Table 2.

A scenario and illustration of narrow and slightly broader approaches to shared decision-making

John has been found to have an abdominal aortic aneurysm. The specialist who identified it briefly explains what it is, and why it is a cause for concern. He outlines three options: no repair, open repair and endovascular repair, and summarizes the main outcome probabilities associated with each.
Narrow understanding of shared decision-making	(Slightly) broadera understanding of shared decision-making
The specialist asks John which he would prefer. John says he doesn't know. He asks which the specialist recommends. The specialist says he shouldn't recommend one. They're all on offer, so they're all reasonable, but they have different benefits and risks. John must choose, but the specialist will give him more information that he can take away to help him think about his choice. He can let him know by phone what he's decided. John visits his GP, tells her what the specialist said, and confesses he is undecided. He thinks that now he knows about the aneurysm he probably wants to have something done about it, but he can't choose between the open and endovascular repair. In fact, he is getting so stressed about the choice, perhaps he'd be better not having either. The GP acknowledges that it is a difficult decision, but says that her preferences are probably different from John's, and she isn't well placed to advise him. Reflecting on their consultations, both doctors recognized John's difficulties and felt a bit uncomfortable about them. But they reasoned that they shouldn't have helped him any further with decision guidance because he was a competent adult and to respect his autonomy, they should not interfere with his preferences.	The specialist asks John what he thinks about those options and whether he has any questions. John says that now he knows about the aneurysm, he'd probably rather something was done about it. And maybe the overall survival rate makes the endovascular repair the better option? But the complications sound worrying. The specialist says he also tends to favour repair, and the endovascular repair in particular because of the overall survival rate. John is right to be concerned about possible complications, though, and they can discuss those a bit further. The specialist outlines the kinds of complications that can arise, and how these might be dealt with. He asks about John's family and work and what support he might have after an operation. The specialist asks John what he's thinking now. John says the endovascular repair seems to be the way to go, although he's still a bit anxious (but he can see that the anxiety should be short term). The specialist says that sounds like a good decision, and he will reserve a slot for surgery. He gives John information about the condition and both kinds of repair to take away and share with his family. He invites John to contact him if he has any further questions or concerns. The specialist reflected that John seemed to understand the key issues and express his thoughts and concerns well. He felt confident that the plan of action was mutually agreed and appropriate.

^aThis illustration of enactment of a slightly broader understanding is an interpretation consistent with many extant definitions and models of shared decision-making. A clinical example involving a less able patient and greater clinician influence would require a more detailed description and extensive commentary to clarify whether and why the clinician's approach could be considered appropriate and supportive of the patient's autonomy capability.