GERIATRIC EM
Shared Decision Making for Persons Living with Dementia and Care Partners: A Complex Conversation
SAEM PULSE | JULY-AUGUST 2023
By Justine Seidenfeld, MD and Fernanda Bellolio, MD, MS on behalf of the SAEM Academy of Geriatric Emergency Medicine
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When caring for persons living with dementia (PLWDs) in the emergency department (ED), there are many situations in which there is more than one reasonable option, and a decision needs to be made. This can pertain to different types of decisions, such as whether to obtain a certain lab or imaging test, what type of medication to try, and whether to admit or discharge a patient home, among others. In these situations, shared decision making (SDM) can facilitate conversations between patients, care partners, and health care providers, and increase patient and care partner understanding of their options. Despite concerns about decision making
capacity in PLWDs, they are able to communicate values and preferences, and thus can participate in SDM when done appropriately. Below, we outline steps involved in SDM and important considerations when discussing ED decisions with patients and care partners.
Decisional Roles
One of the first steps is determining who will be involved in making the disposition decision. • PLWDs can reliably communicate their values and choices, but their decision making capacity is often overlooked by both health care and family members.
• Additionally, the care partner present at the ED visit with them may not be the documented legally authorized representative. In these cases, ideally both the bedside care partner and the legally authorized representative would be involved along with the patient. If there is no care partner at the bedside, do your best to reach out to the most appropriate party. • PLWDs will experience a range of “good days and bad days.” Patients with low dementia severity and high decisional capacity when at their baseline may be having more severe symptoms at the time of the ED visit. Likewise, a patient with high severity dementia may be