Effective Shared Decision Making for Optimal Patient Outcomes

Core Elements of Shared Decision Making

The American College of Cardiology recommends that the most effective shared decision making template should include three core elements: information exchange, deliberation, and treatment decision documentation to ensure optimal patient outcomes and quality of life 1, 2
Document the clinical situation requiring shared decision making, including diagnosis, prognosis, and reason for the preference-sensitive decision, as suggested by the Critical Care Medicine guidelines 3
Note the patient's capacity to participate in decision making and identify surrogate decision-makers if applicable, in accordance with the Critical Care Medicine recommendations 4
Record who was present during the SDM discussion, including the patient, family members, and other healthcare team members, as recommended by the Critical Care Medicine guidelines 1

Document the medical information shared with the patient, including a clear explanation of the diagnosis and current clinical situation using simple language, as suggested by the Critical Care Medicine guidelines 5
Provide a description of treatment options presented, including risks, benefits, and alternatives, in line with the Otolaryngology-Head and Neck Surgery guidelines 6, 7
Share prognosis information, including both mortality risk and functional outcomes, as recommended by the Critical Care Medicine guidelines 4
Discuss the option of palliative care or conservative management when applicable, as suggested by the Critical Care Medicine guidelines 8

Record the discussion of advantages and disadvantages of various options, as recommended by the Critical Care Medicine guidelines 2
Document how the patient's values and preferences were incorporated into the deliberation, in accordance with the Critical Care Medicine guidelines 8
Note any misperceptions that were addressed during the discussion, as suggested by the Critical Care Medicine guidelines 5
Document the patient's preferred level of involvement in the decision-making process, as recommended by the Critical Care Medicine guidelines 9

Clearly state the decision that was reached, as recommended by the Critical Care Medicine guidelines 1
Document the rationale for the decision, linking it to the patient's expressed values, in accordance with the Critical Care Medicine guidelines 2
Note any contingency plans or circumstances under which the decision would be revisited, as suggested by the Journal of the American College of Cardiology guidelines 10
Record follow-up plans and timeline for reassessment, in line with the Journal of the American College of Cardiology guidelines 10

Tailor the template to the specific clinical context while maintaining the core elements, as recommended by the Critical Care Medicine guidelines 9
Document time spent in shared decision making to support appropriate billing, as suggested by the Critical Care Medicine guidelines 3
Integrate the template into your electronic health record system for ease of use, in accordance with the Journal of the American College of Cardiology guidelines 10