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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36 FEBRUARY 2019 | EMSWORLD.com COLLABORATIVE CARE acceptance or refusal of a treatment (e.g. transport). 10 In a 2015 article for EMS World Magazine, Thom Dunn posed a stabbing victim who refused transpor t. That patient faced only two options: allow transpor t or die. This situation is not proper for SDM. Situations of high risk and high cer taint y of outcome aren't applicable to SDM but still require informed consent. Shared decision-making is not applicable in cases of time-critical trauma, altered mental status, or legally binding transport orders. Dunn mar veled at the paucity of decision-making resources prehospital professionals suffer compared to physicians. 10 Doc- tors typically have access to law yers, ethicists, and other deci- sion facilitators. This is not to argue that paramedics should use statistical averages to inform patients and dissuade transport, nor is it to diminish medical control as an ultimate authority. Rather, SDM may enhance clinical care through better con- versations. Paramedics may provide better ser vice if they understand how people arrive at decisions, appreciate how personal beliefs or cultural norms af fect how some decisions are made, and utilize tactics to elicit comprehension. Comprehension is a bidirectional outcome of effective communication. How many times each day do paramedics suggest transport based on a "gut feeling"? And what percentage of patients refuse because "I don't want to"? Both these decisions have no further clari- fication. Patients do not need a valid reason to refuse, but if they are merely afraid, might that patient change their mind by exploring "I don't want to"? Paramedics harness experiences to guide their treatment; conversely, patients likely do not and may not value the risk. However, through a structured conversation during which para- medics strive to understand patients' reluctance, meaningful dialogue occurs. Another consideration is looming healthcare reform and pay- ment changes that always threaten to trickle down to EMS. SDM has been tied to value-based care. The AHRQ (Agency for Healthcare Research and Quality) hosts an extensive librar y of SDM resources. SDM application has also been researched in conjunction with mental health, chronic conditions, and misuse of resources. Two research projects found success with SDM in the pre- hospital setting. Investigators led by Nor th Carolina physi- cian Jef ferson Williams, MD, evaluated falls by residents of an assisted-living facility. 11 And New York emergency doc Kevin Munjal, et al., sur veyed EMS users on their views regarding destination choices. 12 Embedded in this sur vey, par ticipants were asked about their involvement in deciding where to go if they are transported. Both studies reinforce paramedics act- ing as a partner and conduit between patient and physician. Finally, SDM has been linked to value-based care and is pro- jected to improve healthcare outcomes. There is also little doubt SDM's impact on regulation and reimbursement will increase. Some have called for Medicare penalties to be as high as 20% for those who do not use SDM or its decision aids. 8 SDM's explicit addition to the ACA and suppor t from AHRQ indicate its importance to regulators. It is only a matter of time before some benchmarked form of patient involvement in decision-making reaches EMS. Shaping the Future We don't know what the future holds. Leaders in EMS fret over reimbursement schemes, value-based care, and benchmarked outcomes. No one knows for sure when payment reform will affect EMS, or even what regulations will impact how we get paid. Yet adopting a strategy like EMS Agenda 2050 means applying future solutions to today's problems. Photo: Aaron Webster Mounting System Solutions For all types of Portable Medical Devices Designed for Flexibility Engineered for Safety Made for Medical Environments

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