Panelists discussed the benefits of shared decision making a process that includes collaborative patient-physician discussion regarding the multitude of health care options at the College's annual "Law Day" panel. The policy of shared decision making is in the process of being implemented at Dartmouth Medical School and Dartmouth-Hitchcock Medical Center, according to the panelists.
Shared decision making has become important in discussions of patients' rights to end-of-life care, according to Elliott Fisher, director of the Center for Population Health and professor of community and family medicine at DMS. Shared decision making can result in a patient with a serious medical condition choosing physician-assisted suicide, an option that still remains controversial, according to Fisher.
"A family in California struggled with issues surrounding compassionate care and the administering of opiates to a loved one in pain," Fisher said. "They brought a suit over the horrific way the family member died and after that incident California mandated shared decision making."
Shared decision making operates under the assumption that not only do informed patients make better decisions, but that patients should have a say in medical decisions, according to Dale Collins Vidal, director of the Center for Informed Choice for The Dartmouth Institute for Health Policy and Clinical Practice.
"Do people have the right knowledge?" Vidal asked. "Are patients well-informed? What values and reasons are their decisions based on? Patients shouldn't make decisions based on fear."
Shared decision making is an important tool for both physicians and patients, but patients must be able to fully understand the advantages and disadvantages of each treatment plan while incorporating those options in with their personal priorities and values, several panelists said.
"There are different barriers to shared decision making," Ben Moulton, senior legal advisor for the Foundation for Informed Medical Decision Making and Harvard School of Public Health professor, said. "One cultural barrier is that the public believes that only physicians should be mediating medicine."
Health care systems reward intervention as opposed to watchful waiting, particularly when it comes to surgery, Moulton said.
"Shared decision making becomes more possible under health care reform," Moulton said.
Although pilot tests incorporating more physician-accountability have been implemented in various research settings, it has still been difficult to institute national health care programs, according to panelists.
"Shared decision making now has 86 randomized trials to go before being approved," said Fisher. "Yet state legislatures will be very bold, they won't wait for 20 randomized trials. I think the states might get there before the federal government."
If the New Hampshire state legislature actively advocates for patients' rights and shared decision making, there will be enough momentum to bring the process to the federal level, according to Lisa Snow Wade '85, an attorney at Orr & Reno who focuses on health care law.
The traditional, paternalistic concept of the physician as the sole decision-maker has begun to fall apart, a DHMC nurse said during a question and answer session.
"Doctors should learn about shared decision making during medical school," she said.
Shared decision making allows hospitals and clinics to cut costs while incorporating the preferences of patients, Fisher said.
"It's not about death panels," he said. "Shared decision making and health care reform has to be implemented because the current system is bankrupting states. There's an ethical imperative to allow patients to make informed decisions."
The panel discussion moderated by general counsel for the College Bob Donin was co-sponsored by the Rockefeller Center, the Dartmouth Legal Studies Faculty, the Dartmouth Lawyers Association and Center for Health Care Delivery Science.
