Tag Archives: shared decision-making

What are the priority Emergency Department (ED) presenting conditions for which ED-based Shared Decision-Making should be most urgently developed?

An article in this week’s Wall Street Journal focused on the development and use of shared decision-making (SDM) tools in the emergency department (ED).  Decision tools can help engage patients in making decisions about their care, including decisions about which tests and treatments to pursue.  In the ED, relevant decisions are (1) decisions involving two similarly reasonable options (“preference-sensitive health care decisions”) and (2) decisions that patients or their families can take some time to consider. The examples mentioned in the WSJ article are

  1. children with uncomplicated acute appendicitis: IV antibiotics versus surgery
  2. adults with chest pain and normal initial test results: watchful waiting (not doing any tests) versus extensive testing (you can try out this tool here)
  3. mild traumatic injury: watchful waiting versus head CT scan

Other scenarios for which SDM tools have been studied include

  • testing for bacterial infections among children with fever-without-an-obvious-source
  • choice of anesthesia and sedation for the repair of small lacerations in children
  • choice of hydration methods (IV or oral) for children with dehydration from a vomiting/diarrhea illness.
  • management of acute musculoskeletal pain in adults

shared-decision-making-were-in-this-together-3-728Selection of SDM is the focus for the 2016 Academic Emergency Medicine consensus conference, “Shared Decision-making in the Emergency Department: Development of a Policy-relevant Patient-centered Research Agenda”. I pose here one of the many questions to be addressed at that conference: What are the priority ED presenting conditions for which ED-based SDM should be most urgently developed?

 

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Patient choice in management of acute appendicitis

imageIn an article in JAMA Surgery this week, the authors show not only that it is safe (and perhaps safer) to treat uncomplicated appendicitis nonoperatively but also that letting parents choose  the treatment option for their child is an effective strategy. The question of safety has been addressed in prior adult and pediatric trials, leading to growing consensus that in a specific subset of patients with uncomplicated acute appendicitis it is safe to treat nonoperatively. Further, they found that patients whose parents selected nonoperative management incurred  less morbidity (days of normal activity missed by the patient or parent) and lower costs than those whose parents chose surgery.

This study is important not only because it reproduces prior findings of the safety of nonoperative management in certain patients, but even more so because it highlights the concept of patient choice–driven treatment. As I mentioned in a post earlier this week, this concept has been shown to both empower the patient and improve overall patient satisfaction.

The invited commentary accompanying the article paints shared decision making in black and white extremes: “Further study is needed in this arena before we completely abdicate the responsibility for guiding our patient’s decision making. Many patients still want us to be “doctors,” not Google impersonators.” As a patient or provider, does patient choice feel like providers are completely abdicating their responsibility for guiding decision-making?