Shared decision-making and development of a care plan

Question

Recommendations

1. Despite the prognostic uncertainty in many cases, start a shared decision-making process as soon as possible during the course of the disease, or at the beginning of the clinical relationship if this has not been done previously by other clinicians.
2. At the start of the shared decision-making process, explore the level of involvement the patient wants or can have, and be honest and transparent in discussions on the development and implementation of a care plan.
3. During the decision-making process, explore patients’ expectations, wishes, and preferences regarding the care they would like to receive, in line with their values. In cases in which patients cannot make decisions, review:
   • Whether there is a living will or other type of advance directive document.
   • Any notes in the clinical history regarding shared advanced care planning .
   • Any preferences expressed to their families and close friends concerning the care they would like to receive.
   • Whether the patient has a designated representative. If there is no representative or family and/or close friends, the healthcare team takes decisions, seeking the greatest possible level of consensus and always working to provide the greatest benefit for and in the best interest of the patient.
4. Record the topics addressed and the care plan developed in a suitable place in the medical record, accessible to all the clinicians involved in the patient’s care, and share this information not only with the rest of the care team but also with the family and close friends involved in caring for and/or accompanying the patient.

Rationale

The GDG has issued a series of recommendations to promote appropriate shared decision-making and development of a care plan. The recommendations are based on qualitative evidence on barriers and facilitators, and the experience of the group. The GDG considers that it is important to promote shared decision-making and an ongoing process of planning throughout the entire course of the disease, as it is common that patients in their last days lose the ability to make their own decisions or are not willing to do so. In any case, the approach of clinicians should be to promote patient involvement as far as possible until death.

Complete clinical question

For full information on this question (available in Spanish), see:
http://portal.guiasalud.es/guia-en-capas/gpc_612__atencion_paliativa_sud-2/#question-3

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