Table 1

Forms of shared decision making, according to the Purposeful SDM framework

Forms of purposeful SDMType of decision soughtExample
1. Weighing alternativesA determination that pros, cons and preferences are optimally balanced in the selected optionEmma, a 52-year-old woman, has had type 2 diabetes for over 10 years. Her HbA1c has been rising for over 9 months. She is increasingly fatigued and would like to feel better soon. With her clinician, she decided that it is time to change her diabetes medication regime. After considering the different medications available and their respective pros and cons, they decided to start basal insulin.
2. Negotiating conflicting desiresAn agreement reconciling conflicting positions or desires within or between parties to decisionmakingEmma has been on insulin for a few years now. Her fear of complications has led to a programme of care with which she has frequent and dangerous severe hypoglycaemic events. These are scary to her and her family, who is pushing Emma to stop or cut back on her medicines. Emma feels torn between easing her glycaemic control to reduce the incidence of hypoglycaemia, but potentially also increasing the risk of complications due to hyperglycaemia. Together with her clinician she develops a compromise by which she will reduce the intensity of her programme, discontinuing insulin, and switches to a non-hypoglycemic agent.
3. Solving problematic situationsThe conclusion that different potential ways of understanding and advancing the problematic situation have been sufficiently uncovered, evaluated and coordinated.With the oral medication in combination with diet and regular exercise, Emma’s diabetes has been regulated well over time. Over the last few months, however, she has become the primary caregiver of her spouse, who was diagnosed with cancer. With caring for him taking up most of her time, she struggles with sticking to her diet and regular exercise. Together Emma and the clinician try to find ways to stay healthy physically and emotionally, that will fit with the demands and limitations of her new situation. They come up with a plan to try out and refine over the upcoming months.
4. Developing existential insightThe existential insight into what ultimately matters that has developed sufficiently that what to do becomes obvious and meaning is found in the splintered elements of a person’s life.At 81, Emma has been receiving dialysis for end-stage diabetes-related kidney disease for 3 years. As they talk, it tearfully emerges how life-diminishing dialysis is becoming for her and how she feels that her life is breaking apart. Together Emma and her clinician develop an understanding that it might be time to step away from dialysis and to implement a palliative care approach.
  • Based on Hargraves et al. 23; Hargraves et al.37 and Hartasanchez et al.26

  • HbA1c, haemoglobin A1c ; SDM, shared decision-making.