Thursday, March 24, 2016 2:00 p.m. Eastern Dial In: 888.863.0985 - - PowerPoint PPT Presentation

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Thursday, March 24, 2016 2:00 p.m. Eastern

Dial In: 888.863.0985 Conference ID: 58897575

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Speakers

Brownsyne Tucker Edmonds, MD, MPH, FACOG

Assistant Professor of Obstetrics and Gynecology Indiana University School of Medicine

Lisa Kane Low, PhD, CNM, FACNM, FAAN

Associate Professor, & Associate Dean, Practice and Professional Graduate Studies, Health Behavior and Biological Science University of Michigan School of Nursing

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Disclosures

• Brownsyne Tucker Edmonds, MD, MPH,

FACOG has no real or perceived conflicts of interest to disclose.

• Lisa Kane Low, PhD, CNM, FACNM, FAAN

has no real or perceived conflicts of interest to disclose.

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Objectives

• Describe why patient education and shared

decision making is critical to maternity care

• Explore the differences between shared,

informed, and paternalistic decision making models

• Outline the importance of effective and timely

education to assist patients in making informed decisions related to maternity care

• Provide tips and techniques to promote both

informed and shared decision making in maternity care, as well as tips for how to manage patient expectations

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Setting the Stage

In the U.S., acts and regulations, as well as professional guidelines, state that every pregnant woman has the right to base her maternity care decisions on accurate, up-to- date, comprehensible information.

Goldberg H. Informed Decision Making in Maternity Care. The Journal of Perinatal

• Education. 2009;18(1):32-40. doi:10.1624/105812409X396219.

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Setting the Stage

• Patients involved in shared decision making feel an

increased sense of responsibility for health of baby and self baby (Harrison, et al., 2003), and experience shorter recovery periods (Green & Baston, 2003)

• Patients involved in childbirth decisions have lower

levels of fear (Green & Baston, 2003; Green et al., 1990) and experience less depressive and posttraumatic stress symptoms after birth (Green & Baston, 2003; Green et al., 1990)

• Women who had a cesarean were more likely to indicate

feeling pressure from a health-care practitioner to have an intervention that women who had a vaginal birth (Green & Baston, 2003; Green et al., 1990)

Goldberg H. Informed Decision Making in Maternity Care. The Journal of Perinatal

• Education. 2009;18(1):32-40. doi:10.1624/105812409X396219.

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Setting the Stage

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Setting the Stage Shared Decision Making

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Preference-Sensitive Care

“Medical care for which the clinical evidence does not clearly support one treatment option such that the appropriate course of treatment depends on the values of the patient or the preferences of the patient [. . .] regarding the benefits, harms and scientific evidence for each treatment option.”

Patient Protection and Affordable Care Act (2010)

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Conceptual Framework: Decision Making in the Setting of Uncertainty

MD Expertise Medical Knowledge & Experience Pt Expertise Preferences, Values, & Goals

SDM

Shared Decision- making

Adapted from Sackett, D. 2002. and Charles, et al. 1999.

Evidence

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Shared Decision-Making

Characterized by a bidirectional flow of information between patients and providers, resulting in deliberation and negotiation between these parties, which is followed by the physician and patient jointly deciding on a treatment strategy.

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Models of treatment decision-making Analytical stages Models Paternalistic Shared Informed Information exchange Flow Direction Type Amount 1-way Physician  patient Medical Legal minimum 2-way Physician ↔ patient Medical and personal All relevant information 1-way Physician  patient Medical All relevant information Deliberation Physician Physician and patient Patient Deciding on treatment to implement Physician Physician and patient Patient

Charles et al, 1999

Comparison

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Informed Decision-Making

• Communication process between a patient

and one or more health care providers.

• Reflects the ethical principle that a patient

has the right to decide what is appropriate for them, taking into account their personal circumstances, beliefs, and priorities.

• In order for a patient to exercise this right to

decide, they require relevant information.

Queensland Government. Guide to Informed Decision-making in

• Healthcare. February 2011.

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Shared vs. Informed Decision-Making

Informed DM

• Providing information
• Eliciting a preference

Shared DM

• IDM PLUS:
• Eliciting goals
• Identifying and

negotiating competing priorities

• Clarifying values
• Establishing priorities
• At times, providing

recommendations

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Important Distinctions

Informed Consent Informed Decision Informed Decision Shared Decision

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Informed Consent

From a legal sense, it reflects that a patient has received the information relevant to them to make an informed decision and they have given permission.

