EMS World

FEB 2019

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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EMSWORLD.com | FEBRUARY 2019 35 as physicians; instead, command of SDM simply arms paramed- ics to better communicate with patients. History of Shared Decision-Making Medical ethicist Rober t Veatch, PhD, first conceived shared decision-making in 1972. 4 His goal was to restructure the rela- tionship bet ween physician and patient. Veatch addressed ethical and moral concerns when he described medicine as a contract that lacked "real sharing of decision-making." 4 Since then SDM theor y has been incorporated into medical school education. However, it has never enjoyed widespread use out- side the academic setting. Consider the renaissance of medical ethics in the 1970s. A Congressionally commissioned panel evaluated medical and social science research on humans. In 1979 it produced the Bel- mont Report, which determined such research should hinge on 1) respect for persons, 2) beneficence, and 3) justice. 5 Additionally it discussed informed consent, comprehension, and balancing risks and benefits. A major difference between these research ethics and SDM is Belmont's instruction to researchers to con- sider their impact on research subjects. A similarity is that SDM also has roots in beneficence, patient autonomy, and justice. 9 Soon thereafter SDM proved to be on the minds of lawmakers. In 1982 a presidential commission published a 210-page report called Making Health Care Decisions. 6 Its authors referred to SDM no fewer than 50 times. After ward, though, Making Health Care Decisions seemed to have little impact, despite tackling clinical ethics from a foundation of informed consent. By the late 1990s SDM debuted in research. It was a theor y of interest to architects of patient-centered healthcare, ethicists, and those concerned with better resource management. By 2013 several hundred entries per year investigating SDM appeared in literature reviews. 1 Today SDM enjoys policy-level recognition in 13 countries, including the United States. The idea was even included in the Affordable Care Act, which contains a program to facilitate shared decision-making. Writing in the New England Journal of Medicine, Emily Oshima Lee and Ezekiel Emanuel called that language, Section 3506, a "sleeper provision" to illustrate SDM's general lack of awareness and adoption. 7 The provision is an extensive directive regarding SDM, guiding agencies to incorporate the framework, design associated decision aids, and conduct SDM research. SDM in EMS Few mentions of SDM can be found in EMS trade journals or peer-reviewed literature. Additionally, it remains primarily a pre- cept for physicians when dealing with diagnoses and prognoses. However, research that evaluates the team-based approach to care is slowly emerging. And if reliance on medical control isn't teamwork, what is? Consider emotional intelligence (EI). EI is the ability to read cues and signs from others and moderate one's own communi- cation. Doing so facilitates better interactions and more effec- tive outcomes. SDM does the same for medical conversations. It need not be applied only to high-risk transport refusals but can be done for ever y patient encounter, especially when patients and paramedics are at an impasse. EMS providers are familiar with decision aids. We may think of medical protocols as provider-side decision aids. They are carefully crafted by medical directors to protect patients and paramedics. Protocols navigate paramedics to consider all pos- sibilities, specifically looking for threats to life. The International Patient Decision Aid Standards (IPDAS) Collaboration works to standardize decision tools for the SDM process. The SDM model should also work well with mobile integrated healthcare (MIH). Communit y paramedics work closely with primar y care and specialt y doctors to help patients stay out of the hospital. Informed Consent What SDM is not is informed consent. While similar, informed consent is a legal function to assess a patient's ability to make decisions. It involves high-risk options and boils down to their In this philosophy a healthcare provider takes part in a treatment plan, as opposed to dictating it. 888-458-6546 3121 Millers Lane Louisville, KY 40216 Tel: 502-775-8303 Fax: 502-772-0548 S A F E T Y A P P L I A N C E C O M P A N Y www.junkinsafety.com PROUDLY MANUFAC TURED IN THE USA JSA-400 Aluminum Break-Apart Stretcher Specifications Dimensions: 66 ¼" L x 17 ½" W x 2 5⁄8" H Folded Length: 49 ½" Folded Depth: 3 ½" Adjustable to: 80" Load Capacity: 400 lbs. Shipping Weight: 21 ½ lbs. Designed to gently maneuver stretcher under patient without rolling or lifting. The center of the Junkin Aluminum Break-Apart Stretcher can be opened to allow the patient to be X-rayed while secured on the stretcher. Features sturdy, lightweight aluminum construction with an adjustable length and three patient restraint straps. Folds for easy storing and separates in half during application and removal. JSA-400

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