special subjects
Medical Treatment Decisions
Shared decision making
In earlier days of medical care, doctors often made decisions for their patients without their input and without explaining the risks and benefits of all available treatments. This approach has been recognized as inappropriate. Because the goal of medical treatment is to improve outcomes, as defined by a person’s own goals and values (see Defining goals ), doctors and other primary care practitioners now share medical decision making with their patients. Information is exchanged in two ways: Doctors provide patients with information about available treatments and the benefits and risks of those treatments. Patients share personal information about their lifestyle, preferences, and values with their doctor. The doctor and patient discuss treatment options and agree on the best treatment plan. Shared decision making does not mean that doctors leave people completely on their own to decide among various, sometimes confusing treatment options. Doctors still make recommendations based on standards of care and the best medical evidence, but they present the reasons behind those recommendations and how they think those recommendations meet the individual's needs and goals. In shared decision making, doctors help guide people through the decision process, neither dictating to them nor abandoning them. In some cases, people need to work with their doctors to make decisions that take into account quality of life. Aggressive cancer therapy may prolong life but have severe negative effects that greatly reduce quality of life. The person's preference for quality of life versus duration of life and tolerance for risk and uncertainty help inform health care goals and determine what medical interventions to pursue. Quality-of-life issues may be particularly important to older people (see Therapeutic Objectives in Older People ). Sometimes, people are unable to make decisions on their own behalf because they have illnesses, such as dementia, that affect their ability to understand information. Sometimes, they have severe illnesses such as delirium or coma that affect their level of consciousness. In such cases, a doctor will ask the person’s next-of-kin or other holder of a Health Care Power of Attorney to help make treatment decisions. Doctors weigh the potential risks against the potential benefits of treatment before they recommend a treatment. The results of research studies must be carefully evaluated to determine whether the results apply to a particular person. 