In recent years, experts have called for greater partici­pation by patients in medical decision-making processes, but research suggests that shared decision making is not yet routinely incorporated into medical care. “In some cases, there may be a perception among patients that they need to defer decision making to their physicians,” says Harlan M. Krumholz, MD, SM. “This is certainly the sense by many cardiologists about patients hospitalized with an acute myocardial infarction (AMI).”

Surveying the Scene

To further investigate decision-making preferences among patients, Dr. Krumholz and colleagues conducted a study using combined data from two similar AMI registries. Published in JAMA Internal Medicine, the study group asked patients to indicate who they felt should make decisions on treatment options in AMI after they are given information about the risks and benefits of the possible treatments.



More than two-thirds of patients reported that they preferred to actively participate in decision making about their care, but about one-quarter stated that they wanted to make the decision alone. Most patients indicated that physicians and patients should have equal participation. About 15% suggested that patients should dominate the decision. “The key take-home message is that decision-making preferences vary among patients after an AMI, but many prefer an active style,” says Dr. Krumholz.

Difficult to Predict

Seven variables were associated with a greater likelihood of patients preferring active decision making, including female sex, Caucasian race, higher education, smoking, heart failure, lower Global Registry of Acute Coronary Events risk score, and not undergoing PCI during the hospitalization. Those who preferred an active role tended to be younger, but the majority of all age groups assessed in the study still preferred active engagement. When compared with patients who did not complete high school, those who had a college or graduate degree had a much greater likelihood of preferring an active approach. However, 57.5% of those with less than a high school education preferred an active style.

Dr. Krumholz says it is important to note that, overall, demographic and clinical characteristics were not good predictors of which patients would prefer an active role in decision making. “Our research shows that clinicians shouldn’t make assumptions as to which patients will be active or passive in decision-making processes,” he says. He adds that more prospective studies on how best to incorporate patient preferences into decision making are warranted.

Challenges Ahead

According to Dr. Krumholz, physicians who aspire to provide patient-centered care should have open and direct dialogue with patients to assess their decision-making preferences. “To know a patient’s preference requires a specific conversation,” he says. “The challenge for physicians is to develop systems and protocols that fully respect patient preferences and ensure that those who prefer an active role are given that opportunity.”