Shared Decision-Making: Whose Choice Is It, Really?

Shared decision making is more than being asked what you want. It combines clinical evidence with your circumstances, priorities and right to decide. The depth of the discussion changes with the decision and urgency.

Decisions are made with people, not simply for them Shared decision making is a collaborative process between a person and healthcare professionals. It supports an informed decision about tests, treatments, referrals, monitoring and other care. It is especially important when options involve different benefits, harms or practical consequences. However, involvement is not limited to decisions where two treatments seem equally suitable. A clinician may strongly recommend one option because it offers greater likely benefit. The person still needs relevant information and an opportunity to ask questions or refuse. The depth of the conversation should be proportionate to the decision. A low risk routine choice may need less discussion than major surgery or long term treatment. What counts as an option The clinician first identifies the clinically appropriate options for that person. These are options supported by evidence, professional judgement and the person's circumstances. Options can include treatment, testing, referral, monitoring, no treatment or no change. Taking no action is not automatically safe or clinically appropriate in every situation. The clinician should explain the healthcare aim of each option. They should discuss likely benefits, harms, burdens, uncertainty and what may happen without intervention. A person can request another option or a second opinion. However, a clinician does not have to provide treatment they judge clinically inappropriate or unlikely to provide overall benefit. When recommending one option, the clinician should explain why. They should also discuss reasonable alternatives without applying pressure. What matters to the person People can value the same outcomes differently. One person may prioritise symptom relief, while another prioritises avoiding side effects or preserving independence. Work, caring responsibilities, beliefs, previous experiences and access to support can also affect which plan is workable. The clinician should ask what the person hopes to gain and what worries them. They should not assume which risks or outcomes matter most. Risk information should be personalised where possible and presented clearly. Numerical information can help, but uncertainty should also be explained. A patient decision aid can support the discussion by comparing options and helping people clarify their priorities. It supplements rather than replaces conversation with a professional. Shared decision making is not abandonment Some people want to take a very active role. Others prefer the clinician to make a recommendation and guide the final decision. Both preferences can be supported. A person should not be left to interpret complex evidence alone or feel responsible for predicting the future. An adult with capacity cannot ask another person to make the legal decision on their behalf. They can still ask the clinician for a clear recommendation and substantial support. The clinician should check understanding, answer questions and offer more time when the decision allows. Communication support, interpreters, advocates or family involvement may also help. Consent is related but not identical Shared decision making is the conversation that helps identify and compare suitable options. Consent is the person's voluntary and informed agreement to the chosen examination, test or treatment. Valid consent requires capacity for that specific decision. A signature alone does not replace an adequate discussion or prove that consent was informed. Consent continues after the initial decision. A person can change their mind or withdraw consent, although some completed procedures cannot be reversed. A person with capacity can refuse treatment, even when refusal may cause serious harm. The clinician should confirm understanding and discuss likely consequences without coercion. Capacity is decision specific Capacity means being able to understand, retain, use and weigh relevant information, then communicate a decision. Adults are presumed to have capacity unless there is significant evidence otherwise. Capacity relates to the particular decision and the time it must be made. An unusual or unwise choice does not by itself show that someone lacks capacity. Communication difficulty, disability or mental illness also does not automatically remove capacity. Clinicians should provide practical support before concluding that capacity is absent. Legal rules differ across the United Kingdom, but these core principles remain important. When an adult lacks capacity, decisions are made under the relevant legal framework. The person's wishes, values, rights and overall benefit must be considered. Emergencies change the timing, not the principles Emergency decisions may allow less time for detailed discussion. A conscious adult should still be presumed to have capacity, and consent should be sought. If someone is unconscious or lacks capacity, immediately necessary treatment can be provided to save life or prevent serious deterioration. When more than one emergency option exists, the approach should restrict the person's rights and future choices as little as possible. Once the person regains capacity, clinicians should explain what was done and discuss any ongoing treatment. A cataract surgery example A cataract is clouding of the eye's natural lens. It often causes gradual blurred vision, glare and difficulty with reading or night driving. NICE says referral and surgery decisions should not rely on visual acuity alone. The discussion should include how vision affects daily life and quality of life. The clinician explains what surgery involves, its likely benefits and possible complications. They also explain what may happen if surgery is delayed or declined. The person's priorities matter because the same measured vision can affect two lives differently. Driving, work, caring and confidence may change the value of surgery. The eye assessment also checks whether another condition could limit the expected benefit. A confirmed cataract does not prove that it explains every visual problem. The final plan may be referral for surgery, more time to decide or continued review. A person with capacity can decline surgery after an informed discussion. Call 999 or go to A&E for sudden loss of vision, a serious eye injury, or severe pain or vision loss soon after eye surgery. Taking part in the conversation Ask what options are clinically appropriate and what each aims to achieve. Ask about benefits, harms, uncertainty and what happens without treatment. Tell the clinician which outcomes and burdens matter most to you. Ask for a recommendation if you want one and ask why it is preferred. Request more time, written information, communication support or a quality assured patient decision aid when these would help. Confirm what has been agreed, what happens next and when the decision will be reviewed. You can ask to revisit the choice earlier. This lesson explains professional decision making and consent. It does not determine which option is medically appropriate for your situation.

Shared decision making applies across healthcare decisions, although its depth varies. Clinicians identify clinically appropriate options and explain evidence. The person contributes priorities and gives or refuses consent when they have capacity.