Clinicians face unique challenges to shared decision-making in the ED setting. These include:
• time constraints;
• lack of previous physician-patient relationship;
• lack of privacy.
Shared decision-making is an important concept for patient autonomy, but how does it play out in the unique ED setting?
“There is a moral imperative to perform shared decision-making in the ED setting when the appropriate preconditions are met,” according to Marc Probst, MD, MS, an assistant professor of emergency medicine in the Icahn School of Medicine at Mount Sinai in New York City. Probst is the primary author of a recent paper on this topic.1
Shared decision-making should be the default approach to decision-making in the ED — except in clinical situations lacking clinical uncertainty or equipoise, patient decision-making ability, and time, the authors wrote.
For example, a patient who presents to the ED under the influence of drugs or alcohol would generally not be eligible for shared decision-making, and nor would a patient suffering from acute psychosis.
“The emergency physician has medical expertise in diagnostic testing and therapeutic interventions. Patients know their goals and values best,” says Probst. Shared decision-making uses these two perspectives to arrive at a mutually agreed-upon plan of care.
“Important information, education, and perspectives, based on physician assessment, should be balanced with patient preferences,” says Catherine A. Marco, MD, FACEP, a professor in the department of emergency medicine at Wright State University in Dayton, OH.
Unique Challenges of ED
Shared decision-making in the ED setting is difficult due to time constraints, lack of previous physician-patient relationship, and lack of privacy, Marco says.
“Despite these challenges, it is crucial to undertake shared decision-making whenever possible to agree on the best possible course of action,” says Marco. Clinicians must take into account patient preferences, goals of treatment, recommended therapeutic interventions, and expected outcomes. Marco offers the following two examples of shared decision-making in the ED:
• A 55-year-old woman presents with chest pain, with risk factors of diabetes mellitus and hypertension. The initial cardiac troponin and EKG both are normal. Her heart score is calculated at three, placing her at low risk of an adverse cardiac event. Through shared decision-making, the physician and patient agree that she can be safely discharged home with outpatient follow-up with her primary care physician, who will see her within 24 hours.
“This case illustrates the importance of shared decision-making as a route to consider treatment recommendations and expected outcome, in conjunction with patient preferences and goals of therapy,” says Marco.
• An 88-year-old man presents with shortness of breath. He has known metastatic lung cancer and currently is undergoing chemotherapy. He is experiencing significant nausea, vomiting, and chest pain. He states his doctors have not discussed his prognosis or expected disease course. Through shared decision-making with the patient, emergency physician, and oncologist, the patient is informed of his diagnosis and treatment options. These include hospital admission, discharge to home, or discharge to hospice. The patient and family agree that he does not wish any further chemotherapy or hospitalizations. He is agreeable to hospice care, and is discharged to hospice from the ED.
“This case illustrates the importance of multidisciplinary care, and consideration of patient goals of therapy,” says Marco.
1. Probst MA, Kanzaria HK, Schoenfeld EM. Shared decision-making in the emergency department: A guiding framework for clinicians. Ann Emerg Med 2017; 70(5):688-695.
• Marc Probst, MD, MS, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York City. Phone: (212) 824-8094. Email: firstname.lastname@example.org.
• Catherine A. Marco, MD, FACEP, Professor, Department of Emergency Medicine, Wright State University, Dayton, OH. Phone: (937) 395-8839. Email: email@example.com.