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Paul Glare


Background: Cancer raises many questions for people afflicted by it. Do I want to have genetic testing? Will I comply with screening recommendations? If I am diagnosed with it, where will I have treatment? What treatment modalities will I have? Will I go on a clinical trial? Am I willing to bankrupt my family in the process of pursuing treatment? Will I write an advance care plan? Will I accept hospice if I have run out of available treatment options? Most of these questions have more than one correct answer, and the evidence for the superiority of one option over another is either not available or does not allow differentiation. Often the best choice between two or more valid approaches depends on how individuals value their respective risks and benefits; “preference-based medicine” may be more important than “evidence-based medicine.” There are various models for eliciting preferences, but applying them can raise a number of challenges.Objectives: To present the concepts, the value, the strategies, the quandaries, and the potential pitfalls of Shared Decision Making in Oncology and Palliative Care.Method: Narrative review.Results: Some challenges to practicing preference-based medicine in oncology and palliative care include: some patients don’t want to participate in shared decision making (SDM); the whole situation needs to be addressed, not just part of it; but are some topics out of bounds? Cognitive biases apply as much in SDM as any other human decision making, affecting the choice; how numerically equivalent data are framed can also affect the outcome; conducting SDM is also important at the end of life.Conclusions: By being aware of the potential pitfalls with SDM, clinicians are more able to facilitate the discussion so that the patients’ choices truly reflect their informed preferences, at a time when stakes and emotions are high.

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