The practice of SDM has gained proponents, critics, and researchers from all around the world over the past two decades. An international panel of medical experts convening in 2010 came to a consensus and released the Salzburg Statement on Shared Decision Making, declaring that the implementation of effective SDM would make the single most profound improvement to healthcare quality [4]. The statement included instructions for health policy makers, as well as physicians and patients. It asserted that physicians have an ethical imperative to practice SDM with patients, engage in two way communication, field and answer patients’ questions, and solicit patients’ values and personal preferences. Physicians should also provide accurate and individually tailored information about treatment options and the uncertainties, benefits, and harms inherent in them. They must allow patients sufficient time to consider their options and recognize that most decisions need not be made immediately. The Salzburg Statement implored patients to recognize their right to participate, to voice their concerns, questions, and values, and seek out and utilize the highest quality information available [4].

Survey data indicate that the cancer patient population expresses desire for SDM, but that significant variance still exists in patient preferences for decisional control, as some patients still desire the physician to take a guiding role [5]. A qualitative interview study from 2010 indicated that older, frail patients expressed a desire for information but not necessarily to have input into the treatment choice [6]. Cancer patients often desire to have important information even when they indicated that they don’t prefer a very active role in settling on the treatment choice. Though there will continue to be an overall increasing desire for information and continuing movement towards more patients wanting to be active participants in SDM, multiple decision making styles will persist.

SDM is said to be performed effectively when patients accurately comprehend all of the necessary information regarding their options, identify their values and preferences, and determine which treatment choice gives them the best odds of realizing their goal [7]. Having a more equal informational footing, the patient and physician can often come to an agreement about what treatment best fits an individual patient’s health state preferences and tolerance for risks, but if an agreement is not struck the patient’s preferences should ultimately prevail [4].

In much of the SDM literature, the “important information” is only vaguely if ever defined, but it is, to some degree, specific to the diagnosis and available treatment options. When considering surgery for cancer, it is important that the patient know the essential information at the critical time because this treatment cannot be discontinued and is irreversible. This is a serious concern with older patients who are observed to take different strategies in decision making and bias their attention in ways that younger patients do not [8].

Unfortunately, nationally representative survey data suggest that patients do not know the relevant information about a disease, prognosis and available options at multiple important points in care [9]. As a result, an entire decision support aid movement has started with the mission of developing and verifying the quality of tools intended to improve patient knowledge, including tools relevant to cancer care and surgery [10, 11]. Many of these tools are intended to avoid ineffective SDM participation by uninformed or confused patients that could lead to treatment choices that do not match the patient’s preferences and goals.

Several barriers to patient participation in SDM, which all could jeopardize patient education, have been identified and include dealing with multiple professionals unfamiliar with their preferences, diverse treatment strategies among physicians, fast patient turnover in hospitals, stressed medical personnel, and communication barriers [6]. All of these factors are risks that hinder the communication between patients and surgeons and contribute to patients having poor comprehension when a decision is to be made.

Currently, the downstream consequences for succeeding or failing to practice good SDM are not well-documented or understood. The rationale is that if a patient is to express their values, goals, and preferences and work with the physician to choose the treatment option that best fits, they must have an accurate understanding of the problem in their mind. There is some evidence that suggests that the quality of SDM is predictive of patient-centered, clinical and care-cost outcomes. Decision conflict is a construct that largely reflects how satisfied a patient is about their treatment decision shortly after making it and usually prior to fully realizing the treatment outcome. There is debate about the tenability and value of lowering patients’ decision conflict [12]. But it seems that helping patients feel secure and confident in their treatment choice will benefit overall satisfaction with care.

Although, the ethics of SDM should make it immune to cost considerations, the potential to lower or raise costs is on many people’s minds. Good SDM could improve satisfaction and functional outcomes, but poorly executed SDM could disproportionately increase costs and worsen clinical outcomes, satisfaction with care, and quality of life. Patients are unlikely to be as influenced by financial incentives as much as physicians sometimes are, but it is not a certainty how SDM will influence the cost of care until more appropriate and longitudinal data are available. However, some theories have been proposed as to how SDM might lower costs, and one in particular, costs of litigation, is highly relevant to surgery. Some data indicate that it is health care professionals’ style as much as the content of their communication that predicts litigation. There is evidence that failures of SDM such as devaluing patient or family views, delivering information poorly, and failing to understand the patient’s perspective of the problem were predictive of litigation [13–15]. It is clear that improving patient comprehension and participation in SDM could lower the high rate of litigation in surgery, and potentially decrease health care costs.

When presenting to a thoracic surgery clinic for probable or confirmed NSCLC, patients are regularly evaluated on their surgical candidacy. Although surgical lung resection has been the most popular treatment choice for early stage (I or II) NSCLC for decades, the decision about having surgery is not obvious when the patient is at higher risk for complications or less likely to benefit from the operation. Without additional concerns, surgery is preferred because removing cancer from the patient’s body provides the highest probability of 5 year survival. However, the immediate and long-term risks associated with surgery provide reason for pause, and more thorough pre-surgical assessment reveals that not all patients prove to be good surgical candidates.