title: Shared decision-making as an existential journey: Aiming for restored autonomous capacity.
abstract: We describe the different ways in which illness represents an existential problem, and its implications for shared decision-making.
  
  
  
  We explore core concepts of shared decision-making in medical encounters (uncertainty, vulnerability, dependency, autonomy, power, trust, responsibility) to interpret and explain existing results and propose a broader understanding of shared-decision making for future studies.
  
  
  
  Existential aspects of being are physical, social, psychological, and spiritual. Uncertainty and vulnerability caused by illness expose these aspects and may lead to dependency on the provider, which underscores that autonomy is not just an individual status, but also a varying capacity, relational of nature. In shared decision-making, power and trust are important factors that may increase as well as decrease the patient's dependency, particularly as information overload may increase uncertainty.
  
  
  
  The fundamental uncertainty, state of vulnerability, and lack of power of the ill patient, imbue shared decision-making with a deeper existential significance and call for greater attention to the emotional and relational dimensions of care. Hence, we propose that the aim of shared decision-making should be restoration of the patient's autonomous capacity.
  
  
  
  In doing shared decision-making, care is needed to encompass existential aspects; informing and exploring preferences is not enough.
authors.affiliation: Institute of Clinical Medicine, University of Oslo, Oslo, Norway; HØKH Research Centre, Akershus University Hospital, Lørenskog, Norway. Electronic address: pal.gulbrandsen@medisin.uio.no.
authors.forename: Pål
authors.initials: P
authors.lastname: Gulbrandsen
authors.affiliation: American Institutes for Research, 10 S Riverside Plaza, Suite 600, Chicago, IL, USA.
authors.forename: Marla L
authors.initials: ML
authors.lastname: Clayman
authors.affiliation: Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Mary Catherine
authors.initials: MC
authors.lastname: Beach
authors.affiliation: Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME, USA.
authors.forename: Paul K
authors.initials: PK
authors.lastname: Han
authors.affiliation: Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Emily F
authors.initials: EF
authors.lastname: Boss
authors.affiliation: Department of Internal Medicine, Nordland Hospital, Bodø, Norway.
authors.forename: Eirik H
authors.initials: EH
authors.lastname: Ofstad
authors.affiliation: The Preference Laboratory, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.
authors.forename: Glyn
authors.initials: G
authors.lastname: Elwyn
mesh_terms: D003142:Communication; D032882:Comprehension; D003657:Decision Making; D005086:Existentialism; D006801:Humans; D010358:Patient Participation; D026684:Personal Autonomy; D010817:Physician-Patient Relations; D011209:Power, Psychological; D035502:Trust; D035501:Uncertainty; D035862:Vulnerable Populations
keywords: Autonomy; Decisional agency; Dependency; Existential process; Physician roles; Power; Responsibility; Shared decision-making; Trust; Uncertainty; Vulnerability