From Patient-Centered to Patient-Directed Care

A new paradigm of shared decision making

Mar 1, 2019 Barbara Coombs Lee Author

In Finish Strong: Putting Your Priorities First at Life’s End, I propose three attributes to look for in physicians to enable true partnership: humanity, candor, and deference.

As I discuss in the chapter “Talking About Death Won’t Kill You (But It Could Improve Your Life), deference to you and your wishes is perhaps the newest concept in the doctor-patient relationship. It implies that the patient should be in ultimate charge of choosing treatments in line with individual priorities. The doctor cannot make such decisions alone.

This should not be a revolutionary idea, but in our current medical culture, it is actually quite radical. Doctors are still formidable authority figures and most people still believe on some level that the doctor is the boss. Physicians, for their part, generally do little to dispel this notion. Even when they say “patient-centered care,” they do not mean patient-directed care. Practically speaking, “patient-centered” can still mean doctors and other providers form a circle around the patient, telling him or her what to do. This simply places the patient at the center of a huddle of external authority.

The new paradigm of shared decision making

For several years I’ve used an image of crow behavior to help visualize the difference between patient-centered and patient-directed.

In the first image, the birds forming the circle mean well. They have benevolent intentions toward the poor bird at the center of their attention, who clearly has no authority. The “centered” one stands anxiously on the receiving end of a lot of scrutiny and opinion and it’s clear he’s not going to have much to contribute to the final decision.

The second image is a bird in charge. His posture says he is the ultimate decision-maker. He still receives information and opinion, but he holds his own prize—the values, beliefs, and priorities that are important to him. This bird is respectful and attentive to the expertise and experience of his advisors. But the discussion is about the fate of the treasure he holds, and he maintains his autonomy until the determined course of action meets his approval.

Consultation and Collaboration

We are, or should be, in charge of our own healthcare. Healthcare decisions should be about consultation and collaboration, not authority and direction.

My strong advice is to find a physician who knows that and forge a relationship in which the trust and dialogue runs both ways. There can be no hope of genuine decision making and truly informed consent to treatment without that.

Through an empowered attitude and the sharing of tools for a more productive doctor-patient relationship, I hope Finish Strong helps people be strong in their understanding and resolve as they apply the final touches to their well-lived lives.