**2. Shared decision-making**

When there are numerous treatment options in the healthcare systems, healthcare professionals should involve patients and their families in the process of decision-making on their care so that they can select care that meets their preferences and value needs and reflects what is important to them. This process is called shared decision-making [8]. Shared decision-making (SDM) is defined as a process in which patients, their family, and healthcare professionals try to collaborate with each other to choose the best treatment option for patients [9]. SDM engage patients and their families in the process of decision-making about diagnosis, treatment, or follow-up when more than one medically reasonable option is available [10, 11]. In fact, SDM is made by knowing and understanding the best available evidence on the benefits, harms, risks, and effectiveness of all available options; considering the patient's personal preferences and values; and mutually agreeing upon the course of care [8].

SDM is based on the notion that healthcare professionals are the expert persons on the evidence of medical and patients are the experts on what matters most to them [12].

In a systematic review by Makoul & Clayman [13], 161 definitions were found for SDM. They summarized the main elements of SDM in an integrative model of SDM. The model showed nine crucial elements and features that can be used in a variety of healthcare settings. Healthcare professionals could use these SDM-related specific behaviors during consultations with patients and families:


In many healthcare encounters, the notion that only healthcare providers could access evidence is no longer accepted. As a substitute, shared decision-making assumes that both the healthcare professional and patient require access to information about the evidence for providing a decision. Thus, considering and respecting both the healthcare professional's recommendations and the patient's preferences is necessary for providing an effective SDM [8].

## **2.1 Outcomes of shared decision-making**

Shared decision-making (SDM) has many positive outcomes for patients and families. A systematic review showed that SDM was most likely related to affectivecognitive patient outcomes (54%), compared with 25% of health outcomes and 37% of behavioral outcomes [14].

Shared decision-making (SDM) is considered an essential factor of safe and effective healthcare when there are available options to patients. Moreover, SDM is in line with the notion of "No decision about me without me" and supports patient-centered healthcare [15].

#### **2.2 The steps of shared decision-making**

Although there are some models for SDM, the following simple steps proposed by Stiggelbout et al. [10] could be understood easily:

Step 1. The healthcare professional should inform the patients and their families that a decision is to be made, and it is important to consider the patient's view.

Step 2. All the available choices should be explained by healthcare professionals. Moreover, they should clarify the pros and cons of each option.

Step 3. Both the patient and healthcare professional discuss the patient's values and preferences; the professional try to support the patient in the discussion.

Step 4. Both the patient and healthcare professional discuss the patient's decisional role preference, make the decision or defer it, and discuss possible follow-up plans.
