Monday, May 29, 2017

An ED Model for Shared Decision Making

The Gist: Shared decision making (SDM) is increasingly common in the ED, yet most people, particularly trainees, are untrained in this area. A proposed framework in an Annals of Emergency Medicine article by Probst et al proposes a framework to guide clinicians (or train them) in the implementation of SDM in the busy ED and combats common misconceptions regarding SDM.
  1. Ask yourself: is this clinical scenario appropriate for SDM - is there clinical uncertainty or equipoise, is the patient capable of engaging in SDM, and is there time?
  2. Have the conversation - Acknowledge that a decision needs to be made and share information about the risks and benefits of each option. Explore the patient's values and circumstances to help come to a decision.
The Case:  The nurses give you a heads up the next patient to be seen is in a lot of pain.  You see a 25-year-old healthy male who is doing the “kidney stone dance” – pacing around the room while holding an emesis basin. He's had left flank pain for the past two hours, nausea, but has a reassuring abdominal exam with minimal tenderness.  His urinalysis shows red cells in the urine and he's feeling better after analgesia.  What's next - CT scan? Ultrasound? Discharge with neither?

An SDM in the Emergency Department Framework from the Probst et al Annals article

1.  Is this scenario appropriate for SDM? 
  • Is there more than one reasonable option at this time?
The current literature regarding renal colic in the ED supports multiple options as the next reasonable

step [1-5]. Non-contrast CT scan is the historic option; yet, recent evidence supports ultrasound as a reasonable next step, and an ultrasound-first diagnostic plan might decrease radiation exposure for this young patient [2]. Experts have also argued that renal colic can be diagnosed clinically, and imaging is not necessary in classic cases with low probability of dangerous alternative diagnoses [1]. The trade-offs between these options might be important to this patient; if he’s feeling better or concerned about lifetime radiation risk, he may not want to wait for a CT scan, and conversely, if he’s about to set off hiking the Appalachian Trail, he may want to know the location and size of his stone.  
Obviously, there are clinical reasons why some cases of suspected renal colic warrant CT scans – fever, concern for an alternate diagnosis, or solitary kidney [6].
  • Is the patient able to make his own medical decisions? 
While this patient may know little about the trade-offs involved in the clinical question, research has
shown that patients do want to be told about the risks of radiation prior to CT scans [7]. This patient isn't altered or otherwise incapacitated - he can participate in decision making.
  • Do you have time? Does your patient have time?
The latter question is easy to answer: unless he’s eloped because he’s feeling better, your patient
clearly has time to have this conversation. Whether you have time depends on the severity of other patients’ conditions and your ability to explain the trade-offs in a manner that he can understand. The more you practice this skill, the better you will be at it, and it’s worth noting that the results of your conversation may speed up his discharge, creating space for another patient and increasing throughput.

2.  Have the conversation (if the answers to the above questions are yes)
  • Acknowledge that a decision needs to be made - 
“I suspect that you have a kidney stone – kidney stones cause severe pain, vomiting, and blood in the urine, all of which you had. At this point, we have to decide if it makes sense to do some more imaging.”
  • Share Information in Regard to Management Options and the Potential Harms, Benefits, and Outcomes of Each - 
“For some people, we do a CT scan – the benefit of a CT is that we know exactly how big the stone is, which helps us know if you’re going to need a procedure from a urologist to get it out. Most people with kidney stones pass the stone by themselves, and the CT isn’t helpful. The downside of a CT is that it takes time and it exposes you to radiation – and we know that every time you get exposed to radiation it increases your future risk of cancer ever so slightly. Also, if your pain comes back and doesn’t go away, it might make more sense to get a CT later – and we wouldn’t want to have to do two CT scans. Most people who have one kidney stone will have another one in the next 10 years – so you could end up with multiple CT scans over your lifetime. The other option is an ultrasound: it gives us some information and sometimes we get a CT scan if we see a lot of swelling in your kidney, but it doesn't show us how big the stone. Because I can do the ultrasound right now, people often go home sooner when they have an ultrasound, if they don’t need a CT. If we decide on the ultrasound, it’s important that you have a doctor you can follow-up with if you are feeling worse.”
  • Explore Patient Values, Preferences, and Circumstances - Probing the patient about what's important to them is key - they may not disclose difficulties with transportation, their activities of daily living, or their travel plans.
“How are you feeling? Do you have a doctor you can see in the next week or so? Would you be able to get back to the ED if you had a problem? Kidney stones usually pass in a week or two – do you have any travel planned?”
  • Decide Together on the Best Option for the Patient, Given His or Her Values, Preferences, and Circumstances
If a patient has a preference, this part is easy – maybe they’re in a hurry, worried about the cost of a CT, or have had multiple CT scans, or maybe they have an upcoming trip and want certainty.
Many patients won't have a preference, and they may ask you for advice. Share your opinion but recognize that there is a huge power differential.

“If I had a kidney stone, and the pain medication worked, I wouldn’t be in a rush to get a CT scan – but might get one in a week or two if I still had alot of pain. If I had some reason that I felt like I needed more information right now, like I was going on a cruise, then I might get the scan.”

Presenting both sides in the explanation of your opinion empowers the patient to choose either the
option you endorsed or the other option without feeling like they are disagreeing with the expert.

1. Wang RC. Managing Urolithiasis. Annals of Emergency Medicine 2016;67(4):449–54.
2. Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis. N Engl J Med 2014;371(12):1100–10.
3. Brisbane W, Bailey MR, Sorensen MD. An overview of kidney stone imaging techniques. Nat Rev Urol 2016;:1–9.
4. Fiore M. A proposal algorithm for patients presenting to the Emergency Department with renal colic. Eur J Emerg Med 2016;23(6):456–8.
5. Xiang H, Chan M, Brown V, Huo YR, Chan L, Ridley L. Systematic review and meta-analysis of the diagnostic accuracy of low-dose computed tomography of the kidneys, ureters and bladder for urolithiasis. J Med Imaging Radiat Oncol 2017;:1–9.
6. Türk C, Petřík A, Sarica K, et al. EAU Guidelines on Diagnosis and Conservative Management of Urolithiasis. European Urology 2015;:1–7.
7. Robey TE, Edwards K, Murphy MK. Barriers to computed tomography radiation risk communication in the emergency department: a qualitative analysis of patient and physician perspectives. Acad Emerg Med 2014;21(2):122–9.


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