Table 2.

Peter’s Case Using Goal-Based SDM.

Goal-team talk: Providing support and eliciting goals at multiple levels	Peter visits his clinician often for hip pain and dizziness. She invites Peter to talk about his goals. She summarizes the problems and mentions the risk from falls, from diabetes, and the decline in his ability to live independently. After exploring what bothers him most, she suggests they “work as a team” to set goals and the best interventions.
Goal setting	The clinician asks Peter about his hopes and what he is “most afraid of losing.” Peter admits that he really wants to stay living at home, despite his loneliness. Peter’s limited ability to walk is reducing his motivation to get out, and he finds himself watching television and drinking whiskey. Hip pain and insomnia bother him most. He accepts the need to clean his home but lacks motivation. His clinician is afraid he will fall down the stairs. Ideally, his diabetes also needs better control. Peter knows these problems are linked, but he does not know where to start. Peter and his clinician set collaborative goals at 3 levels, summarized below.
Goal levels	Fundamental goals Continue to live at home, independently. Reduce loneliness. Functional goals Better mobility: walk to bar and local shops. Meet wider circle of friends. Improve self-hygiene. Improve housekeeping. Disease- or symptom-specific goals Reduce pain. Reduce risk of falls. Better sleep. Improve diabetes control.
Goal interdependency and conflict	The clinician notes that the goals of living independently and reducing loneliness, given his reduced mobility, are not easy to achieve. Building a wider social group may be difficult for Peter. The clinician offers that living in different accommodation may bring with it more opportunities to meet other people. Peter admits he had not considered that possibility.
Prioritizing goals	Peter says his urgent need is to reduce pain levels so that he can walk more and be less concerned about the stairs. However, Peter also says that he puts a high priority on being able to stay at home (a fundamental goal). He understands that improving his mobility (a functional goal) is a key contributor to realize his fundamental goal. Improving the management of Peter’s diabetes, a prominent clinical concern, is acknowledged, but discussions about this problem are postponed.
Goal-option talk: Goal-option talk is about considering the synergistic as well as conflicting nature of interventions as a means to goal attainment.	The Goal Board (Figure 2) helps display prioritized goals to both Peter and his clinician. It helps them discuss the potential positive and negative impact of intervention options on more than 1 goal. They notice that the interventions are not all medical and that some depend on Peter changing his behavior (using low-alcohol beer, for instance). Pain relievers may have impact on both sleep and mobility. Lowering alcohol intake and increasing mobility reduce the risk of falls (a functional goal) as well as increases the potential for Peter to stay living at his home (a fundamental goal). Similarly, looking after a dog could improve his mobility (a functional goal) and reduce loneliness (a fundamental goal). Shifting from whiskey to low-alcohol beer has the potential to improve his control of diabetes (a disease-specific goal) and reduce self-neglect (a functional goal). The sequence is relevant. It may be better to improve pain and mobility, before considering a dog.
Goal-decision talk: Goal-decision talk has 3 components: (1) clarifying the next steps (decisions that have to be made); (2) agreeing who takes those actions; and (3) agreeing how and when to evaluate the outcomes.	Given Peter’s goal priorities, the clinician’s would wish to address pain as effectively as possible, which may require considering listening to Peter’s preferences as he shares his views about options. Changing to low-alcohol beer seems logical to his clinician but may well be difficult for Peter if alcohol dependence exists. Perhaps, the decision to get a dog would be considered by many as the least urgent and most risky. But it is also possible that this intervention could have the maximum impact: It might also excite Peter. Peter’s sense of loneliness and his motivation to self-care might change; he may walk more, meet others, and take more pride in his home. The outcomes are unknown, so Peter and his clinician decide to focus on pain relief first and to evaluate this decision in 4 weeks. The clinician’s role is supportive, employing the skills of motivational interviewing where behavior change is required, and SDM when comparing options (40).

Abbreviation: SDM, shared decision-making.