Shared Decision Making in SLP Practice

This is the first in my promised series on the topic of Evidence Based Practice versus Patient Centred Care. This blogpost is a response to the concern that patients’ preferences may lead to the selection of treatment options that are not evidence-based. This is increasingly possible given the large amount of consumer health information on the internet. However, this information, while sometimes emanating from credible sources, tends to be supplier- rather than consumer- driven, and information by itself does not help patients make the best decisions about their own care. Furthermore, enabling patients to “choose” options that are not in their own best interests can hardly be described as “patient centred care”.

The current best model for PCC is shared decision making in which there is a two-way exchange of information between the SLP and the patient and/or patient’s family. This decision making model can be contrasted with a paternalistic model in which the health care provider makes the decision with limited input from the patient and the informed patient choice model in which the patient is provided with information and then expected to make their own decision independently.

The SLP provides expert information and decision making support and the patient/family provides information about preferences and expectations. The exchange should clarify expectations about the goal of the intervention, identify evidence based interventions and service delivery options, highlight the benefits and risks of those options, and reveal the patient’s values, supports and decision making needs. A tool that has been developed to help patients make decisions about varying health care options is the Ottawa Personal Decision guide, available in several languages. Note that the patient is expected to review the information with the health care provider so that they can make the decision together.

We can consider this model in the context of an extremely common but controversial treatment decision. Let’s say that you have assessed a 18-month-old boy who has low normal receptive language skills and produces only three words. The child has a severely restricted phonetic repertoire when considering both meaningful and nonmeaningful utterances (one stop, one nasal, one vowel). Mum is especially concerned because her own brother is dyslexic and her sister’s son is currently receiving speech-language services at school. You discuss three potential treatment options with the parent in view of the potential risks and benefits and the mother’s preferences:

  1. Watchful waiting: this is the standard recommendation of the hospital in this case because the evidence suggests that late talkers tend to have a good outcome and 18 months is too earlier to predict language impairment on the basis of late talking. The risk is that the child will not catch up and there is evidence that reading outcomes are better in the case of late talking plus family history of dyslexia when the child achieves good vocabulary scores at an early age. Mum is not favourable to this option because her brother and nephew both struggled at school, academically and socially, and she wishes to prevent that outcome for her son at all cost.
  2. Referral to a parent group that is offered by the local health unit in which the SLP teaches the parents responsive interaction techiques. The benefit is that she may learn some useful strategies for stimulating her child’s language at home and she will have the opportunity to connect with parents of other late-talking children. If her son’s language skills do not start to increase rapidly she will be connected to a community resource that can act quickly. The risk is that she will invest time in an intervention that has not been shown to be more effective than watchful waiting over the long term for this population. Mum is not favourable to this option because her husband is about to have hip surgery and he will need her support over the next three months. She does not feel that she will have the time resources to participate in this program at the present time.
  3. Private therapy, using her work-based insurance plan, with grandma taking the son to therapy sessions (12 sessions are covered under the plan). The benefit is that the private SLP can focus on the child’s speech sound repertoire as well as his expressive vocabulary development. Mum will also know that she is doing all she can to accelerate her son’s language development. Grandma will likely be spending a lot of time with her grandson due to the other stresses currently in the family and she has the time resources to attend and follow-through on the therapy sessions. The risks are associated with the opportunity costs – there is a possibility that the child’s language development may pick up without therapy and the child and family might be better off to engage in other valuable pursuits. Mum discusses this option with the rest of the family and they decide to proceed given the family history of slow language development and dyslexia. They are particularly anxious to prevent the need for therapy during school if at all possible. The SLP agrees that this is a reasonable course of action given the concomitant speech delay (restricted phonetic repertoire) and family history, although she would have been willing to wait six months as well and then reassess. She helps the family to identify an appropriate private service provider. She recommends a hospital reassessment in one year’s time.

The goal is to make decisions jointly with the patient taking into account the patient’s needs, the family’s values and particular circumstances, the benefits and risks of the possible actions as informed by the research evidence, and the constraints of the service providers in the local community. In a future blogpost I will bring in some qualitative research on the nature of these interactions and the features that lead to a successful outcome.

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  1. Evidence Based Practice versus Patient Centred Care | Developmental Phonological Disorders
  2. CAMs & Speech Therapy | Developmental Phonological Disorders

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