Why Asking Patients What Matters Most Could Fix Fragmented Care

Millions of people live with more than one chronic condition at the same time, a situation clinicians call multimorbidity. According to a new perspective article published in the Journal of General Internal Medicine, more than a third of the general population and over half of adults aged 60 and older now manage two or more chronic diseases simultaneously, with prevalence particularly high in North and South America and rising globally, including among younger adults. The consequences are far-reaching: multimorbidity is associated with reduced quality of life, functional decline, increased mortality, and higher healthcare costs. Yet the authors, led by Laura Vriese of Maastricht University, argue that the biggest problem may not be the diseases themselves but how care is organized around them. When each condition is treated in isolation, patients can end up with a pile of recommendations that no one has ever considered as a whole.

The technical heart of their argument concerns a step in shared decision-making known as values clarification. Shared decision-making, or SDM, is the process by which clinicians and patients jointly weigh options, benefits, and harms before arriving at a choice together. Within that process, values clarification means identifying what matters to an individual in relation to a specific health decision, including their goals, preferences, broader values, and personal context. The authors distinguish three related concepts that often blur together in clinical conversation: goals are desired outcomes, such as being able to walk to the supermarket; preferences describe how desirable a person finds a particular option or health state, for example wanting to avoid medication; and values are broader still, encompassing things like family or cultural priorities. In practice, they argue, decision-making conversations still center primarily on medical options and outcomes, leaving this crucial step underused.

Why does this matter so much for people with multimorbidity? Because most clinical guidelines, patient decision aids, and SDM models were built for single diseases. A patient with diabetes, heart failure, and arthritis receives separate, often uncoordinated recommendations from different specialists in different consultations, each involving multiple tests, medications, and proposed lifestyle changes. These recommendations may overlook combined or conflicting treatment effects, ignore patient values, and ignore the cumulative burden of disease and treatment. Without clarifying values from the outset, clinicians may simply apply each recommendation cumulatively, producing fragmented or overly intensive care that prioritizes disease-specific metrics over outcomes patients themselves consider meaningful. The authors note that increasing medical specialization reinforces this fragmentation, and the result can be care that is overwhelming, unnecessary, or even counterproductive.

To illustrate the stakes, the authors draw on a well-known hypothetical case, originally described by Cynthia Boyd and colleagues, of a 79-year-old woman with multiple chronic conditions. If clinicians rigidly apply every relevant guideline to her case, the result is a regimen of multiple medications taken several times a day, numerous non-pharmacological recommendations, and frequent healthcare appointments. Such a regimen is difficult to follow and may actively increase the risk of harm through polypharmacy, the dangerous accumulation of interacting drugs. Without values clarification, care drifts out of alignment with the patient’s preferences and can undermine the very quality of life it is meant to protect. With it, clinicians can prioritize interventions based on what the patient actually wants to achieve, trimming away the rest.

The paper adds a second, often overlooked layer of complexity: limited health literacy, meaning difficulty finding, understanding, and using health information. Multimorbidity and limited health literacy frequently co-occur, and both are independently associated with poorer health outcomes and increased healthcare use. Paradoxically, the authors argue, patients facing this combination may have the greatest need for, and stand to benefit the most from, values clarification and shared decision-making, yet they are also the most likely to struggle with the tasks those processes demand. Health literacy researchers typically distinguish three levels: functional literacy, the ability to read health information; interactive literacy, the ability to apply information and engage in dialogue; and critical literacy, the ability to weigh options and assert preferences. Limited health literacy can compromise all three.

Applied to the hypothetical 79-year-old, the consequences become concrete. Complex medical information, such as blood glucose targets or medication interactions, may be difficult for her to understand. Comparing options, such as a single daily pill that provides only mild symptom control versus multiple, more effective but harder-to-manage medications with a higher risk of side effects, can be overwhelming. The predictable result is that she adopts a more passive role in decision-making, tending to agree with proposed plans rather than expressing her own preferences. If her clinicians knew what mattered most to her, for instance having enough energy to visit her grandchildren, entirely different and better-aligned decisions could follow. The authors frame this as a critical equity concern: the patients who most need person-centered care are the least likely to receive it.

What can be done? The authors survey the existing toolkit and find it wanting. Most values clarification tools were developed for single-disease contexts, focusing on the treatment options and outcomes of one specific condition, and may overlook interactions between conditions, treatments, and broader goals such as maintaining independence or quality of life. Worse, the majority are text-heavy, conceptually complex, require medical knowledge and abstract reasoning, or exist only in digital formats, limiting accessibility for people with limited health literacy or low digital skills. Two multimorbidity-focused tools do explicitly address health literacy, using visual prompts for agenda setting, asking what the patient wants to talk about today, or goal setting, asking what the patient wants to achieve. But the authors caution it remains unclear whether even these are sufficient to elicit patients’ deeper values and genuinely support decision-making.

Their most provocative proposal is to reverse the usual sequence of the consultation. In traditional SDM models, values clarification typically comes after discussing the available options. The authors argue that patients with multimorbidity and limited health literacy may benefit from starting with values clarification instead: first exploring the patient’s broader goals and values, then tailoring the discussion of options to what matters most. This reordering may reduce cognitive burden by helping patients evaluate options within the context of their own goals rather than comparing multiple disease-specific recommendations in isolation. It also helps clinicians focus the conversation on options that best align with the patient’s values and avoid presenting interventions unlikely to support outcomes the patient considers meaningful. Values clarification, they stress, is iterative, beginning in dialogue at the start of a consultation or even earlier, at home, though patients may struggle to prepare without support.

Practical supports round out the proposal. Inviting an informal caregiver, such as a family member or trusted friend, into the consultation can help patients articulate goals and link decisions to their broader life context, particularly in stressful situations when comprehension is reduced. But the authors warn that caregivers can unintentionally shift the discussion toward their own preferences, so clinicians must ensure the final decision reflects the patient’s values. Continuity of care and trusting relationships are also critical: distributing values clarification across multiple consultations, or dedicating specific appointments to it, allows patients to reflect over time and reduces the pressure of immediate decisions. Although this may seem difficult in time-pressured practices, better alignment with patients’ contexts may ultimately save time by reducing follow-up visits, and practice nurses could play a key role by regularly revisiting treatment goals and documenting them in a shared care plan.

The authors close with a call for targeted training for healthcare professionals, covering awareness of the challenges faced by patients with multimorbidity and limited health literacy, the use of adapted values clarification tools, and the conversational skills central to meaningful dialogue. Future work, they argue, should develop and evaluate values clarification methods in collaboration with patients and clinicians, ensuring they are accessible, feasible, and genuinely person-centered. The underlying message is deceptively simple: medicine has become extraordinarily good at generating disease-specific recommendations, but for the growing population living with several diseases at once, the decisive question is no longer just what the evidence supports, but what the patient actually wants. Answering that question first, rather than last, may be the key to making complex care humane.

Subject of Research: Values clarification in shared decision-making for patients with multimorbidity and limited health literacy

Article Title: Shared Decision-Making with Patients with Multimorbidity and Limited Health Literacy: The Importance of Values Clarification

Article References: Vriese, L., Pel-Littel, R., Giguere, A., Rademakers, J., Knottnerus, B., van der Weijden, T., & Jansen, J. (2026). Shared Decision-Making with Patients with Multimorbidity and Limited Health Literacy: The Importance of Values Clarification. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10728-5

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10728-5

Keywords: shared decision-making, multimorbidity, health literacy, values clarification, patient preferences, chronic disease, primary care, polypharmacy, patient-centered care, clinical guidelines, caregivers, continuity of care