Shared Decision Making with Vulnerable Populations in the Emergency Department
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, mixed-methods 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.
Overview of article
- This article proposes a research agenda that includes community-engaged approaches, mixed-methods studies, and cost-effectiveness analyses to address the following questions: 1) What are the best processes/formats for shared decision-making (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 emergency department (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?
- First, the article outlines best processes/formats for SDM among specific minority populations as follows:
1) Race and ethnicity: SDM requires partnership between patient and provider and may be more difficult among racial/ethnic minority populations with less trust in the healthcare system. Additionally, power differentials (e.g., feeling like providers are “talking down” to patients) between providers and patients can inhibit SDM. Implicit bias and assumptions can also affect SDM
2) Culture and religion: Physicians require cultural competency when conducting SDM in vulnerable populations as cultural and religious backgrounds can affect the ways in which a patient would like to make a decision
3) Limited English proficiency (LEP): Culturally and linguistically fluent interpreters should be used for SDM engagement. Providers who do not have that level of fluency should not use their own second-language skills. Additionally, it is not optimal to simply translate SDM clinical decision tools into other languages. Ideally, SDM materials and decision aids should be specifically developed for each LEP population
- Socioeconomic disadvantage: Perceived power differential may be a barrier to effective SDM engagement and patient-provider communication. Implicit bias may also play a role and affect SDM
4) Gender identity and sexual orientation: Lack of knowledge or experience treating members of the LGBTIQ community may affect SDM. Inherent biases may also affect SDM engagement and communication
5) Disease stigma: Special consideration should be given to addressing disease stigma issues when developing or implementing SDM processes to mitigate patient marginalization or insult
- It is imperative that physicians maintain respect and be nonjudgmental during SDM to elicit patient engagement and trust. Additionally, patients must actively participate in the SDM process, which may be difficult in the ED. Decision aids assist physicians in SDM conversations, but none have been developed specifically developed for vulnerable populations
- Collection of data on race, ethnicity, language preference, gender identity and sexual orientation, and socioeconomic status should be embedded into research and clinical databases to allow for extraction of accurate, group-specific data to guide SDM as well as interventions to eliminate healthcare disparities. Additional research on implicit bias and its effects is also warranted
- Further research is needed on systems and guidelines to support SDM in the ED in ways that limit potential for bias. The effects of SDM strategies on trust in the healthcare system, disparities in care provision, and patient outcomes will need to be characterized
- More work is needed to understand the effects of implicit bias on emergency care communication and the factors driving the decision to pursue a SDM strategy