Shared Decision Making With Vulnerable Populations in the Emergency Department

Abstract

The emergency department (ED) occupies a unique position within the healthcare system, serving as a safety net for vulnerable patients, regardless of their race, ethnicity, religion, country of origin, sexual orientation, socioeconomic status, or medical diagnosis. Shared decision making (SDM) presents special challenges when used with vulnerable population groups. The differing circumstances, needs, and perspectives of vulnerable groups invoke issues of provider bias, disrespect, judgmental attitudes, and lack of cultural competence, as well as patient mistrust and the consequences of their social and economic disenfranchisement. A research agenda that includes community-engaged approaches, mixedmethods studies, and cost-effectiveness analyses is proposed to address the following questions: 1) What are the best processes/formats for SDM among racial, ethnic, cultural, religious, linguistic, social, or otherwise vulnerable groups who experience disadvantage in the healthcare system? 2) What organizational or systemic changes are needed to support SDM in the ED whenever appropriate? 3) What competencies are needed to enable emergency providers to consider patients' situation/context in an unbiased way? 4) How do we teach these competencies to students and residents? 5) How do we cultivate these competencies in practicing emergency physicians, nurses, and other clinical providers who lack them? The authors also identify the importance of using accurate, group-specific data to inform risk estimates for SDM decision aids for vulnerable populations and the need for increased ED-based care coordination and transitional care management capabilities to create additional care options that align with the needs and preferences of vulnerable populations.

Importance of Shared Decision-Making for Vulnerable Populations: Examples from Postmastectomy Breast Reconstruction

“…For example, some patients may distrust the healthcare system or experience heightened power differentials with their providers; distrust and power imbalances presents challenges for partnership through SDM. 12 Implicit biases held by providers can also limit patients' options and exclude them from the decision-making process, as this patient quote from our recent study demonstrates 1 : He [surgeon] said, ‘Well, you're old anyhow, so what difference does it make?’ Isn't that cruel? Those were the words.…”

“… 11 Yet, some patient populations continue to report barriers to engaging with providers about preference-sensitive decisions. 12 , 13 In this context, we define vulnerable patients as those who are economically disadvantaged, racial and ethnic minorities, uninsured, low income, and/or elderly. 14 , 15 Patients with multiple vulnerabilities may benefit from additional support to meaningfully engage with providers.…”

Racial disparities in the treatment of acute overdose in the emergency department

“…Racial disparities in ED care are particularly troubling, considering that the ED serves as an important health care safety net; at times, the ED represents the only accessible medical care for a subset of some racial minorities and vulnerable socioeconomic groups. 14,15 To date, racial disparities in clinical toxicology have yet to be evaluated in the literature.…”

Sharing Is Caring: Can an App Help?

“…It remains to be seen if this app will have a positive impact on patient and family‐centered measures and clinical outcomes. Because SDM is affected by many factors such race, 17 culture, 18 and health literacy, 19 the effectiveness of this tool will have to be assessed in different settings. Furthermore, because of the perpetually evolving approach to febrile young infants, 20–22 this tool will likely require continued refinement and revision.…”