The principles of Shared Decision Making can be used in many settings.  The objective is to respect the disabled person (decision maker) by encouraging their engagement in understanding the situation (or diagnosis) as well as the review of options and potential outcomes, possibly with the help of one or more support persons or trusted advisors.  A common misconception is that persons who have impaired decision-making capacity cannot be trusted in their decision making.  This is overly simplistic.  It also can lead to conflict where the decision maker is told what to do without any input.  

Logically, some decisions are easier than others.  Also, timing can affect any person’s ability to make a good decision.  Cultural context, personal experiences, and social relationships will affect the decisional outcome. By including a support person or trusted advisor as part of the process, the decision person has help in many areas including:  listening, note taking, remembering details and personal preferences, research, and review of various factors — sometimes more than once.  The support person may be more able to understand the decision maker’s background and concerns and be able to find way to engage the decision maker.  

Capacity-adjusted shared decision making incorporates the assessment of a person’s decision-making capacity.  A trusted support person may ask an individual’s preferences, as they break down the process slowly and step-by-step.  This slower approach may help an individual express their preferences.

1. Assess the person’s decision-making capacity and openness to shared decision making in 3 stages:
   1. Team talk. Explain that a decision is needed and that you will support the person’s decision-making process.
   2. Option talk. Explain the options in terms that are clear, accessible, and relevant to the person’s goals.
   3. Decision talk. Ask about personal preferences to the extent possible. 
2. Reflect on whether the steps above suggest that person’s decision-making capacity is impaired, and, if required, engage formal assessment by a psychiatrist of a person’s decision-making capacity.
3. Tailor next steps to personal decision-making capacity, taking a more direct approach and including decision supporters when available.  It may be helpful to have visual aids, lists of pros and cons or a decision tree.
4. Reassess both the individual’s preferences and decision-making capacity over time.

When persons can make simple decisions (for instance, whether they want surgery) but cannot engage nuanced decisions (ie, they cannot choose between competing surgical options), then a surrogate decision maker can provide more nuanced input that builds on the person’s preferences. For persons who lack decision-making capacity entirely, a surrogate decision maker decides on their behalf, but will likely need some written authority to do so.

Some people might initially be reluctant to express an opinion for fear they have insufficient expertise or are simply unaccustomed to having their preferences asked.  Nevertheless, with support and patience, it may be possible to have a productive discussion and a supported decision that the individual is a part of.  This respect for personal autonomy is important and frequently leads to more satisfactory outcomes.

Law Office of Kathleen M Toombs PLLC

157 Barrett Street, Schenectady, NY  12305

(518) 688-2846

Attorney Advertising