SDM Clinic Model

M – Medical Assessment

Comprehensive clinical assessment, covering medical conditions, and health, function, frailty and cognition, where relevant.

Medical Assessment isn't a new idea. Geriatricians have long practised this through Comprehensive Geriatric Assessment (CGA) - a structured, multidimensional review of a person's medical, functional, cognitive and social status, shown to improve outcomes for older adults, including increased likelihood of living independently at home after hospital admission.⁵˒⁶˒⁷

MAP takes this same thinking and applies it more broadly. Frailty and cognition are assessed where relevant, not by default - a younger patient with significant comorbidities may benefit from the same careful assessment as an older patient, while for others these domains may not be relevant at all.

This is the foundation everything else in MAP is built on.

This is also where Realistic Medicine³˒⁸ matters most. Realistic Medicine means care that genuinely fits the person in front of you, not a one-size-fits-all approach applied regardless of their circumstances. Clinicians bring genuine expertise in their own medical or surgical field, and shared decision-making includes the confidence to use that expertise to guide, not only to inform. For a patient with multimorbidity or frailty, the same treatment plan that suits one person may carry very different risks and benefits for another with the same diagnosis. Once you've properly understood the patient through Medical Assessment and ALL, you're well placed to be clear about what genuinely fits them - and comfortable saying so, as part of the shared decision.

Psychological safety

Patients feeling able to voice concerns, uncertainty, or disagreement without fear of judgement - is what makes this conversation genuine rather than procedural.⁹

Communicating across language and health literacy

Not every patient starts this conversation from the same place. Language, health literacy, and cultural background all shape how clearly information lands - and for migrant populations in particular, this is often where shared decision-making genuinely breaks down, not in the clinical complexity itself.¹⁰

Plain language, professional interpreters where needed, and translated resources are what make ALL BRAN genuinely accessible, not just technically offered.

Metaphor and analogy are a legitimate clinical communication tool, shown to support patient understanding and shared decision-making.¹¹ The road-trip analogy used throughout this platform - the car as the body, the mechanic's check as pre-admission assessment, prehab as preparing for the journey - was developed for use in clinic and has been useful in practice, though not yet formally evaluated.

Equity is achieved when information is understandable, not simply available.

The full picture of risk

Patients aren't just consenting to a risk when they understand it - they're consenting to uncertainty when they don't.

A common gap is talking about risk as if it belongs only to the treatment, procedure, or intervention itself. In practice, a great deal of risk sits elsewhere:

After surgery, many of the most significant risks are medical, not surgical. Delirium is a clear example, particularly in frail or cognitively impaired older patients, where the risk often has little to do with the operation itself and everything to do with the person's baseline vulnerability.¹⁰ Falls are another well-recognised risk during hospital admission and periods of deconditioning, not the procedure performed.

In oncology, broader risks worth keeping in view alongside treatment-specific toxicity include infection risk during immunosuppression, and the effect frailty can have on a patient's ability to tolerate a full treatment course. 

This is precisely why our clinician form splits Risks into three groups, not one - Medical, Anaesthetic, and Procedure-specific - rather than a single list centred on the intervention alone. Patients deserve the full picture, not just the part of it that's easiest to name.

Individualised care plan, optimising health and wellbeing, advance care planning, multidisciplinary coordination, and an agreed treatment, alternative, or supportive care plan.

A decision is not the end of the process. Whatever is decided - proceeding, choosing an alternative, or choosing supportive care instead - active planning continues.

Plan & Support includes:

• An individualised care plan, built from the assessment and the aligned decision

• Optimising health and wellbeing, including prehabilitation where relevant, particularly for frail or multimorbid patients facing a procedure

• Advance care planning, where appropriate

• Multidisciplinary coordination, ensuring the plan is followed through, not just documented

An agreed plan does not mean the patient's care stops here, whichever path is chosen - treatment, an alternative, or supportive care continues to be actively planned and coordinated.