Contains two major elements: 1) Comprehension

• Awareness and understanding of situation and possibilities.

2) Free consent

• Intentional and voluntary choice that authorizes someone else

to act in certain ways.

It’s not just a signature on a form!

Queensland Government. Guide to Informed Decision-making in Healthcare. February 2011. Informed consent. ACOG Committee Opinion No. 439. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009; 114:401–8.

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Braddock’s SDM Components

1) Patient’s role in decision making 2) Patient’s goal and the context of the decision 3) Clinical issue or nature of the decision 4) Uncertainties 5) Alternatives 6) Risks and benefits 7) Patient’s understanding assessed 8) Patient’s desire for others’ input assessed 9) Patient’s preference explored

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Applying Braddock

1) Patient’s role in decision making

• There’s a decision we need to make together.
• It helps me to know how you feel about the risks

and benefits, and what’s most important to you. 2) Clinical issue or nature of the decision:

• There’s been some debate re:
• There are multiple safe and effective options
• There’s no right answer

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Applying Braddock

3) Uncertainties

• We can’t predict
• We don’t know for certain
• Though X is most likely, Y is also possible

4) Patient’s goal and the context of the decision

• It really depends on how you feel about the risk.

Some patients want to avoid X; while others want to achieve Y. 5) Alternatives

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Applying Braddock

6) Risks and benefits

• Risks: pain, anxiety, over-diagnosis, overtreatment,

costs (to patient), and procedure-related harms 7) Patient’s understanding assessed

• Ask-Tell-Ask
• Teach-back Technique

8) Patient’s desire for others’ input assessed 9) Patient’s preference explored Does that sound reasonable to you? Which way are you leaning?

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A Provider’s Role

• Providers play an active role in the patient's

decision making by offering advice, guidance, recommendations, or some combination thereof.

• Recommendations are oftentimes

appropriate and welcomed.

• Does not violate, but rather, may enhance,

the SDM process.

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Take Homes

• Patient’s goals and preferences should be

incorporated into preference sensitive clinical decision-making.

• SDM (vs IDM) is an optimal model for

patient-centered care.

• “Must Discuss”, Ask-Tell-Ask, Teach Back,

& Hypothetical Patients.

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Examples within the Safe Cesarean Bundle

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Timing of Admission in Labor

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Admission in Labor and Shared Decision Making

• Goals and Preferences

– Type of birth experience – Comfort and support

• Expectations

– Birth Plan – Role of Professionals vs Family

• Values

– What is most important

• Evidence

– Knowledge and understanding – Options/alternatives

• Decision-Making

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Choice of Comfort Measures and Shared Decision Making

• Woman central in making the decision
• What are her goals
• What is the clinical scenario
• Clinical issue or nature of the decision

– Standard care in this situation, – What we know about the options – What we do not know about the options or uncertainties – What are the alternatives – Risks and benefits of each

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Comfort Measures

• The woman’s understanding of the options

– Opportunity for questions – Clarify her understanding – Correct misunderstandings

• The woman’s desire for input from others

– Some challenges in the maternity care context

• Clarify preferences and values in

relationship to the woman’s goals

• Shared decision-making about final option

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Outcomes

Feeling Heard, Respected in the Decision Making Process, Making the “Best” Decision in the Situation

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Q&A Session

Press *1 to ask a question

You will enter the question queue Your line will be unmuted by the operator for your turn

A recording of this presentation will be made available on our website:

www.safehealthcareforeverywoman.org

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Next Safety Action Series

Using a Team-Based Care Approach to Preventing Surgical Site Infections in Gynecologic Surgery

Tuesday, April 12, 2016 | 1:00 p.m. Eastern

David Soper, MD, FACOG

Professor & Director, Obstetric & Gynecologic Specialists, Medical University of South Carolina

Paloma Toledo, MD, MPH

Associate Professor, Anesthesiology Northwestern University

Click Here to Register

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Future IVB Safety Action Series

Fostering Labor Support and Culture Change to Promote Vaginal Birth

Thursday, May 12, 2016 | 2:00 p.m. Eastern

Abraham Lichtmacher, MD, FACOG

Chief of Women’s Services Lovelace Health System, New Mexico

Lowry Simpson, MSN, CNM

Lead Certified Nurse Midwife Lovelace Health System, New Mexico

Click Here to Register