Decision aids are a solution, but to which problem?

Shared decision making has become a prominent model in health care communication over the last 3 decades in response to 2 core motivations. First, there is longstanding concern in medical ethics that the practice of clinical informed consent does not match the theory—in particular, that it often plays out as medicolegal administrative ritual rather than a substantive means of information exchange and patient involvement. Second, the academic medical community has moved toward a normative conception of the patient’s role in his or her care that is not satisfied by mere information delivery. It also stipulates that this information should be used to arrive at a decision that incorporates the specific values and preferences of the patient. As it has become apparent that medical consultations often do not meet this standard, proponents of shared decision making have turned to decision aids as the primary means of achieving an ideal state of patient involvement in decision making. Decision aids have steadily gained attention in health policy circles as the foremost solution for better-involving patients in decisions about their care, even featuring prominently in the Affordable Care Act.

The review of anesthesia-related decision aids by Urman et al in this issue of Anesthesia & Analgesia is a timely contribution, in large part because our specialty has lagged behind others in examining issues of decision making and informed consent. We thus commend them for taking on this highly pertinent topic. However, their article also prompts us to advise caution and reflection when interpreting data on the effects of decision aids. It has become common practice to cite the Cochrane Database systematic review of decision aids by Stacey et al as evidence of these aids’ effectiveness and of the urgent need for their implementation. Unfortunately, the findings of this Cochrane review are frequently misrepresented. For example, the review does not conclude that decision aids increase patients’ satisfaction with the decision-making process, as Urman et al state, but that they are not better than usual care in this regard. Furthermore, the Cochrane review by Stacey et al does not support the notion of decision aids “facilitating shared decision-making”—instead finding no significant effect.