How often have you completed a refusal of transport but left frustrated and concerned for the patient’s well-being? You may have asked yourself, What made this patient so stubborn? Could I have said something different to get them to go to the hospital?
In these situations the strategy of shared decision-making (SDM) can improve communication and facilitate more effective discussions between prehospital personnel and their patients, leading to care decisions that are more satisfactory for all.
A tenet of EMS Agenda 2050 is to create a people-centered EMS system. The project’s work group suggested this will be achieved when we “understand and address the patient’s perspective.” SDM is an approach designed to guide providers in connecting with those they aim to treat and seeing things their way. For EMS this may have implications for transport, longer-term care, and potentially reimbursement.
What Is Shared Decision-Making?
In simplest terms SDM is a process by which healthcare professionals and patients work together to make healthcare choices.1 It is easy to assume this is how all healthcare transactions take place.
However, SDM is much more than a physician giving a patient a prognosis and offering a solution to accept or refuse. Instead, SDM is a process of joint deliberation through mutual understanding.
Others have described SDM as “an interactive decision-making process conducted on an equal footing.”2 In this philosophy a healthcare provider takes part in a treatment plan, as opposed to dictating it. SDM requires the provider to try to understand the patient’s cultural views and beliefs that influence their choices, as well as ensuring the patient comprehends all their options.
Equal footing also means providers appreciate patients’ autonomy to help direct their own course. When applicable a paramedic must provide all options—this includes alternatives, risks and benefits, and possibilities if nothing is done. The patient has the right to express their “values, preferences, and opinions.”3
As a framework for the healthcare professional, SDM relies on knowledge, available data, and clinical authority to present a comprehensive array of options to patients. The idea is not to hold prehospital providers to the same standard as physicians; instead, command of SDM simply arms paramedics to better communicate with patients.
History of Shared Decision-Making
Medical ethicist Robert Veatch, PhD, first conceived shared decision-making in 1972.4 His goal was to restructure the relationship between physician and patient. Veatch addressed ethical and moral concerns when he described medicine as a contract that lacked “real sharing of decision-making.”4 Since then SDM theory has been incorporated into medical school education. However, it has never enjoyed widespread use outside the academic setting.
Consider the renaissance of medical ethics in the 1970s. A Congressionally commissioned panel evaluated medical and social science research on humans. In 1979 it produced the Belmont Report, which determined such research should hinge on 1) respect for persons, 2) beneficence, and 3) justice.5 Additionally it discussed informed consent, comprehension, and balancing risks and benefits. A major difference between these research ethics and SDM is Belmont’s instruction to researchers to consider their impact on research subjects. A similarity is that SDM also has roots in beneficence, patient autonomy, and justice.9
Soon thereafter SDM proved to be on the minds of lawmakers. In 1982 a presidential commission published a 210-page report called Making Health Care Decisions.6 Its authors referred to SDM no fewer than 50 times. Afterward, though, Making Health Care Decisions seemed to have little impact, despite tackling clinical ethics from a foundation of informed consent.
By the late 1990s SDM debuted in research. It was a theory of interest to architects of patient-centered healthcare, ethicists, and those concerned with better resource management. By 2013 several hundred entries per year investigating SDM appeared in literature reviews.1 Today SDM enjoys policy-level recognition in 13 countries, including the United States. The idea was even included in the Affordable Care Act, which contains a program to facilitate shared decision-making.
Writing in the New England Journal of Medicine, Emily Oshima Lee and Ezekiel Emanuel called that language, Section 3506, a “sleeper provision” to illustrate SDM’s general lack of awareness and adoption.7 The provision is an extensive directive regarding SDM, guiding agencies to incorporate the framework, design associated decision aids, and conduct SDM research.
SDM in EMS
Few mentions of SDM can be found in EMS trade journals or peer-reviewed literature. Additionally, it remains primarily a precept for physicians when dealing with diagnoses and prognoses. However, research that evaluates the team-based approach to care is slowly emerging. And if reliance on medical control isn’t teamwork, what is?
Consider emotional intelligence (EI). EI is the ability to read cues and signs from others and moderate one’s own communication. Doing so facilitates better interactions and more effective outcomes. SDM does the same for medical conversations. It need not be applied only to high-risk transport refusals but can be done for every patient encounter, especially when patients and paramedics are at an impasse.
EMS providers are familiar with decision aids. We may think of medical protocols as provider-side decision aids. They are carefully crafted by medical directors to protect patients and paramedics. Protocols navigate paramedics to consider all possibilities, specifically looking for threats to life. The International Patient Decision Aid Standards (IPDAS) Collaboration works to standardize decision tools for the SDM process.
The SDM model should also work well with mobile integrated healthcare (MIH). Community paramedics work closely with primary care and specialty doctors to help patients stay out of the hospital.
What SDM is not is informed consent. While similar, informed consent is a legal function to assess a patient’s ability to make decisions. It involves high-risk options and boils down to their acceptance or refusal of a treatment (e.g. transport).10
In a 2015 article for EMS World Magazine, Thom Dunn posed a stabbing victim who refused transport. That patient faced only two options: allow transport or die. This situation is not proper for SDM. Situations of high risk and high certainty of outcome aren’t applicable to SDM but still require informed consent. Shared decision-making is not applicable in cases of time-critical trauma, altered mental status, or legally binding transport orders.
