Shared decision-making in the care of individuals with diabetes

People with diabetes often live with other chronic conditions and lead complicated lives. Determining what is the best management decision for a patient requires consideration of each individual's personal, social and biomedical context, what he or she values, the reasons he or she has to value the available options, and the relative contribution of each option in terms of benefits, harms, costs and inconveniences. Empathic conversations between patients and clinicians to diagnose the patient situation that necessitates action and the range of evidence-based actions that best address the situation, so-called shared decision-making, are essential to the personalized care of people with diabetes. The aim of the present review was to present key elements of shared decision-making and propose three different approaches for its application. The first approach focuses on transferring information to patients so that they can make decisions. The second approach, choice, focuses on cultivating the individual's ability to give voice to which choice is best for them. The third approach, conversation, establishes an empathic conversational environment through which the individual with diabetes and their clinician think and talk through how to address the problems of living with diabetes and related illnesses. These approaches are manifest in the design of evidence-based decision aids created to support shared decision-making. In randomized trials, decision aids can efficiently improve patient's knowledge, satisfaction, risk awareness, decisional conflict and involvement. Further research, however, is needed to better understand when and how to promote the empathic conversations, patient, clinician and service and policy contexts necessary to routinely implement shared decision-making in different at scale healthcare systems. In the interim, sufficient evidence and tools exist for persons with diabetes and their clinicians to gain expertise in making decisions together. What's new?: As a tool in the co-management of diabetes, shared decision-making offers patients and clinicians a means of determining what is best for the person living with diabetes. Three shared-decision-making approaches are described: 1) the information approach, which focuses on the information that patients and clinicians need; 2) the choice approach, which emphasizes expressing the individual's values and preferences; and 3) the conversation approach, which centres on establishing empathic conversations in which patients and clinicians can together think and talk through how to address the problems of living with diabetes and its comorbidities (i.e. context). Decision aids are evidence-based tools (e.g. web-based, pamphlets, videos or cards) that facilitate a shared-decision-making approach to occur, be it information, choice or conversation. In people with diabetes, randomized trials have tested, with favourable results, decision aids in urban, rural, academic and non-academic clinical settings. Uncertainty remains about how best to account for people's life with diabetes, their capacity and interest in the decision-making process, the skills needed to communicate and engage with patients, and the sustainability, best practices and cost-effectiveness of large-scale current implementations of shared decision-making. The downstream consequences of shared decision-making also remain unclear.