Patient-centered care and preference-sensitive decision making.

OVER THE PAST 20 YEARS OR SO, THERE HAS BEEN A rise of 2 parallel movements, one toward the explicit use of clinical trial data to guide clinical practice (evidence-based medicine) and the other toward patient empowerment through explicit informed consent, shared decision making, and patient-centered care. Both components have been integrated into models of quality clinical care, but sometimes there are conflicts between evidenceand guideline-driven care and patient-centered care. In most situations, patients value prevention of disease and disability and increased length of life, so patientcentered care and application of evidence-based medicine present no conflict. Despite general preferences for health over disease, however, individuals make trade-offs every day by working in dangerous or stressful jobs, driving too fast, eating too much, smoking, and taking dozens of other risks, large and small. These everyday compromises are also seen in clinical practice. Patients may choose a less expensive medication even if that medication is not quite as effective. They may choose a more limited operation for cancer, explicitly trading off survival for quality of life. They may decline chemotherapy because they feel the adverse effects are not worth the small chance of success. When the choices are about technologies at the end of life, it has now been accepted in the United States and much of the world that patients who value quality of life over length of life are making a reasonable and justifiable decision. Shared decision making is also a common feature of more straightforward medical decisions, but because the immediate stakes are lower, the quality of these negotiations has been subject to less scrutiny. Even the everyday decisions about which blood pressure medicine to choose, how to manage diabetes, when to start dialysis, and what is needed to prevent or treat heart disease present these compromises between increased survival and reduced complication and other goals patients may have including cost, time, and control over their lives.