The NIH has researched a different model of decision making which involves the client in the process and it is referred to as a shared decision making (SDM) process (Elwyn et al, 2012). This model is gaining acceptance and is being reflected in health care policy since 2012. Shared decision making (SDM) has been defined as: ‘an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences’(Elwyn et al, 2012). The three-step model was developed to be practical for clinicians and integrates good communication skills along with patient decision support tools. The NIH article describes the model as follows: Achieving shared decision making depends on building a good relationship in the clinical encounter so that information is shared and patients are supported to deliberate and express their preferences and views during the decision making process. To accomplish these tasks, a model of how to achieve shared decision making that is based on choice, option and decision talk. The model has three steps: a) introducing choice, b) describing options, often by integrating the use of patient decision support, and c) helping patients explore preferences and make decisions. This model rests on supporting a process of deliberation, and on understanding that decisions should be influenced by exploring and respecting “what matters most” to patients as individuals, and that this exploration in turn depends on them developing informed preferences. The guiding principles of SDM are aligned with those of the massage and body professional standards which promote individual self-determination, autonomy, is a critical goal and professionals have an obligation to support patients to achieve this goal. Self-determination in the context of SDM does not mean that clients are left alone to make decisions for which they have inadequate knowledge and experience. It is also not the goal of the model to place the responsibility for decisions solely on the client to relieve the practitioner of liability or blame if a negative outcome results. SDM recognizes the need to support autonomy by building good relationships, respecting both individual competence and interdependence on others (Elwyn et al, 2012). In addition this model advances the concept of informed consent beyond the level of simply understanding the components of treatment where the client is a passive participant in the process. Instead, the client is informed and encouraged to communicate preferences and informed decisions. The NIH stresses the importance of clinical practice that balances these principles with those of beneficence and ethical practice standards. This process includes educating clients about their health care needs as well as the massage and bodywork modalities that are appropriate options for them. This process will help to address low health literacy that is often a barrier to autonomy among clients. For the SDM model to be affective it must be built on the fundamental skills of communication to build trust and openness to consult with the practitioner on all phases of their care and treatment plan. SDM is based on 1) providing information and 2) supporting the Providing Information involves the following (Elwyn et al, 2012): Providing high quality information to clients. We also need to elicit what patients already know, and whether it is correct. If patients are not informed, they will be unable to assess Ethical decision making If a practitioner identifies a potential ethical dilemma is developing they may choose to implement a decision making model to investigate the situation and determine a course of action. decision making process. Providing information
‘what it is important to them’, and so establish informed preferences. ● Ensure that individuals are not making decisions when insufficiently informed about key issues Supporting deliberation The second task is to support patients to deliberate about their options by exploring their reactions to information. When offered a role in decisions, some clients feel surprised, unsettled by the offer of options and uncertainty about what might be best. If all responsibility for decision making is transferred to patients, they may feel abandoned. Some clients initially decline all responsibility in decision making, and are to participate. There are three key steps of SDM for clinical practice including choice talk, option talk and decision talk, and the clinician supports deliberation throughout the process: ● Choice talk refers to the step of making sure that clients know that reasonable options are available. This is a planning phase and includes the following components: ○ Step back. ○ Offer choice. ○ Justify choice. ○ Check reaction. ○ Defer closure. ● Option talk refers to providing more detailed information about options: ○ Check knowledge. ○ List options. ○ Describe options. ○ Discuss risks and benefits. ○ Provide decision support. ○ Summarize. ● Decision talk refers to supporting the work of considering preferences and deciding what is best: ○ Focus on preferences. Clients will need time to study new information and to consider their personal preferences, particularly for topics that new to them or that they have not experienced. Recognizing this need, and allowing time for it, is a cornerstone for effective SDM (Elwyn et al, 2012). The model also includes the use of decision support tools to provide information in formats that are accessible to patients, using the most up to date evidence about the risks and the benefits of proposed options. Some tools include formats, such as in brief text or diagrams, booklets, websites, videos, and DVDs (Elwyn et al, 2012). The term “deliberation” describes the process of considering information about the pros and cons of their options to consider a range of possibilities. At this stage, clients work collaboratively with professionals as well as other health providers in the integrated team. The deliberation begins as soon as options have been described and understood (Elwyn et al, 2012). This model builds on a foundation of ethical standards that clients be informed of all procedures, give consent, have right of refusal, maintain open and ongoing communication with clients, and the SDM model encourages autonomy and client centered practice. The decision making model that is used most frequently and complements most of the professional codes of ethics is an eight-step model (Corey et al, 2015). The eight steps are: 1. Identify the problem or dilemma. 2. Identify the potential issues. 3. Look at relevant codes of ethics for general guidance. ○ Elicit a preference. ○ Move to a decision. ○ Offer a review (Elwyn et al, 2012).
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