The interplay between shared decision making and uncertainty – a conceptual analysis and empirical illustration

OBJECTIVE: Uncertainty about the most appropriate treatment option is the fundamental reason to involve patients in shared decision making (SDM). Clinicians and patients involved in SDM processes both face uncertainty. The various ways in which SDM and uncertainty may intersect, have not yet explicitly been explored. We aimed to a) conceptually describe the various ways in which uncertainty may manifest and affect clinicians and patients during SDM processes, and b) empirically illustrate how uncertainty is expressed and responded to during treatment decision making. METHODS: A limited-scope, focused literature search was conducted in PubMed/Medline on how authors have described the role of uncertainty in SDM. Next, we conducted an explorative analysis informed by microanalysis of clinical interactions of two purposefully selected videotaped consultations of treatment decision making consultations in oncology. We focused on how mismatches in perceived uncertainty between clinician and patient/caregiver became apparent and were subsequently addressed. RESULTS: Our conceptual and empirical analyses illustrate various ways in which uncertainty about the most appropriate treatment is navigated. Also, they show how patient involvement entails and elicits a mutual exchange of multiple manifestations of uncertainty between clinicians and patients. Empirical analysis revealed multiple ways in which patient and clinician clarified their own perceptions of uncertainty. Clinicians adopted various strategies for negotiating uncertainty with the patient. It remained unclear to what extent consensus was ultimately achieved about the level of uncertainty. CONCLUSIONS: This paper contributes to a better conceptual and empirical understanding of the interplay between uncertainty and SDM. Addressing uncertainty in SDM may be an ongoing process, and negotiating uncertainty may be necessary to facilitate effective patient participation. PRACTICE IMPLICATIONS: SDM training programs could incorporate support for clinicians to address and reach a shared understanding of uncertainty.