Professionalism, Ethics, and Communication
A 41-year-old woman presents to the emergency department (ED) for evaluation of fever and headache. She initially went to her primary care physician’s office for evaluation. A rapid influenza test and strep screen were negative. She says she was instructed to come to the ED to rule out meningitis. She denies neck stiffness, photophobia, pain with extraocular movements, or focal neurologic complaints. Her vital signs on arrival to the ED are temperature 100.1°F, blood pressure (BP) 118/80 mm Hg, heart rate (HR) 98 beats/minute, respiratory rate (RR) 12 breaths/minute, and oxygen saturation 100% on room air. Her neurologic exam is normal, including her alertness and awareness, and she has no petechial rash or meningismus. You are unable to contact the referring provider and there is no documentation of the patient’s encounter with her primary care physician. Which of the following is the best approach regarding lumbar puncture in this patient?
a. Consult neurology for lumbar puncture as she likely has atypical meningitis
b. Do not perform the lumbar puncture because she is no longer febrile
c. Explain the benefits, risks, and alternatives of the procedure and utilized shared decision-making with the patient
d. Perform lumbar puncture because her primary care doctor recommended it
e. Perform lumbar puncture because the patient had a fever and headache
The answer is c. Shared decision-making with patients means allowing patients who have medical decision-making capacity to play a key role in their care. By explaining the risks, benefits, and alternatives of diagnostic or therapeutic interventions, patients are given autonomy to engage in their health care choices. The patient’s core values and goals must be communicated, understood, and adhered to when shared decision-making is implemented. Oftentimes, shared decision-making leads to less resource utilization (eg, less testing, fewer consultations) and improved patient experience. When an invasive procedure is being considered (such as a lumbar puncture) and the likelihood that such a procedure will change the outcome of the patient’s care, shared decision-making can be a decision tool to aid providers in delivering the best patient-centered care.
Answer choice (a) is incorrect because the patient does not have clinical findings that strongly suggest meningitis and neurology does not need to be consulted. Answer choice (b) is incorrect because the reason for not performing lumbar puncture is not because the patient has defervesced, but because it does not seem to be clinically indicated since the likelihood of her having meningitis based on clinical assessment is low (at least low enough to engage the patient in a shared decision to forego the procedure). Answer choice (d) is incorrect because providers should not blindly perform invasive procedures at the request of ...