Thursday, March 24, 2016 2:00 p.m. Eastern Dial In: 888.863.0985 Conference ID: 58897575 Slide 1
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 Slide 2 Slide 2
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. Slide 3
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 Slide 4
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. Slide 5 Goldberg H. Informed Decision Making in Maternity Care. The Journal of Perinatal Education . 2009;18(1):32-40. doi:10.1624/105812409X396219.
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) Slide 6 Goldberg H. Informed Decision Making in Maternity Care. The Journal of Perinatal Education. 2009;18(1):32-40. doi:10.1624/105812409X396219.
Setting the Stage Slide 7
Setting the Stage Shared Decision Making Slide 8
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.” Slide 9 Patient Protection and Affordable Care Act (2010)
Conceptual Framework: Decision Making in the Setting of Uncertainty MD Expertise Pt Expertise Medical Preferences, Values, & Goals Knowledge & Experience SDM Shared Decision- Evidence making Adapted from Sackett, D. 2002. and Charles, et al. 1999. Slide 10
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. Slide 11
Comparison Models of treatment decision-making Analytical Models Paternalistic Shared Informed stages Information Flow 1-way 2-way 1-way exchange Direction Physician Physician ↔ patient Physician patient patient Type Medical and personal Medical Medical Amount All relevant Legal minimum information All relevant information Deliberation Physician Physician and patient Patient Deciding on treatment to Physician Physician and patient Patient implement Charles et al, 1999 Slide 12
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 Slide 13 Healthcare. February 2011.
Shared vs. Informed Decision-Making Informed DM Shared DM • IDM PLUS: • Providing information • Eliciting goals • Eliciting a preference • Identifying and negotiating competing priorities • Clarifying values • Establishing priorities • At times, providing recommendations Slide 14
Important Distinctions Informed Consent Informed Decision Informed Decision Shared Decision Slide 15
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. Slide 16 Informed consent. ACOG Committee Opinion No. 439. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009; 114:401 – 8.
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 Slide 17
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 Slide 18
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 Slide 19
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? Slide 20
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. Slide 21
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. Slide 22
Examples within the Safe Cesarean Bundle Slide 23
Timing of Admission in Labor Slide 24
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 Slide 25
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 Slide 26
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 Slide 27
Outcomes Feeling Heard, Respected in the Decision Making Process, Making the “Best” Decision in the Situation Slide 28
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 Slide 29
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