Shared Decisionmaking in the Emergency Department: A Guiding Framework for Clinicians
Shared Decisionmaking in the Emergency Department: A Guiding Framework for Clinicians
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DOI：
10.1016/j.annemergmed.2017.03.063
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发表时间：
2017-11-01
影响因子：
6.2
通讯作者：
Hess, Erik P.
中科院分区：
文献类型：
--
作者：
Probst, Marc A.;Kanzaria, Hemal K.;Hess, Erik P.
共享决策已被提出作为一种方法，以促进积极参与的病人在紧急护理决策。尽管最近在急诊医学界受到了关注，包括成为2016年学术急诊医学共识会议的主题，但对于该术语的确切含义，过程以及最有价值的条件仍然存在误解。在患者代表和交互设计师的帮助下，我们开发了一个简单的框架来说明在临床实践中应如何处理共享决策。我们认为这应该是首选或默认的决策方法，除非在临床情况下，其中3个因素的干扰。这三个因素是缺乏临床不确定性或平衡、患者决策能力和时间，所有这些因素都可能导致共享决策不可行。临床平衡是指有2种或2种以上医学上合理的管理方案的情况。患者决策能力是指患者参与其紧急护理决策的能力和意愿。时间是指临床情况的紧急程度（可能需要立即采取行动）和临床医生必须投入到共享决策对话中的时间。在只有一种医学上合理的管理选择的情况下，应表示知情同意，并酌情采用同情劝说。如果时间或病人能力不足，医生指导的决策将发生。在此框架的基础上，我们讨论了共享决策的过程，以及如何在实践中使用。最后，我们强调了5个常见的误解，在ED的共享决策方面。随着对共享决策的理解的提高，这种方法应该被用来促进提供高质量的，以病人为中心的紧急护理。
Shared decisionmaking has been proposed as a method to promote active engagement of patients in emergency care decisions. Despite the recent attention shared decisionmaking has received in the emergency medicine community, including being the topic of the 2016 Academic Emergency Medicine Consensus Conference, misconceptions remain in regard to 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 shared decisionmaking should be approached in clinical practice. We believe it should be the preferred or default approach to decisionmaking, except in clinical situations in which 3 factors interfere. These 3 factors are lack of clinical uncertainty or equipoise, patient decisionmaking ability, and time, all of which can render shared decisionmaking infeasible. Clinical equipoise refers to scenarios in which there are 2 or more medically reasonable management options. Patient decisionmaking ability refers to a patient's capacity and willingness to participate in his or 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 shared decisionmaking conversation. In scenarios in which there is only one medically reasonable management option, informed consent is indicated, with compassionate persuasion used as appropriate. If time or patient capacity is lacking, physician-directed decisionmaking will occur. With this framework as the foundation, we discuss the process of shared decisionmaking and how it can be used in practice. Finally, we highlight 5 common misconceptions in regard to shared decisionmaking in the ED. With an improved understanding of shared decisionmaking, this approach should be used to facilitate the provision of high-quality, patient-centered emergency care.