Shared Decisionmaking in the Emergency Department: A Guiding Framework for Clinicians

Abstract

Shared decisionmaking (SDM) has been proposed as a method to promote active engagement of patients in emergency care decisions. Despite the recent attention SDM has received in the emergency medicine community, including being the topic of the 2016 Academic Emergency Medicine Consensus Conference, misconceptions remain regarding the precise meaning of the term, the process, and the conditions under which it is most likely to be valuable. With the help of a patient representative and an interaction designer, we developed a simple framework to illustrate how SDM should be approached in clinical practice. We believe SDM should be the preferred or default approach to decisionmaking, except in clinical situations where three factors interfere. These three factors are lack of: 1) clinical uncertainty or equipoise, 2) patient decisionmaking ability, and 3) time, all of which can render SDM infeasible. Clinical equipoise refers to scenarios in which there are two or more medically reasonable management options. Patient decisionmaking ability refers to a patient’s capacity and willingness to participate in his/her emergency care decisions. Time refers to the acuity of the clinical situation (which may require immediate action) and the time that the clinician has to devote to the SDM conversation. In scenarios where there is only one medically reasonable management option, informed consent is indicated, with compassionate persuasion employed as appropriate. If time or patient capacity are lacking, physician-directed decisionmaking will occur. With this framework as the foundation, we discuss the process of SDM and how it can be employed in practice. Finally, we highlight five common misconceptions regarding SDM in the ED. With an improved understanding of SDM, this approach should be used to facilitate the provision of high-quality, patient-centered emergency care.

Patient Preferences Regarding Shared Decision Making in the Emergency Department: Findings From a Multisite Survey

“…Although research has suggested that younger and more educated patients are more likely to want SDM as opposed to physician‐directed decision making, we intentionally decided against analyzing subsets to avoid promoting the perception that we as physicians can tell by demographics and clinical interactions how much involvement a particular patient would like. Our data suggest that if clinical equipoise exists, nearly all ED patients would like to be aware of the options available to them …”

“…This “healthier‐person” bias may have been introduced because only stable and alert patients were approached and sicker patients may have been more likely to refuse. While being alert is a prerequisite for SDM, hemodynamically stability is not, if clinical equipoise exists and time allows . Furthermore, as this survey was clearly about SDM, it is possible that the same forces that encourage people to defer to physicians may also encourage them to agree with survey questions—our knowledge of the pitfalls of surveys suggest that an “acquiescence effect” may account for 10% of agreement with positive statements …”

“…Patient engagement and shared decision making (SDM) have received increased attention from the emergency medicine community . SDM is defined as a collaborative deliberation whereby patients and clinicians consider the potential harms and benefits of various medical options to come to a mutual agreement on how to proceed, accounting for the patient's values, goals, and preferences .…”

A Qualitative Analysis of Patients’ Perceptions of Shared Decision Making in the Emergency Department: “Let Me Know I Have a Choice”

“…1 A recently published framework suggests that only 3 factors are necessary for SDM to be appropriate in the ED: some degree of clinical equipoise, a willing and able patient or proxy, and time. 2 Although research in the field of SDM has been ongoing for several decades, recent attention to the opportunities for SDM in the Emergency Department (ED) has heightened the need for ED-specific research. 3,4 Several studies have examined SDM from the perspective of the ED physician, recognizing the importance of the physician-as-stakeholder.…”

Bilateral ureterolithiasis: A true positive and false negative PoCUS exam in a patient with renal colic

“…Probst et al have proposed a framework for shared decision-making in the ED, which they argue is applicable in cases where 1) there is more than one reasonable medical option, 2) the patient is willing and able to make decisions, and 3) there is sufficient time. 15 This framework can be applied to cases of renal colic. As we have discussed, there is growing evidence for avoiding CT scans in patients with suspected kidney stones by using different imaging pathways.…”