Values-based practice in surgical care gives clinicians the skills to engage in dialogue about values with their patients in shared decision-making between the evidence-based options available

In most clinical situations there is more than one evidence-based option available. Shared decision-making means clinician and patient deciding together which option is best where ‘best’ means from the perspective of that particular patient’s individual values.

 

This page:

• Explains why shared decision-making based on values is important clinically
• Illustrates its incorporation in evidence-based guidelines and contemporary codes of practice and
• Introduces the UK Supreme Court 2015 Montgomery judgment making shared values-based decision-making the legal basis of consent to treatment

The clinical importance of shared values-based decision-making

Shared decision-making based on values is important clinically because it improves patient outcomes and offers a time- and cost-effective way of providing evidence-based care

For the full story of Mrs Jones and the decision about whether to do a knee replacement or opt for conservative management see ‘To operate or not to operate?’ in What is Values-based Practice in Surgical Care?
Most people in Mrs Jones’ situation would have wanted knee replacement. But for Mrs Jones, given what mattered to her (to be able to garden again), this would have made a bad situation worse (by further reducing her mobility). In a decision shared with the surgeon Mrs Jones opted for conservative treatment.

Shared decision-making based on values thus improves clinical outcomes in a time- and cost-effective way. This is why it has been emphasised for some time in evidence-based guidelines and codes of practice. It is also why, following the 2015 Montgomery judgment, it is now the legal basis of consent in the UK.

Values-based shared decision-making in evidence-based guidelines

The importance of patients’ individual values in shared decision-making has been recognised from the early days of evidence-based medicine. David Sackett, the inaugural Director of Oxford’s Centre for Evidence based Medicine, was one of the first to spell this out

On the first page of their pathfinder textbook David Sackett and his colleagues defined evidence-based medicine as combining best research evidence with clinical experience and with patients’ values in ‘a diagnostic and therapeutic alliance which optimises clinical outcomes and quality of life.’

They go on to make clear that by ‘values’ they means the unique values of each individual: ‘By patient values we mean the unique preferences, concerns and expectations each patient brings to a clinical encounter …’

Reference: Sackett, D.L. Straus, S.E., Scott Richardson, W., Rosenberg, W., and Haynes, R.B. (2000) Evidence-Based Medicine: How to Practice and Teach EBM (2nd Edition). Edinburgh and London: Churchill Livingstone.

Contemporary evidence-based medicine

Contemporary evidence-based medicine focuses on the first of David Sackett’s three elements (best research evidence) but the importance of connecting this up with individual values is reflected in how evidence-based guidelines are intended to be used in practice

In the UK for example all NICE guidance emphasises that treatment and care should take into account individual needs and preferences and this is reinforced in a statement about shared decision-making on the NICE website

See Nice Guidelines

NICE (the National Institute for Health and Care Excellence) is responsible for reviewing and issuing evidence-based guidelines for the UK’s National Health Service

Values-based shared decision-making in contemporary codes of practice

Similar commitments to connecting up evidence with values are made in many professional guidelines. The GMC (General Medical Council), the regulator for medical practice in the UK, includes a number of statements to this effect in its guidance on Consent

The guidance opens with a general statement of the Duties of a Doctor. One of these is to work in partnership with your patients: this includes ‘listen to, and respond to, their concerns and preferences’. Similar statements with slight variations in wording occur throughout the guidance

GMC: Working with doctors Working for patients

Read More: For more on the above publications including illustrative extracts please go to:
How is Values-based Practice in Surgical Care Implemented? and follow the links to Resources Library

Values-based shared decision-making and ‘Montgomery’ consent

Values-based practice is particularly important when making difficult or complex decisions with patients but recent changes in the law on consent mean that shared decision-making based on values will become increasingly important in all areas of care

The importance of patients’ individual values in shared decision-making has been marked by a recent Supreme Court decision on consent, the (2015) ‘Montgomery judgement’.

Exactly how the Montgomery judgement will be interpreted in different contexts remains to be seen. But the bottom line is that ‘Montgomery consent’ is based on patients’ individual values being taken into account in clinical decision-making.

Read More

Montgomery consent: for more on Montgomery consent including key extracts and a link to the full text of the judgment, please go to: How is Values-based Practice in Surgical Care Implemented? and follow the links to Resources Library

A Conference on Montgomery Consent: a conference on the Montgomery judgment including a key note by Baroness Hale, Deputy President of the Supreme Court and one of the Montgomery judges, see: Conference announcement