Shared decision-making: A vehicle for participation and individualized clinical care pathways? A Scoping review on patients’ and physicians’ perceived facilitators and barriers for shared decision-making for frail and elderly patients in the clinical sett

Abstract

Introduction: Shared decision-making (SDM) is considered to be a promising approach to enable person-centredness and tailored treatment pathways, according to persons’ individual needs. Foremost, this concerns frail and elderly patients, who suffer from multiple health issues and increased vulnerability, requiring individualized healthcare. SDM and person-centred projects are being conducted and policy and regulatory settings are being implemented worldwide. However, little is known about facilitators and barriers for implementing SDM into clinical practice for the specific needs of frail and elderly patients.

Objective And Method: We aim to gain a comprehensive overview over original studies on perceived facilitators and barriers for the adoption of shared decision-making within the clinical setting by elderly and frail patients and clinical physicians. Our objective is twofold: First, we aim at collecting and understanding facilitators and barriers addressed by elderly and frail patients and clinical physicians. Second, we aim at understanding the underlying approaches and methods employed in respective studies.

We conducted a scoping review, following the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR). Based on the databases PubMed, Medline and CINAHL, we identified and reviewed 11 articles.

Results: For the first research question, the articles indicate that patients want to participate in decision-making, fostering autonomy; while communication barriers, asymmetric power relationships between patients and clinical physicians and a lack of patients’ health literacy remain crucial barriers. For the second research question, quantitative and qualitative studies are equally applied. Second, research on perceived facilitators and barriers for the adoption of shared decision-making within the clinical setting by elderly and frail patients and clinical physicians are almost exclusively conducted after participation in a SDM consultation. Third, the evaluation of the conceptual approaches demonstrates that the selected articles are primarily concerned with the collection of determinants that enable or impede the implementation and adoption SDM, without employing a distinct theoretical framework for explaining these determinants and assessing underlying relationships. Forth, the selected studies mainly used surveys and interviews.

Conclusion: Overall, we identified only a limited number of articles addressing patient and clinical physician perceptions on facilitators and barriers for SDM. These findings further imply that SDM research concerning elderly and frail patients should become more encompassing by employing research that incorporate theory-based qualitative analysis, patient and clinician development of SDM perceptions (before and after SDM consultation), and observations of SDM consultations. Observations are particularly relevant as these remain as a black box.

Implications: We suggest conducting a qualitative study that examines facilitators and barriers of clinical physicians and patients both prior to and post to SDM consultation, in combination with a non-participatory observation of actual SDM consultations. The observation of practice is indispensable to enable a thorough understanding of SDM and its’ application.