Diverging opinions about shared decisions

Shared decision making is an emerging physician-patient interaction model for clinical practice [1]. Essentially, shared decision making implies that both the physician and the patient contribute to and bear responsibility for the clinical decision to be taken. It offers an alternative for the paternalis-tic model, in which it is the physician who informs the patient and proposes the decision to be made. Shared decision making emphasizes patient's autonomy and recognizes the argumen-tation and preferences of the informed patient as valid elements in the decision process. Thus, it can dramatically influence the physician-patient relationship. E.g., in a given case, the choice for doing nothing as an alternative for pharmaco-therapy could be considered as an acceptable outcome of the shared decision making process, while it could be considered as disobedient behavior of the patient in the paternalistic model. Clinical practice guidelines usually define a single best option in a given case [2]. Seen from this perspective, guidelines leave little freedom for the patient and reinforce the paternalistic model rather than shared decision making. Moreover , the shared decision making model is not universally preferred; numerous situations can be mentioned in which either patient or physician would prefer the paternalistic model [1]. Shared decision making is, however, particularly important when trade-offs between options strongly depend on individual preferences. This includes recommendations within guidelines for which the evidence is scarce or conflicting or for which there is more than one relevant treatment option that different individuals may value differently [2]. This explains why more and more recommendations for shared decision making appear in new guidelines. One of these guidelines is the 2012 version of the Guidelines on the Management of Valvular Heart Disease, by the Joint Task Force on the Management of Valvular Heart Disease of the Eu-ropean Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) [3], that reads, on page S9: " Finally, a decision should be reached through the process of shared decision-making, first by a multidisciplinary 'heart team' discussion, then by informing the patient thoroughly, and finally by deciding with the patient and family which treatment option is optimal ". Also the new 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease [4] mentions shared decision making several times. Amongst others, this guideline gives the following class I, level of evidence C recommendation: " The choice of valve intervention, that is, repair or replacement, …