss at your next visit."|
AHRQ Resources for Patients
- Consumer Research Summaries—consumer-friendly English- and Spanish-language summaries that compare treatment options, including risks and benefits.
- Interactive Patient Decision Aids—Web-based decision aids.
Use the teach-back technique to check for understanding
After presenting the information, it is important to make sure that your patient understands the information you have shared. Ask your patient to explain in his or her own words what the options are.
Refer to Using the Teach-Back Technique: A Reference Guide for Health Care Providers (Tool 6) for more information on teach-back technique.
If your patient appears apprehensive or actively disagrees, offer additional information or try presenting the information in a different way. Being able to use different approaches, such as Web-based decision aids, printed handouts, or handwritten drawings, will help you adapt to the different ways in which people learn and process information.
Your patient may:
- Verbalize uncertainty about the choice or concern about undesired outcomes.
- Waver between choices.
- Delay the decision.
- Question personal values or what is important to them.
- Be preoccupied with the decision.
- Show signs of distress or tension.
|Try These Conversation Starters To Check for Understanding|
|"Could you tell me how you understand the treatment choices I’ve presented to you for your [condition]?"|
|"We've talked about your treatment options. To make sure I’ve explained things well, would you tell me how they're different?"|
Step 3: Assess your patient's values and preferences
Studies have shown that most health care providers are not aware of the outcomes that matter most to patients.6,11 Moreover, a number of studies have shown that patient treatment decisions change after patients become well informed about their options and the associated risks.8,11,12
- Encourage your patient to talk about what matters most to him or her. For example, ask your patient to consider how each option will affect his or her daily life, or how important it is to relieve the symptoms he or she is experiencing.
- Ask open-ended questions. For example, ask "What do you think is causing your symptoms?"
- Listen actively to your patient. Use prompts that encourage your patient to continue talking. For example, "Go on," or "I'd like to hear more about that." Use nonverbal cues such as nodding your head and having an engaged listening posture.
- Show empathy and interest in the effect that a problem is having on your patient's life. For example, name the likely emotion that your patient is feeling. Say, "That sounds really upsetting."
- Acknowledge the values and preferences that matter to your patient. Paraphrase what you have heard from your patient. This signals to your patient that he or she has been heard, and that you are listening to his or her unique perspective.
- Agree on what is important to your patient.
|Try These Conversation Starters To Learn About Your Patients' Values and Preferences|
|"As you think about your options, what's important to you?" "When you think about the possible risks, what matters most to you?"|
|"Which of these potential side effects worries you the most?"|
|"Which of the options fits best with treatment goals we’ve discussed?"|
|"Is there anything that may get in the way of doing this?"|
Assessing preferences matters, especially when patients defer decisions to clinicians
Clinicians should ensure that the dialogue reflects important information about the options (e.g., specific procedures, risks, and benefits) and that a patient's preferences are acknowledged. This may impact greatly on achieving satisfactory health outcomes and patient satisfaction.14
Step 4: Reach a decision with your patient
Making a decision, particularly for complex and potentially life-altering health care conditions, may take time. This is especially true when treatment decisions are irreversible, such as surgery. Patients may not identify their preferred option until they have had time to think it over or speak with others. Patients may also want to talk with family members, friends, or their caregivers before making a decision.
This additional time provides a good opportunity to share with patients decision support materials, such as AHRQ consumer summaries and interactive decision aids, or other evidence-based resources, that they can take home and discuss with others.
- Help your patient move to a decision. Ask if he or she is ready to make a decision or if they have any additional questions.
- Ask your patient if he or she would like additional information tools such as educational materials or decision aids to help make a decision.
- Check to see if your patient needs more time to consider the options or discuss them with others. Schedule another session if your patient requests more time to consider the options.
- Confirm the decision with your patient when he or she is ready to make a decision. Ask your patient to describe the treatment options and which one he or she chose.
- Verify the next steps to be taken and timing of these actions with your patient.
- Schedule followup appointments to carry out the preferred treatment or active surveillance.
|Try These Conversation Starters for the Decision and Followup Phases|
|"It is fine to take more time to think about the treatment choices. Would you like some more time, or are you ready to decide?"|
|"What additional questions do you have for me to help you make your decision?"|
|"This is a big decision and it's important for you to consider which treatment option you prefer."|
|"Let's meet again next week. In the meantime, here is some information for you to read and think about. We can continue the discussion once you've had a chance to do that."|
|"Are there other people that you want to talk to in order to help you make this decision?"|
|"Now that we had a chance to discuss your treatment options, which treatment do you think is right for you?"|
Step 5: Evaluate your patient's decision
Once a decision has been made, it will be important to follow up with your patient on how he or she is doing.
For patients facing life-threatening conditions, some of the decisions will be irreversible, so careful consideration prior to making a decision is critical (e.g., a decision for mastectomy versus lumpectomy in early stage breast cancer).
For many decisions, however, particularly those centered on the management of a chronic illness, decisions can and should be revisited after a trial period.
- Make plans to review the decision in the future. Remind your patient that decisions may be reviewed and some can be changed if they are not working well for your patient.
- Monitor the extent to which the treatment decision is implemented.
- Assist your patient with managing barriers to implementing the decision. For example, provide access to self-management support programs and other community-based resources that can assist your patient.
- Revisit the decision with your patient to determine if other decisions need to be made.
|Try These Conversation Starters for Prompting Future Evaluation|
|"Can we talk next [appropriate timeframe] to see how you are doing?"|
|"Let's plan on reviewing this decision next [appropriate timeframe]."|
|"If you don't feel things are improving, please schedule a followup visit so we can plan a different approach."|
Patient buy-in is essential to adherence
The patient, not the health care provider, is generally responsible for implementing many of the decisions made during a clinical encounter, particularly decisions made in a primary care setting (e.g., making necessary lifestyle changes or taking medications as prescribed).
