Shared decision-making (SDM) represents a vital advancement in patient-centered care, where healthcare professionals and patients collaboratively choose the most appropriate treatment path. Despite the benefits of SDM - improved treatment adherence, better clinical outcomes and patient empowerment - its adoption remains limited, with many clinicians having yet to fully integrate this SDM into their patient interactions, particularly in Portugal.¹ This highlights the urgent need for discussion and investment in its implementation throughout the Portuguese healthcare system.

The fundamental principle of shared decision-making (SDM) is the acknowledgment of patient preferences and values, engaging the patient as an active collaborator in health-related decisions.² Evidence shows that SDM enhances both patient satisfaction and the patient-doctor relationship.¹ However, significant barriers hinder its widespread adoption in Portugal. Challenges include addressing patients' needs and concerns, facilitating informed decision-making, and managing the limited duration of medical appointments. Additionally, cultural hesitancy towards active patient involvement, combined with limited health literacy and patient self-advocacy, further complicates the SDM process.³

To overcome these barriers, structured strategies and resources are needed. Training programs for healthcare providers should incorporate experiential learning and reflective practices to enhance SDM skills. Tools like the BRAN questions - where providers discuss the benefits of a treatment, risks involved, alternatives available, and the consequences of doing nothing- serve as practical guides to thoroughly evaluate treatment options, assess patient preferences, allocate time for decision-making, and outline the next steps.⁴ Additionally, the OPTION scale (“observing patient involvement”) can enhance the SDM process by ensuring that all critical aspects of patient-centered decision-making are systematically addressed. This scale acts as an external evaluation tool to assess clinicians' performance, specifically their ability to provide information, understand patient preferences, and support patient participation, offering constructive feedback to enhance future practices.⁵

However, it is essential to recognize that patients' ability to participate in SDM can vary significantly based on their cognitive skills. Effective decision-making requires the recognition of the skills and rights of individuals with cognitive challenges, allowing them to influence decisions, share information, and express preferences with appropriate support.^6-8 To address these challenges, tailored interventions such as Talking Mats, a picture-based communication framework, provide effective solutions by enabling patients to visually express their feelings and preferences within specific topics, thereby overcoming cognitive or communicative barriers.⁹ Similarly, visual aids and computer-based tools have demonstrated positive outcomes in supporting patients, their care partners, and healthcare professionals in navigating the decision-making process.⁷ Adapting tools and strategies to the cognitive capacities of each patient is crucial to ensure that SDM remains inclusive and empowering for all.

Integrating these SDM tools into clinical systems can support healthcare teams in consistently applying these frame-works to make patient-centered decisions more streamlined, accessible, and effective in routine practice. We also encourage clinicians to engage in self-assessment to reflect on their ability to integrate patient preferences effectively. Regular self-evaluation can help identify areas for improvement and foster a stronger patient-provider relationship.

Prioritizing shared decision-making is essential to enhance patient autonomy, improve healthcare outcomes, and foster a more compassionate healthcare environment. By adapting SDM practices to address cognitive impairments, Portugal can take a significant step toward inclusive healthcare. We urge Portuguese healthcare leaders to initiate discussions, provide training, and adopt policies that promote SDM. By doing so, Portugal can move towards a healthcare system where patients’ voices are integral to their care, promoting a more inclusive and effective approach to treatment.