25 Shared decision making for high risk major surgery: genres of consultation

Shared decision making represents a shift from a paternalistic, ‘doctor knows best’ approach to a collaborative approach that values and centres patients’ knowledge of their own best interests. Resources such as training for clinicians, awareness raising for patients and the public, and decision support tools are used to achieve shared decision making. Despite these efforts, patients can feel that they have little choice about treatment, and some patients say they prefer to trust in their clinicians’ recommendations. During our qualitative study of how patients, their families and clinicians make decisions about high-risk major surgery (Shaw et al., 2020), we asked: to what extent can shared decision making address the asymmetries of power and knowledge between patients and clinicians as they approach decisions about treatment? Informed by ethnography of communication, we drew on the concept of genre in our analysis of empirical data (video recordings of decision-making consultations, interviews with patients, family members and clinicians and ethnographic fieldnotes). We analysed the interactions between context and language, considering how talk during consultations between surgeons, patients and family members interacted with the clinical, organisational and social context of the decision. We found that shared decision-making was understood and practised in distinct, varied ways to produce three different genres of ‘decision-making’ consultation: ‘problem-solution’, ‘option selection’ and ‘assessment of benefit’. These genres served different functions, shaping the extent to which patients perceived and participated in decision-making. We consider the implications of how different external framings (how and when the consultation was organised in relation to the patient’s trajectory) and thematic framings (how clinicians and patients approached the consultations) shaped the resulting genre of consultation. We conclude that attempts to address asymmetries of power and knowledge through decision-making talk during consultations can potentially be thwarted by the framing effects of the clinical, organisational and social context.