Because of recent incidents of sudden cardiac arrest (SCA) among high-profile athletes, including Damar Hamlin and Bronny James, there has been greater scrutiny regarding the medical evaluation process for athletes. With mainstream discussions about screening protocols and emergency action plans, it is easy to lose sight of the person at the center of the outcomes: the athlete. Medical experts historically used a binary yes or no approach for decisions on athletic participation, which was illustrated by the 1996 case of Knapp v Northwestern University, in which Nicholas Knapp was unilaterally disqualified from playing basketball by the university's medical staff without his input.¹ In recent years, this seemingly authoritarian paradigm has been replaced by the model of shared decision-making (SDM). Through SDM, there is an inherent acknowledgment of the impact a return-to-play (RTP) decision may have on the athlete and their family, as well as the immense ethical responsibility of the medical staff and athletic institution (e.g., team, league, school) to act in the athlete's best interest.

Dr. Jonathan Kim recently led a discussion through the ACC CardiaCast: Courtside with the Chair: Shared Decision-Making with Athletes: A Discussion of "Why"? podcast about SDM with Drs. Marty Maron, Kim Harmon, and Aaron Baggish.

Conversation Highlights*

Kim: Why is SDM important? Do you believe it to be important?

Harmon: In 2003, I had an athlete who [experienced] SCA. She survived, [got] a defibrillator, and wanted to [return] to play basketball. We had a number of different opinions and navigating that process was really hard. We ended up letting her [RTP] against the guidelines at the time. [That] started this whole journey for me in trying to figure out when the athlete gets to have input, particularly in the setting of uncertain risk.

Maron: The short answer is yes. SDM is compatible with the team physician model. Over the last 3 decades, we have [emphasized] the importance of SDM as one of the [key] components of the team physician model, but it's not the only component. The team physician also relies on the expertise of the athletes' consultants, their own consultants, guidelines, and the desires of the athlete and their family.

Baggish: I would present the concept of SDM differently; I see it as the ultimate framework that informs the team physician model rather than one isolated component. SDM is never a [single] discussion, it is an iterative process of many discussions over time, and it involves the team physician. It works out best when consensus is reached, but when consensus can't be reached, the team physician assumes the responsibility of being final arbiter.

Kim: As somebody who strongly advocates for SDM, I want to mention that SDM is not a rubber stamp. It's not [as simple as], the athlete comes in, I tell them the risk is high, and they say I still want to play, so I say OK. That is not what SDM is.

Kim: Who should be involved in SDM?

Baggish: If done effectively, it is a conversation in which all relevant stakeholders, including the team physician, practicing cardiologist, university administration, athletic trainers, family members, and athlete are brought to the table before a final decision is made. [The] decision may not be what the athlete wants, but at least [they] hear all opinions [regarding] the final decision.

Kim: Do athletes have appropriate insight into the risks of their condition and the ability to make a rational decision about RTP?

Harmon: Absolutely. I think the vast majority of athletes have really good insight into their motivations and stakes—and they are really the most appropriate person to assess risk for themselves. Someone's continued play on the field is their ticket to professional career and financial success for their family.

Maron: For certain athletes, there may be a disproportionate weight that is influencing certain decision-making and perception, including financial, scholarship, and pressures from family or teammates. [These] may weigh disproportionately on an individual athlete and impact their ability to unpack the perceived risks.

Baggish: In my experience with athletes, the majority of them do have the capacity to responsibly participate in SDM and they are a lot more thoughtful than we would give them credit for. We just need to be really careful in separating our own value system and beliefs from those we are taking care of; what is proportionate and disproportionate depends on the lens of the person making that decision.

Kim: What are the limitations and potential pitfalls of SDM?

Maron: We are not really taught how to engage in the specifics of SDM. We need to develop more [standardized] approaches. We also have to ask: Can we produce evidence to say that SDM is actually beneficial or that we are not doing harm with SDM? We don't really know that. We need to produce the science to show that SDM is safe and beneficial in terms of risk on the athletic field.

Harmon: I think that was the perfect setup to plug the ORCCA (Outcomes Registry for Cardiac Conditions in Athletes), where we are trying to find elite athletes with cardiac conditions, determine whether they experienced SDM, and evaluate their mental health and cardiovascular (CV) outcomes.

Baggish: I approach this with intense humility; we think we are doing the right thing, but we really don't know that. We can't go back to the days of unchecked paternalism and we can't move forward to the days of unchecked autonomy.

Conclusion

Although there is no consensus approach, early evidence suggests that implementation of SDM by expert clinicians with appropriate risk stratification and follow-up is associated with low risk of adverse cardiac events (no fatalities), even among a high-risk athletic cohort with genetic heart disease, including hypertrophic cardiomyopathy and long QT syndrome.² Recent data further suggest that SDM improves athletes' understanding of CV risk associated with RTP and reduces conflicts regarding the decision about RTP.³ When used appropriately, the SDM and team physician models are complementary tools to facilitate a decision that works best for the athlete, the university, and interdisciplinary consultants.

References

1. Knapp v Northwestern University, 101 F.3d 473 (7th Cir. 1996).
2. Martinez KA, Bos JM, Baggish AL, et al. Return-to-play for elite athletes with genetic heart diseases predisposing to sudden cardiac death. J Am Coll Cardiol 2023;82:661-70.
3. Mitropoulou P, Grüner-Hegge N, Reinhold J, Papadopoulou C. Shared decision making in cardiology: a systematic review and meta-analysis. Heart 2022;109:34-9.