Selecting Topics for PDSTs
Many, if not most, health care decisions could be improved through the use of patient decision support tools. The Institutes of Medicine (2014) emphasizes the broad applicability of patient decision support tools:
In practice, decisions must be made about which topics should be prioritized for the selection and implementation of patient decision support tools. The following questions may be considered by those tasked with choosing topics for patient decision support tools implementation.
Little has been written about ethical considerations in the use of patient decision support tools. In general, decision support tools are thought to promote patient-centered care and autonomy.
Brehaut and colleagues (2010) suggest that shared decision making may help alleviate concerns about inadequate informed consent processes. Washington State has even established shared decision making as an alternative to traditional informed consent in statute (Revised Code of Washington, Section 7.70.065).
However, there is a possibility that decision support tools can be expressly designed to lead patients toward a decision deemed desirable by actors other than the patient. Such “nudges” or “libertarian paternalist” approaches have been advocated in the creation of decision aids for PSA screening for prostate cancer (Wheeler, et al, 2011) and in other clinical situations including colorectal cancer screening and treatment of deep vein thrombosis (Blumenthal-Barby, et al, 2013). There is active debate about the ethics of using decision aids to lead patients toward pre-selected choices, but standards promulgated by the International Patient Decision Aids Standards Collaboration emphasize that decision support tools should offer balanced, unbiased interpretations of systematically summarized data and non-judgmental elicitation of patient values and preferences. At a minimum, those involved in the creation and use of decision support tools must disclose any conflicts of interest.