Shared decision-making as an existential journey: Aiming for restored autonomous capacity.

OBJECTIVE We describe the different ways in which illness represents an existential problem, and its implications for shared decision-making. METHODS We explore core concepts of shared decision-making in medical encounters (uncertainty, vulnerability, dependency, autonomy, power, trust, responsibility) to interpret and explain existing results and propose a broader understanding of shared-decision making for future studies. RESULTS Existential aspects of being are physical, social, psychological, and spiritual. Uncertainty and vulnerability caused by illness expose these aspects and may lead to dependency on the provider, which underscores that autonomy is not just an individual status, but also a varying capacity, relational of nature. In shared decision-making, power and trust are important factors that may increase as well as decrease the patient's dependency, particularly as information overload may increase uncertainty. CONCLUSION The fundamental uncertainty, state of vulnerability, and lack of power of the ill patient, imbue shared decision-making with a deeper existential significance and call for greater attention to the emotional and relational dimensions of care. Hence, we propose that the aim of shared decision-making should be restoration of the patient's autonomous capacity. PRACTICE IMPLICATIONS In doing shared decision-making, care is needed to encompass existential aspects; informing and exploring preferences is not enough.

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