Table 1.

Barriers and facilitators of effective communication in SDM discussion on diagnostic testing in the ED

	Barriers	Facilitators
Patient characteristics	Being in poor health Cognitive impairments (e.g., dementia, intoxication)	Limited debility and intact cognition Prior exposure to a similar process
Decision characteristics	Significant decisions are a barrier and facilitator Timing relative to the disease course (e.g., will the diagnostic test change management)	Significant decisions are a barrier and facilitator
Interaction Characteristics	Power imbalance in the patient– clinician relationship The desire to be a ‘‘good’’ patient and perceived benefits that might arise (e.g., lack of conflict in the encounter) Perception that there are ‘‘right’’ and ‘‘wrong’’ decisions Perceived unacceptability of asking the physician questions and raising options These barriers are affected by the patient’s cultural background and health literacy.	Physicians who effectively listen to patients, respect their concerns, and seek to understand individual needs The presence of an advocate or caregiver

Patient-reported barriers and facilitators to SDM relate to how the healthcare system is organized (i.e., time available, continuity of care, organization of workflow and the setting itself) and to what happens in the ED visit (i.e., predisposing factors such as patient characteristics, interactional influences including the power imbalance between patient and clinician, and SDM encounter and the process itself, including knowledge gain). Most patient-reported barriers and facilitators are potentially modifiable.

Clinician-reported barriers are time, lack of agreement with the applicability of SDM to the patient, and lack of agreement with the applicability of SDM to the clinical situation, suggesting clinicians presume that many patients will not benefit from SDM, or do not wish to take part.