Dunn marveled at the paucity of decision-making resources prehospital professionals suffer compared to physicians.10 Doctors typically have access to lawyers, ethicists, and other decision facilitators. This is not to argue that paramedics should use statistical averages to inform patients and dissuade transport, nor is it to diminish medical control as an ultimate authority. Rather, SDM may enhance clinical care through better conversations.
Paramedics may provide better service if they understand how people arrive at decisions, appreciate how personal beliefs or cultural norms affect how some decisions are made, and utilize tactics to elicit comprehension. Comprehension is a bidirectional outcome of effective communication. How many times each day do paramedics suggest transport based on a “gut feeling”? And what percentage of patients refuse because “I don’t want to”? Both these decisions have no further clarification. Patients do not need a valid reason to refuse, but if they are merely afraid, might that patient change their mind by exploring “I don’t want to”?
Paramedics harness experiences to guide their treatment; conversely, patients likely do not and may not value the risk. However, through a structured conversation during which paramedics strive to understand patients’ reluctance, meaningful dialogue occurs.
Another consideration is looming healthcare reform and payment changes that always threaten to trickle down to EMS. SDM has been tied to value-based care. The AHRQ (Agency for Healthcare Research and Quality) hosts an extensive library of SDM resources. SDM application has also been researched in conjunction with mental health, chronic conditions, and misuse of resources.
Two research projects found success with SDM in the prehospital setting. Investigators led by North Carolina physician Jefferson Williams, MD, evaluated falls by residents of an assisted-living facility.11 And New York emergency doc Kevin Munjal, et al., surveyed EMS users on their views regarding destination choices.12 Embedded in this survey, participants were asked about their involvement in deciding where to go if they are transported. Both studies reinforce paramedics acting as a partner and conduit between patient and physician.
Finally, SDM has been linked to value-based care and is projected to improve healthcare outcomes. There is also little doubt SDM’s impact on regulation and reimbursement will increase. Some have called for Medicare penalties to be as high as 20% for those who do not use SDM or its decision aids.8 SDM’s explicit addition to the ACA and support from AHRQ indicate its importance to regulators. It is only a matter of time before some benchmarked form of patient involvement in decision-making reaches EMS.
Shaping the Future
We don’t know what the future holds. Leaders in EMS fret over reimbursement schemes, value-based care, and benchmarked outcomes. No one knows for sure when payment reform will affect EMS, or even what regulations will impact how we get paid. Yet adopting a strategy like EMS Agenda 2050 means applying future solutions to today’s problems.
One clear issue is patient outcomes, which are affected by communication and satisfaction. Shared decision-making should improve this. Paramedics can learn how to arrive at mutually beneficial plans with patients. SDM leads to both patients and paramedics being better informed. While not intended for time-sensitive situations, SDM could reduce liability pertaining to nonurgent patients who refuse transport. In combination with a community paramedic system, it may help EMS reduce the misuse of 9-1-1 systems.
1. Légaré F, Thompson-Leduc P. Twelve myths about shared decision making. Patient Educ Couns, 2014; 96(3): 281–6.
2. Quaschning K, Körner M, Wirtz M. Analyzing the effects of shared decision-making, empathy and team interaction on patient satisfaction and treatment acceptance in medical rehabilitation using a structural equation modeling approach. Patient Educ Couns, 2013; 91(2): 167–75.
3. Hawley ST, Morris AM. Cultural challenges to engaging patients in shared decision making. Patient Educ Couns, 2017; 100(1): 18–24.
4. Veatch RM. Models for Ethical Medicine in a Revolutionary Age. Hastings Cent Rep, 1972; 2(3): 5.
5. Department of Health and Human Services, National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont Report, www.hhs.gov/ohrp/regulations-and-policy/belmont-report/read-the-belmont-report/index.html.
7. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making Health Care Decisions: The Ethical and Legal Implications of Informed Consent in the Patient-Practitioner Relationship. Washington, D.C.: U.S. Government Printing Office, 1982.
8. Oshima Lee E, Emanuel EJ. Shared decision making to improve care and reduce costs. N Engl J Med, 2013; 368(1): 6–8.
9. Whitney SN, McGuire AL, McCullough LB. A typology of shared decision making, informed consent, and simple consent. Ann Intern Med, 2004; 140(1): 54–9.
11. Williams JG, Bachman MW, Lyons MD, et al. Improving decisions about transport to the emergency department for assisted living residents who fall. Ann Intern Med, 2018; 168(3): 179–86.
12. Munjal KG, Shastry S, Loo GT, et al. Patient perspectives on EMS alternate destination models. Prehospital Emerg Care, 2016; 20(6): 705–11.
Aaron Florin, MSHS, NRP, SPO, has 16 years of prehospital experience with a growing interest in healthcare policy. He currently works for Allina Health EMS in Minnesota as a paramedic and field training officer.