Shared decision-making should be a standard part of surgical care

Abstract

Shared decision-making is here to stay as a means to further high-quality care in modern surgery.This is fostered by current societal and professional developments.More and more treatment options (e.g.drugs, and laparoscopic and robotic techniques) become available and (future) patients can more easily and digitally access medical information about their disease and treatment options.Today's surgeons, as knowledgeable and skilled experts, offer state-of-the-art care using cutting-edge surgical techniques, apply current evidence-based clinical practice guidelines, discuss complex cases in multidisciplinary team meetings in order to decide on the best possible treatment, and, finally, share this outcome with their patients to achieve informed consent.Their advice regarding a certain treatment option is based on expertise, appreciation of the patient's condition, and known evidence about the expected desired or unwanted effects.However, this advice may well be flawed until surgeons acknowledge the patient's autonomy and explicitly involve the patient's expectations regarding their goals in life and preferences for a certain treatment-even if these are not the surgeon's first choice.This requires bidirectional communication between healthcare professionals and patients to elicit and appreciate the patient's preference, and incorporate this in the eventual treatment choice 1 .This process is called shared decision-making (SDM).SDM is particularly valuable in surgery 2 : surgical treatments always run the risk of complications, which may cause clinical decision-making to be quite intricate.Elective interventions may cause immediate harm (i.e.peri-and postoperative complications), while the desired effects (e.g.prevention of death due to cancer) may take years to be seen.In elderly patients or those with multimorbidity, surgical interventions may be even less appealing.Still, many surgeons find SDM difficult, both conceptually and in clinical practice.Most will not have been educated in the principles and practice of SDM.However, SDM is not a completely new paradigm; it is an essential part of the definition of evidence-based medicine (EBM) since the 1990s 3 .Surgeons have become familiar with EBM, but not (yet) with involving patients' preferences.It is an ethical and legal obligation to inform a patient in detail about the expected desired and possible undesired outcomes of any possible intervention before asking for informed consent.It is equally essential to

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