Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA.
Institute for Healthcare Delivery and Population Science, Baystate Medical Center, Springfield, MA.
Acad Emerg Med. 2018 Jul;25(7):716-727. doi: 10.1111/acem.13416. Epub 2018 May 7.
Despite increasing attention to the use of shared decision making (SDM) in the emergency department (ED), little is known about ED patients' perspectives regarding this practice. We sought to explore the use of SDM from the perspectives of ED patients, focusing on what affects patients' desired level of involvement and what barriers and facilitators patients find most relevant to their experience.
We conducted semistructured interviews with a purposive sample of ED patients or their proxies at two sites. An interview guide was developed from existing literature and expert consensus and based on a framework underscoring the importance of both knowledge and power. Interviews were recorded, transcribed, and analyzed in an iterative process by a three-person coding team. Emergent themes were identified, discussed, and organized.
Twenty-nine patients and proxies participated. The mean age of participants was 56 years (range, 20 to 89 years), and 13 were female. Participants were diverse in regard to race/ethnicity, education, number of previous ED visits, and presence of chronic conditions. All participants wanted some degree of involvement in decision making. Participants who made statements suggesting high self-efficacy and those who expressed mistrust of the health care system or previous negative experiences wanted a greater degree of involvement. Facilitators to involvement included familiarity with the decision at hand, physicians' good communication skills, and clearly delineated options. Some participants felt that their own relative lack of knowledge, compared to that of the physicians, made their involvement inappropriate or unwanted. Many participants had no expectation for SDM and although they did want involvement when asked explicitly, they were otherwise likely to defer to physicians without discussion. Many did not recognize opportunities for SDM in their clinical care.
This exploration of ED patients' perceptions of SDM suggests that most patients want some degree of involvement in medical decision making but more proactive engagement of patients by clinicians is often needed. Further research should examine these issues in a larger and more representative population.
尽管越来越关注在急诊科（ED）使用共同决策（SDM），但对于 ED 患者对此做法的看法知之甚少。我们旨在从 ED 患者的角度探讨 SDM 的使用，重点关注影响患者期望参与程度的因素，以及患者认为最相关的障碍和促进因素。
我们在两个地点通过有目的的抽样选择 ED 患者或其代理人进行半结构化访谈。访谈指南是从现有文献和专家共识以及强调知识和权力重要性的框架中制定的。访谈由三人编码团队以迭代方式记录、转录和分析。确定、讨论和组织出现的主题。
共有 29 名患者及其代理人参与。参与者的平均年龄为 56 岁（范围为 20 至 89 岁），13 名女性。参与者在种族/民族、教育程度、之前的 ED 就诊次数和慢性疾病存在方面存在多样性。所有参与者都希望在决策中有一定程度的参与。那些发表表明自我效能高的言论的参与者，以及那些表示不信任医疗保健系统或之前有过负面经历的参与者，希望有更大程度的参与。参与的促进因素包括对手头决策的熟悉程度、医生良好的沟通技巧以及明确划定的选择。一些参与者认为，与医生相比，他们自己相对缺乏知识，这使得他们的参与不合适或不想要。许多参与者没有期望 SDM，尽管他们在被明确询问时确实希望参与，但在没有讨论的情况下，他们很可能会听从医生的意见。许多人没有意识到他们的临床护理中有 SDM 的机会。
对 ED 患者对 SDM 的看法的探索表明，大多数患者希望在医疗决策中有一定程度的参与，但临床医生通常需要更积极地让患者参与进来。进一步的研究应该在更大和更具代表性的人群中研究这些问题。
