The importance and challenges of shared decision making in older people with multimorbidity

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Typically, shared decision making, with or without a decision aid, involves patients in discussions about the options for treatment, the benefits and harms of each therapy, and the patient’s preferences, and a collaborative decision about how to proceed is made. For single conditions, that requires some motivation and teachable skills. But an additional challenge in providing healthcare for older people is the likelihood of multimorbidity: approximately half of older adults have 3 or more chronic conditions [1]. The patterns of comorbidity are largely determined by common conditions in older people, such as coronary heart disease, diabetes, hypertension, chronic obstructive pulmonary disease (COPD), heart failure, depression, arthritis, and cancer. Multiple conditions complicate shared decision making, as management is not the simple sum of the parts. Should a patient with late-stage cancer continue statins? When is an implantable defibrillator appropriate in a patient with dementia? Are beta blockers mandatory in a patient who is depressed after a myocardial infarction? Multimorbidity is a problem itself but also creates interactions that can generate additional problems—of particular concern are polypharmacy and burden of treatment.