‘Doing nothing’ is simply not an option: why framing of choices matters in surgical shared decision-making

Abstract

BackgroundIn the context of high-risk surgery, shared decision-making (SDM) can be hindered by misalignment in expectations regarding the likely surgical outcomes between patients and clinicians. This study investigates the extent of this misalignment in high-risk patients and doctors involved in perioperative care, its’ impact on treatment choices, and its’ amenability to interventions that encourage perspective taking.MethodsHigh-risk patients (N = 55) and doctors involved in perioperative care (N = 54) were asked to consider one of three clinical scenarios: ischaemic heart disease, colorectal cancer, or osteoarthritis of the left hip. They reported on their expectations regarding short- and long-term outcomes of different treatment options available in these scenarios. Participants were initially asked to consider the scenarios from their own perspective as a patient/clinician, and then to adopt the perspective of the other side. After stating their expectations, participants were required to choose between surgical or non-surgical treatment.ResultsSystematic misalignment in expectations between high-risk patients and doctors was observed, with patients expecting better surgical outcomes compared to clinicians. Despite this misalignment, in both groups surgical treatment was strongly preferred. Willingness to consider the non-surgical option was only observed when this option offered a chance to change the undesirable ‘status quo’.ConclusionWhen high-risk surgery is discussed, a non-surgical option may be viewed as ‘doing nothing’, reducing the sense of agency and control. This biases the decision-making process, regardless of the expectations doctors and patients might have about the outcomes of surgery. Thus, to improve SDM and to increase patients’ agency and control over decisions about their care, we advocate framing the non-surgical treatment options in a way that emphasises action, agency, and change.HighlightsMisalignment in expectations regarding treatment outcomes between high-risk surgical patients and their clinicians has been identified in this study, with patients expecting more positive outcomes from surgery than doctorsDespite misalignment, treatment choices were similar for patients and cliniciansFraming the treatment choice as ‘doing something’ (i.e. surgery) vs. ‘doing nothing’ seemed to drive the preference for surgery in both groupsTo increase patients’ agency and control over decisions about surgery, the framing of their options should be targeted for improvement