2.5 Shared Decision-Making, Health Literacy & Engaging Patients in Care Plans
Key Takeaways
- CPCF competency B5 requires engaging patients and families in care plans that reflect the patient's perspectives, priorities, needs, and values.
- Shared decision-making applies wherever genuine equipoise exists, such as destination choice, treat-and-refer decisions, and whether to transport a palliative patient.
- Teach-back — asking the patient to restate the plan in their own words — is the standard comprehension check; closed questions such as 'do you understand?' reliably produce false reassurance.
- Indicator B5.2 requires helping patients access health information technology while recognizing digital exclusion and offering non-digital alternatives.
- When a capable patient chooses differently than the paramedic would, the competent response is to confirm capacity, ensure the decision is informed, negotiate a safety net, and document the conversation rather than only the refusal.
2.5 Shared Decision-Making, Health Literacy & Engaging Patients in Care Plans
Competency B5 of the Canadian Paramedic Competence Framework requires the PCP to engage patients and their families in developing plans that reflect patients' perspectives, priorities, needs, and values. It is the smallest Communication competency by weight (9.44% of Area B, roughly 1 to 2 questions) but it is the one candidates most often answer with a well-meaning wrong answer, because paternalism disguised as efficiency still feels like good care.
Informed Consent Is a Floor; Shared Decision-Making Is the Standard
Informed consent asks a binary question: will you accept the intervention I have chosen? Shared decision-making asks a different one: given what matters to you, which of these reasonable options should we choose together? The CPCF indicators are explicit about the difference:
- B5.1 — Facilitate discussions with patients and families in a respectful, non-judgmental manner by providing culturally safe care
- B5.2 — Assist patients and families to identify, access, and use information and communication technologies to support patients' care and manage their health
- B5.3 — Use communication skills and strategies that help patients and families make informed decisions regarding patients' health
Shared decision-making applies whenever there is genuine equipoise — more than one clinically defensible path. Transport destination, treat-and-refer versus transport, analgesia choice, and whether to move a palliative patient at all are all equipoise decisions. Immediate resuscitation of an unresponsive patient is not.
The Three-Talk Model, Adapted for the Back of an Ambulance
| Step | What you say | Why it works prehospitally |
|---|---|---|
| Team talk | "There are a couple of reasonable ways to handle this. Can we work through them together?" | Signals that the patient has standing, and slows a conversation that fear tends to accelerate |
| Option talk | "Option one is to take you to the regional hospital 40 minutes away where they can do the scan tonight. Option two is the local site, 8 minutes away, which would mean a transfer if the scan is abnormal." | Concrete, quantified, and framed in the patient's currency — time, distance, family |
| Decision talk | "What matters most to you here?" then reflect it back: "It sounds like being close to your husband tonight matters more than the fastest scan." | Surfaces values rather than preferences, and gives you a documentable rationale |
Health Literacy: Assume Less Than You Think
Roughly three in five Canadian adults have health-literacy skills below the level considered necessary to manage their own health, and the number rises sharply among adults over 65 — exactly the population the blueprint weights most heavily. Health literacy is also state-dependent: pain, hypoxia, fear, and hypoglycemia all reduce it temporarily in people who are ordinarily highly literate.
Practical techniques:
- Plain language by default. "Your heart's electrical rhythm is too fast" beats "you're in a supraventricular tachycardia" — then offer the term, because patients deserve the vocabulary of their own illness.
- Chunk and check. Deliver one idea, then confirm understanding, then deliver the next. Three chunks is usually the ceiling in a moving ambulance.
- Teach-back, not "do you understand?" Ask "so I know I explained it clearly — what are you going to tell your daughter when she gets to the hospital?" A yes/no comprehension question reliably produces a yes.
- Numbers as natural frequencies. "About 1 in 20 people get a headache from this spray" is understood; "a 5% incidence" is not.
- Avoid false reassurance. "You'll be fine" is not information, and it destroys credibility the moment the patient is not fine.
Supporting Patients to Use Health Information Technology (B5.2)
B5.2 is easy to overlook and appears on the examination as a patient-navigation item. Entry-level expectations include:
- Helping a patient locate their provincial health record portal, medication list, or lab results rather than reciting values from memory
- Showing a caregiver how to photograph the medication shelf for the receiving team
- Directing patients to 811-style provincial health lines, virtual care, and after-hours services when transport is not the right answer
- Recognizing digital exclusion — no smartphone, no data plan, no private space, limited vision, limited literacy — and offering a paper alternative rather than assuming non-compliance
When the Patient Chooses Differently Than You Would
A capable patient may decline transport, decline an intervention, or choose a destination you consider suboptimal. The competent response is not to escalate pressure but to:
- Confirm capacity for this specific decision at this specific time.
- Ensure the decision is informed — that the patient has heard the realistic consequences, in plain language, including the ones you find uncomfortable to say.
- Negotiate the safest available version of the patient's choice: a safety net, a return-if-worse threshold, a family member staying, a follow-up call.
- Document the conversation, not just the refusal — what options were offered, what the patient was told, what they said mattered, and how capacity was established.
[!TIP] On the examination, options that describe "explaining again more firmly", "involving the family so they can persuade the patient", or "documenting refusal and clearing the scene" are nearly always distractors. The keyed answer usually involves exploring the patient's reasoning, correcting a misunderstanding, and constructing a safety net.
Family Engagement Without Displacing the Patient
Families are a resource and a risk. The patient remains the decision-maker whenever they have capacity, even when a loud, frightened adult child is in the room. Useful moves:
- Ask the patient's permission before discussing their care in front of family — B2.3 requires consent to gather from, and by extension share with, the circle of care.
- Give the family a job. Fetching medications, holding the door, or calling the other sibling converts anxiety into usefulness.
- Name the dynamic when it obstructs: "I can hear this is frightening. I need to hear the answer from your mother, because it's her decision."
A 76-year-old woman with a suspected hip fracture after a ground-level fall is offered transport. She is oriented, understands her injury, and asks to be taken to the smaller community hospital 10 minutes away rather than the regional trauma centre 45 minutes away, because her husband, who has dementia, cannot be left overnight without her. Which response best reflects CPCF competency B5?
A paramedic has explained a new nitroglycerin prescription and the plan to a 68-year-old patient with limited formal education. Which technique best confirms that the explanation was actually understood?
Which action best demonstrates CPCF indicator B5.2, assisting patients and families to identify, access, and use information and communication technologies to support care?