Revisiting Decision Aids: About Definitions and Classifications

Abstract

In the 2009 White Paper Series of the John M. Eisenberg Center for Clinical Decisions and communications, Elwyn and others revisit the issue of patient decision aids (DAs). To summarize, the authors argue that there is a need to consider the aims of these interventions in more depth, which leads them to propose a new definition as well as a classification of interventions into those used by clinicians in face-to-face encounters, those that can be used independently from clinical encounters, and those that are mediated by interactive and social technologies. We appreciate the intention of the authors to start a debate about the aims and types of patient DAs, but we do not see the need for a new definition. And, rather than classifying interventions based solely on their place or mode of administration, we believe there is a need for a theory-based taxonomy of DAs based on a task analysis of the individual-cognitive/affective as well as the socialinteractive process of decision making. There is no need for a new definition of DAs. The authors start from the original definition of DAs by O’Connor and others (‘‘interventions designed to help people make specific and deliberative choices among options by providing information about the options and outcomes that are relevant to a person’s health status’’) but prefer to broaden the term to decision support intervention (DeSI), to recognize that any artifact that attempts to support individuals facing decisions is a patient-orientated DeSI. There are, of course, many ways to support decision making. However, gathering all of these under the umbrella of DAs or, for that matter, DeSIs may only further confuse the field. They mention, for example, risk communication tools, but these can be quite limited, not involving all the ingredients that O’Connor and others ascribed to DAs in the Cochrane definition. Other forms of decision support mentioned, such as telephone coaching by nurses or consultations with nurse navigators, are not simply artifacts but constitute a new form of professional encounter. We risk losing ground when we subsume under DAs—or even DeSIs—anything aimed to support individuals facing tough decisions. Certainly the aim of DAs is to support patients in making decisions, but that is also the aim of many a clinician (if not too paternalistic) in an encounter in which a decision needs to be made. Where do we then draw the line? The definition by Elwyn and others seems more an elaboration on the definition given by O’Connor and others in the first Cochrane Review. It expands on the original definition’s concept of ‘‘deliberative choices,’’ particularly on the shorthand ‘‘providing information about the options and outcomes relevant to the patient’s health status.’’ It specifies one piece of information about these outcomes—namely, information that supports affective forecasting—and it provides more context. As such, it serves as a valuable interpretation of that definition. But all new elements in the proposed new definition may be captured by that widely accepted earlier definition, which is parsimonious, like a good mathematical model. Although one can argue that the design of DAs should go beyond the term provision of information, a definition need not include such specification. Furthermore, not all DAs will have the same goals, and the design of a DA should be tied to the goals the DA is setting out to achieve. Explicitly specifying all the possible ingredients in a definition may hamper the field and runs the risk of discarding useful tools that do not fully fit this specification. We therefore argue that a thoughtful categorization would be more useful.