This tool is to be used in conjunction with the Agency for Healthcare Research and Quality's SHARE Approach workshop. To learn more about the workshop, visit http://www.ahrq.gov/shareddecisionmaking.
3. Légaré F., Ratté S., Gravel K., et al. Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals' perceptions. Patient Educ Couns 2008. Dec;73(3):526-35. PMID: 18752915.
9. O'Connor A., Jacobsen M. Decisional conflict: Supporting people experiencing uncertainty about options affecting their health. Monograph; 2006. Retrieved from: http://careinaging.duke.edu/longtermcare/dynamic/resources/1027/Decisional_Conflict.pdf (PDF File, 718.58 KB).
10. O'Connor A., Stacey D., Jacobsen M. Improving practitioners’ decision support skills. Decision Support Tutorial. Ottawa Hospital Research Institute. 2011. Retrieved from: https://decisionaid.ohri.ca/ODST/pdfs/ODST.pdf (PDF File, 403.45 KB)
11. Mulley A., Trimble C., Elwyn G. PATIENTS' PREFERENCES MATTER Stop the silent misdiagnosis. Published by The King's Fund 11–13 Cavendish Square London www.kingsfund.org.uk © The King's Fund. 2012.
13. Murray E., Charles C., Gafni A. Shared decision-making in primary care: tailoring the Charles et al. model to fit the context of general practice. Patient Educ Couns 2006 Aug;62(2):205-11. PMID: 16139467.
14. BeLue R., Butler J., Kuder J. Implications of patient and physician decision making: an illustration in treatment options for coronary artery disease. J Ambul Care Manage 2004 Oct-Dec;27(4):305-13. PMID: 15495743.
15. Thompson L., McCabe R. The effect of clinician-patient alliance and communication on treatment adherence in mental health care: a systematic review. BMC Psychiatry 2012 Jul 24;12:87. PMID: 22828119.
Additional References for Sample Dialogue
Edwards A., Elwyn G., Mulley A., Explaining risks: turning numerical data into meaningful pictures. BMJ 2002 Apr 6;324(7341):827-30. PMID: 11934777.
Elwyn G., Frosch D., Thomson R., et al. Shared decision making: a model for clinical practice. J Gen Intern Med 2012 Oct;27(10):1361-7. PMID: 22618581.
Epstein R.M., Alper B.S., Quill T.E. Communicating evidence for participatory decision making. JAMA 2004 May 19;291(19):2359-66. PMID: 15150208.
Frankel R.M., Stein T. Getting the most out of the clinical encounter: the four habits model. J Med Pract Manage 2001 Jan-Feb;16(4):184-91. PMID: 11317576.
ICSI Shared Decision-Making Model. The Collaborative Conversation™. Institute for Clinical Systems Improvement (ICSI). 2012. Retrieved from: https://www.icsi.org/health_initiatives/shared_decisionmaking/collaborative_conversation_model/.
O'Connor A., Stacey D., Jacobsen M. Improving practitioners’ decision support skills. Decision Support Tutorial. Ottawa Hospital Research Institute. 2011. Retrieved from: https://decisionaid.ohri.ca/ODST/pdfs/ODST.pdf (PDF File, 95.66 KB).
Peters E., Hibbard J., Slovic P., et al. Numeracy skill and the communication, comprehension, and use of risk-benefit information. Health Aff (Millwood) 2007 May-Jun;26(3):741-8. PMID: 17485752.
Paling J. Strategies to help patients understand risks. BMJ 2003 Sep 27;327(7417):745-8. PMID: 14512489.
Sheridan S.L., Harris R.P., Woolf S.H. Shared decisionmaking about screening and chemoprevention. A suggested approach from the U.S. Preventive Services Task Force. Am J Prev Med 2004 Jan;26(1):56-66. PMID: 14700714.
Stacey D., Murray M.A., Légaré F., et al. Decision coaching to support shared decision making: a framework, evidence, and implications for nursing practice, education, and policy. Worldviews Evid Based Nurs 2008;5(1):25-35. PMID: 18266768.
Wexler R. Six steps of shared decision making. Informed Medical Decisions Foundation. 2012. Retrieved from: http://informedmedicaldecisions.org/wp-content/uploads/2012/02/Six_Steps_SDM_Language.pdf (PDF File, 172.41 KB).
Use this checklist to make sure you are incorporating elements of the SHARE Approach with your patients.
Step 1: Seek your patient's participation
___ I invited my patient to participate in the decisionmaking process.
___ I explained the importance of my patient's role in the decisionmaking process.
___ I discussed the essential issues about my patient's condition.
Step 2: Help your patient explore and compare treatment options
___ I presented all of the reasonable treatment/intervention options to my patient.
___ I discussed the risks and benefits of each option with my patient.
___ I asked my patient to review relevant decision tools (booklets/videos/Web sites).
___ I asked my patient to teach back what was discussed.
___ My patient demonstrated an understanding of the options.
Step 3: Assess your patient's values and preferences
___ I encouraged my patient to talk about what matters most to him or her.
___ I listened actively to my patient and asked open-ended questions.
___ I asked my patient how his or her decision might impact their daily life.
___ I acknowledged and agreed with my patient on what matters most to him or her.
Step 4: Reach a decision with your patient
___ I asked my patient what option he or she preferred.
___ I asked my patient if he or she needed additional information or wanted to consult others before making a decision.
___ My patient and I agreed on the decision.
Step 5: Evaluate your patient's decision
___ My patient and I made plans to review their decision in the future.
___ I worked with my patient to help them manage barriers to implementing their decision.