Introduction

In the last decades, researchers, governments and public campaigns have increased awareness about healthcare overuse.1 Low-value care is described as care unlikely to benefit the patient given the harms, costs or available alternatives.2 Clinical practice guidelines with ‘do-not-do’ recommendations and other de-implementation strategies were promoted to reduce it.1 One of these strategies is shared decision making (SDM).3 SDM was traditionally described as an approach to enhance patient involvement in healthcare decisions by communicating evidence-based information about options, their pros and cons, and eliciting patients' preferences to support them to deliberate about those options.4 Currently, some authors consider SDM as a broader concept, a method that adapts to a wider range of situations where patients and clinicians make decisions together using different approaches (not only limited to cases with a fine balance between benefits and harms, where practitioners help to weigh pros and cons with patients' values and preferences).5

Different studies showed that when patients are better informed about the benefits and harms of interventions (eg, surgeries, screening tests, medications), they tend to decline low-value care.3 6 7 These findings might explain why SDM has been promoted to reduce low-value care.3 6–9

Focusing on the conversations between patients, caregivers and clinicians during the clinical encounter, we reflect on why using SDM for de-implementation of low-value care can be paradoxical.