Shared decision-making seems to be more popular than Snapchat these days. Everyone in emergency medicine is talking about it… but who is actually doing it properly? In our recent concepts piece published in Annals of Emergency Medicine, we describe 3 key factors that must be present for shared decision-making (SDM) to be appropriate in the emergency department (ED).
Shared Decision-Making: What is it?
SDM is a process whereby you (the clinician) present and describe various management options to a patient, all of which are medically reasonable, and get their input on what they feel is the best option for them. When you boil it down, it is simply a dialogue, or conversation, between you and the patient about their care. Ideally, SDM incorporates both the best evidence available and the patient’s values and preferences.
3 Required Factors in Shared Decision-Making
What 3 factors must be present for SDM to be appropriate in the ED?
1. Multiple Reasonable Options
There must be 2 or more medically reasonable management options. For example, imagine you are caring for a gentleman in his late 50s who presents with chest pain. His ECG looks normal, and his two serial troponin levels are undetectable. You could admit him for an exercise stress test in the morning, or arrange outpatient follow-up for him in the next 2-3 days. Both are medically reasonable, so why not discuss them directly with the patient?
2. Appropriate Patient
For SDM to be appropriate, the patient must have the capacity to make decisions. In other words, s/he must be willing and able to engage with you in decision-making. ED patients can lose capacity for a variety of different reasons, such as alcohol intoxication, altered mental status, or dementia. Most patients in the ED do have capacity.
The patient must also want to engage with you in the decision making process. They may not feel comfortable making medical decisions based on cultural reasons or fear/anxiety. The easiest way to determine this is just to try and see how they react.
3. Sufficient Time
Time in the ED is precious. If you need to intervene immediately to save a patient, then SDM is probably not appropriate. Generally because ED decisions can wait a few minutes and because the SDM conversation usually only takes a few minutes, there is often enough time to have a SDM dialogue.
SDM can sometimes save you time, if the patient prefers a less intensive option than you might have otherwise pursued. For example, the patient that wants to go home and monitor her abdominal pain instead of getting a CT scan to rule out appendicitis.
4 Steps in Conducting Shared Decision-Making
Once you identify that all 3 factors are present (reasonable options, ability to make decisions and time), how do you conduct SDM in practice?
Step 1: Acknowledge that a clinical decision needs to be made.
- Example: “Your lab work came back normal. Now we need to decide what to do next.”
Step 2: Describe the options and the pros and cons of each.
- Example: “A CT scan involves some radiation and will take a couple hours, but we will get a better idea of what is going on inside your abdomen. Going home may require a repeat visit to the ED, but you won’t have to stay in this loud and crowded place any longer.”
Step 3: Explore the patient’s values and preferences.
- Example: “Do you feel well enough to go home? Can you come back easily to the ED? Is radiation a big concern for you?”
Step 4: Decide together on the best option for the patient.
- Example: “It sounds like you are feeling better and you’d rather go home. Please come back if you start feeling worse. I’ll go get your discharge paperwork.”
SDM is like riding a bike. It is easy when you know how. There are many scenarios in medicine,1 where more than one reasonable option exists. The next time you have a patient with capacity and some time to talk it through, try it. You will be delivering truly personalized, patient-centered care, and your patients will appreciate it!