By Stacey Kusterbeck
Do patients want to make a decision right away about surgery, or do they want time to think about it? Does a patient want to make a decision independently, or only after weighing the input of family members, or to rely heavily on the physician’s recommendation?
As it stands currently, surgeons usually do not know this important information about their patients. “We need to stop thinking of shared decision-making as one-size-fits-all. We would not go into a patient’s room without looking at their medical record and test results, but we go into the room without knowing their decisional preferences,” says Timothy M. Pawlik, MD, PhD, MPH, chair of surgery at the Ohio State University Wexner Medical Center.
Pawlik recalls listening to a participant on a patient panel at a cancer conference who noted that, with all the focus on shared decision-making, no one had ever asked what he, as a patient, thought about it. “It got me thinking that we use shared decision-making in a somewhat monolithic approach. A clinician has their way of doing shared decision-making, and we are not really personalizing it to the patient,” says Pawlik.
Pawlik says that just as personalized medicine tailors therapy based on the molecular profile of a patient’s tumor, decision-making should be personalized for individual patients. There are some validated tools that can be used to evaluate a patient’s decision control preferences. However, these tools rarely are used by healthcare providers, says Pawlik.
Pawlik and colleagues evaluated studies that looked at 15 available validated assessment tools to evaluate patient decisional preference.1 “This was an attempt to do a landscape review of what tools are out there,” says Pawlik. Most studies identified patients’ information-seeking preferences. Few evaluated providers’ perceptions of patient preferences. “There are few tools currently available for providers to use in the clinical setting to help identify decisional preferences. Virtually none exist that are specifically targeted to surgical patients,” reports Pawlik.
Many of the available tools are not integrated into the clinical workflow. “If it’s not well-integrated, if it’s a standalone thing, it’s hard for people to utilize,” says Pawlik. For healthcare providers, says Pawlik, “There is an opportunity to use certain tools, to better understand how people want decisions being made, so we can truly respect their agency.” This approach could lessen the chance of patients having decisional regret. Some patients are unhappy with the manner in which a decision was made and come to regret that decision. Patients may say, “If I had only known, I never would have made that decision,” or “If you had only explained it to me.” In Pawlik’s experience, if the provider knows and respects the patient’s decision-making preferences, that kind of regret is less likely to happen. “There [are] strong data that decisional regret correlates with worse quality of life, anxiety, and frustration. And what correlates the most with less decisional regret is that the decision was made the way the patient wished,” says Pawlik.
For example, a patient might feel a need to consult with a particular family member before making a decision about whether to have surgery. If the surgeon is unaware of that, the surgeon might approach the discussion in a manner that suggests the patient is expected to make the decision right away. If the patient later has a poor outcome, the patient might blame the decision-making process.
People also vary in how they want to get information to make a decision, ranging from lots of statistics to a colorful visual chart.
Knowledge of patient decision-making preferences is particularly helpful in the surgical setting, says Pawlik, because there is a pressing need for individualized decision-making preferences. Patients may interact with their primary care physician multiple times over months or years, hopefully giving the provider some insight into their communication preferences. In contrast, patients meet with surgeons once or twice before the operation and have to make a decision in a tight timeframe. “We don’t have time to build relationships — they come to me and need an operation in a month,” Pawlik explains.
As a former member of the hospital’s ethics committee, Pawlik often would observe that ethicists were asked to assess issues that were not true ethical dilemmas. Rather, the problem was a breakdown of communication. Therefore, having a good understanding of a patient’s decision-making preferences could prevent some conflicts over end-of-life care.
“The more we can better understand where people are coming from, and what mental construct and framework they are working within, the more likely we can meet them where they’re at. We can be better communicators so they have greater understanding and command of all the factors that are going into a decision,” says Pawlik.
Reference
1. Neshan M, Padmanaban V, Fareed N, et al. Patient decisional preferences: A systematic review of instruments used to determine patients’ preferred role in decision-making. Med Care Res Rev. 2025; Feb 8. doi: 10.1177/10775587251316917. [Online ahead of print].
Do patients want to make a decision right away about surgery, or do they want time to think about it? As it stands currently, surgeons usually do not know this important information about their patients.
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