Table 1.

Summary of Decision-Making Models/Frameworks

Decision Making Model	Main Tenet	Primary Reference	Applications in Health Care
Paternalistic	Physician selects information and decides treatments	- (Emanuel & Emanuel, 1992) - (McKinstry, 1992)	- Highly applicable in medical emergency situations. - Criticized by bioethicists due to lack of respect for patient autonomy. - Still pervasive in some countries, particularly in Asian and in some European countries.
Informative	Physician provides complete information to help a patient discerns what’s best for him/her	(Emanuel & Emanuel, 1992)	Applicable during patient participation in randomized clinical trials. Best demonstrated when a patient signs an informed consent before receiving any treatment (i.e. stem cell transplantation).
Doctor-as-agent	Physician provides complete information, elicits a patient’s preference, and makes decision based on a patient’s preference.	(McKinstry, 1992)	Applicable in situations when a patient expresses his/her desires, wants, and values, but leaves the final decision making to his/her clinician.
Shared decision making (SDM)	Involves two-way information exchange, deliberation between physician and patient, and joint decision making on treatment to implement with emphasis on respecting individual differences in patient preferences.	(Charles, et al., 1997, 1999)	Highly applicable in situations when there is clinical uncertainty. Examples include treatment decision making in patients with newly diagnosed prostate cancer where treatment options have different risks and associated uncertainty. - In a qualitative study sampling both patients with prostate cancer and their physicians, Berry and colleagues (2003) documented four distinct physician roles during treatment decision making. These roles included expert, educator, navigator, and partner, which are reflective of the principles of the SDM model.
Communication model of SDM	Explicitly identifies the communication process as a vehicle for decision making in cancer treatment.	(Siminoff & Step, 2005)	- Applicable in all types of treatment decision making in patients diagnosed with cancer. - Needs empirical testing of the model in actual clinical encounters.
Integrative model of SDM	Combines the essential elements, ideal elements, and general qualities of SDM. Essential elements: Define/explain problem Present options Discuss benefits/risks/costs Patient values/preferences Discuss patient ability Doctor knowledge Check understanding Make or explicitly defer decision Arrange follow-up Ideal elements: Unbiased information Define desire for involvement Present evidence Mutual agreement General qualities: Deliberation/negotiation Individualized approach Information exchange Involves at least two people Middle ground Mutual respect Partnership Patient education Patient participation Process/stages	(Makoul & Clayman, 2006)	Highly applicable in all types medical decision making. However, empirical testing of this model has not been reported.
Family-centered	A patient prefers that his/her families handle medical decision matters.	(Hyun, 2003)and (Schafer, et al., 2006)	This framework of decision making is commonly seen in Asian American and Latino patient populations.
Degner and Beaton’s patterns of decision making	This framework includes four major patterns of decision making: provider- controlled, patient- controlled, jointly- controlled and family- controlled patterns of decision making	(Degner & Beaton, 1987)	Highly applicable in cancer patient populations where huge variations in patient’s level of participation in decision making are well-documented.
Decision support framework (DSF)	Involves three stages: I. Assessment of patient and provider’s determinants of decisions. II. Delivery of decision support interventions that address the determinants of decisions and preparation of patient and provider for decision making through a structured follow-up interaction. III. Evaluation of the decision support and its success in improving the quality of decision making process, decisions, and outcomes of decision.	(O’Connor, et al., 1998)	Highly applicable in decision making conditions where there is ample time to deliberate on choices and involves the use of decisional aids. The DSF is less useful for decisions with no immediate stimulus for deliberation, when the decision’s key challenge is implementing and maintaining the decisions, and when decisions are rapid, repetitive, automatic, impulsive or deferential to authority.
Decisional model of stress and coping	Decision conflict occurs when a choice of options is personal, transactional, and relational in nature.	(Balneaves & Long, 1999); (Janis & Mann, 1977); (Lazarus & Folkman, 1984)	This model has been empirically tested in women with breast cancer diagnosis.
Conflict-theory model of decision making	Posits decisional conflicts as sources of stress and describes five basic coping patterns of decision making: unconflicted adherence, unconflicted change, defensive avoidance, hypervigilance, and vigilance	(Janis & Mann, 1977)	Highly applicable to all consequential decision making processes, especially during emergency conditions.
Normative theory	Decisions are made relative to a clearly recognized probability of benefits and consequences from all possible options.	(Hansson, 2005)	Increasing applicability in oncology treatment decisions as reflected by the rising number of cost-effectiveness analysis comparing one cancer treatment option to others. This is largely driven by the limited resources in health care.
Behavioral decision making	Variations in the decision frames and vagaries in the values individuals place on different choices can cause predictable shifts of preference that are not rational.	(Tversky & Kahneman, 1981)	The way physicians frame a decision problem to a patient could affect the patient preference. This is clearly demonstrated when the benefits of a treatment are overtly emphasized and the risks are downplayed.
Coherent likelihood judgments	Adheres to principles of Probability Theory which include unity summation, generalized disjunction principle, extension principle, conjunction rule (joint and marginal probabilities), general product rule, independence product rule, and Baye’s rule	(Yates, 1990)	This theory is best demonstrated when two cancer therapies are compared in a randomized controlled trial and a treatment is chosen based on the superior outcome of one therapy over the other in terms of survival benefit or improvement in quality of life.
Naturalistic	Decisions are made in an uncertain and constantly changing environment based on different personal and situational factors.	(Zsambok, 1997)	Highly applicable in patients with newly diagnosed prostate or breast cancer where personal factors were found to be influential in the treatment decision process.
Heuristic-Systematic processing model	Involves heuristic processing and systematic processing in arriving to a decision.	(Chaiken, 1980); (Chaiken & Maheswaran, 1994)	Applicable in prostate cancer patients who were found to use expert opinion heuristic due to decisional uncertainty and systematic information processing to deal with the diagnosis.
Prospect theory	Two main tenets: - Describes how individuals regularly assess potential losses and gains. - The way the outcomes are framed influences the preferences of the decision maker.	(Kahneman & Tversky, 1979)	It has a controversial applicability in cancer treatment decision making, especially when monetary gains or losses are in consideration because of the argument that no one should decide about cancer treatments based on monetary values. Putting a monetary value on someone’s life poses a major ethical debate.
Social Decision Theory	Combining individual choices into collective decisions.	(Hansson, 2005)	- Very limited applicability in individual health care decision making except at the policy level involving a specific patient population. - In countries with national health insurance, social decision theory guides the policy maker’s decision on what treatment to cover or deny and at what cost.