Patient Preferences in Decision Making
Changes in culture and technology have resulted in patient populations that are often well informed and educated, even before consulting or considering a healthcare need delivered by a health professional. Fueled by this, health professionals are increasingly involving patients in treatment decisions. However, this often comes with challenges, as illnesses and treatments can become complex.
- What has your experience been with patient involvement in treatment or healthcare decisions?
In this Discussion, you will share your experiences and consider the impact of patient involvement (or lack of involvement). You will also consider the use of a patient decision aid to inform best practices for patient care and healthcare decision making.
To Prepare:
- Review the Resources and reflect on a time when you experienced a patient being brought into (or not being brought into) a decision regarding their treatment plan.
- Review the Ottawa Hospital Research Institute’s Decision Aids Inventory at https://decisionaid.ohri.ca/.
- Choose “For Specific Conditions,” then Browse an alphabetical listing of decision aids by health topic.
- NOTE: To ensure compliance with HIPAA rules, please DO NOT use the patient’s real name or any information that might identify the patient or organization/practice.
By Day 3 of Week 11
Post a brief description of the situation you experienced and explain how incorporating or not incorporating patient preferences and values impacted the outcome of their treatment plan. Be specific and provide examples. Then, explain how including patient preferences and values might impact the trajectory of the situation and how these were reflected in the treatment plan. Finally, explain the value of the patient decision aid you selected and how it might contribute to effective decision making, both in general and in the experience you described. Describe how you might use this decision aid inventory in your professional practice or personal life.
By Day 6 of Week 11
Respond to at least two of your colleagues on two different days and offer alternative views on the impact of patient preferences on treatment plans or outcomes, or the potential impact of patient decision aids on situations like the one shared.
Micheals discussion
In the clinical or within the hospital setting, the health care industry exposes us to people from all works of life to include variations in culture, belief system and even treatment options. As a charge nurse in an inpatient cancer treatment facility a situation came up where I had the pleasure of managing the care of a woman whose religious affiliation was of the Islamic faith. My female patient’s clinical diagnosis was breast cancer and she opted for a surgical removal of the breast which entailed getting a mastectomy with surgical reconstruction of the breast with a flap using abdominal tissues for a donor site, along with that came a foley catheter to help drain urine and periodic monitoring of the flap and surgery site to rule out complications. Some treatment alternatives as presented by the patient decision aid tool for a breast cancer patient includes; “Have surgery to remove the breast (mastectomy). Have surgery to remove just the cancer from the breast (breast-conserving surgery) followed by radiation treatments.” (Ottawa Hospital Research Institute, 2019)
Given my patient’s cultural background, and her religious affiliation, my client was not comfortable with having a male nurse as her care taker, instead she opted for a female nurse, given this scenario and the need to respect her wishes and cultural differences I had to change the assignment to accommodate her cultural preference with regards to post surgical care and ongoing treatment. I personally believe that granting her desires made the treatment plan go as planned with no added stress or tension on the path to recovery because we offered her treatment and care that was culturally appropriate and in line with her believe system, she was relaxed and receptive to care, this approach helped decrease her anxiety about her care, while she focused on the healing process, other arrangements I made was to inform other charge nurses of this development and to ensure every staff assignment to her room was a female per her request.
The value of the patient decision aid I selected was one that is applicable to my patient alongside care that is consistent with her religious and cultural affiliation, while keeping in mind the need to respect her wishes with regards to post surgical care and treatment options to include considerations for patient modesty and patient self awareness and reflection post surgical removal of her breast. The decision aid I utilized for breast cancer patient, presented with considerations to observe while caring for patients saddled with this type of scenario. “Evidence-based medicine (EBM) and shared decision making (SDM) are both essential to quality health care, yet the interdependence between these 2 approaches is not generally appreciated. Evidence-based medicine should begin and end with the patient: after finding and appraising the evidence and integrating its inferences with their expertise, clinicians attempt a decision that reflects their patient’s values and circumstances.” (Hoffman et. al., 2014)
With respect to my professional practice and or personal life, I would say the decision aid inventory presents with a wealth of information concerning various clinical situations that may arise and carefully thought out interventions that a client might be inclined to use, given the circumstance, the expert opinion and other considerable options that the client can choose from, to enhance their treatment process which will in turn improve their overall prognosis with the view of utilizing best practice options that is tailor made for each patients respective scenario. “Evidence based practice is the integration of patient preferences and values, ethical expertise, and rigorous research to make decisions that lead to improved outcomes for patients and families” (Melnyk, 2018, p219).
References
- Hoffmann, T. C., Montori, V. M., & Del Mar, C. (2014). The connection between evidence-based medicine and shared decision making. JAMA: Journal of the American Medical Association, 312(13), 1295–1296. https://doi-org.ezp.waldenulibrary.org/10.1001/jama.2014.10186
- Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Philadelphia, PA: Wolters Kluwer.
- The Ottawa Hospital Research Institute. (2019). Patient decision aids. Retrieved from https://decisionaid.ohri.ca/
Laura’s
I work in a small rural community hospital, IMCU. As COVID-19 hospitalizations increase, I have more conversations of end of life decisions with patients and families. This week, three-fourths of my patient load COVID + and on high flow oxygen at greater than 50 liters with Fio2 of 50% or more. My patients were all over 65 years old with multiple comorbidities. Repositioning met with desaturation levels of 70-80%. These patients dip to 80% just when trying to take a few sips of water. When their Spo2 levels drop, they are slow to recover. On my unit, there are discussions on mechanical ventilation and CPR every day. Most of these people have a poor understanding of how CPR will affect them. They don’t want to make decisions on ventilator use. They’re too afraid to make decisions well.
In particular, one patient was deteriorating and was declining to make any decisions on code status and intubation. Staff was trying to be proactive with education and a treatment plan of care; conversations were conducted daily, if not more. When the team had conversations with him, he would say he did not want to leave his current IMCU room; he liked his nurses and did not want to go to ICU. This meant he remained a full code and would be intubated at the point of emergency. We ended up changing his care level, transferring him to ICU, where he was immediately intubated. The next day, he was flown to a larger parent hospital. This was done because he was the most stable ICU patient that could be moved as we needed an ICU bed for an incoming patient too unstable to travel.
In this case, allowing the patient time to process the information and have preferences in care did not improve decision making. We accepted his choices in care. His condition deteriorated further, and intubation took place later than we would have liked, decreasing his chances of a successful outcome. Had we allowed him more time to decide, his condition could have made him too critical to transport to the parent facility. This delay could have jeopardized another patient (the incoming patient too critical for travel would have had to been flown out).
I looked at the decision tree for “Advance Care Planning: Should I receive CPR and life support” (Healthwise.org, 2020). I think the decision tree was well made and thought the personal stories section helped make the choices more relatable. With my knowledge base, a decision tree is an excellent option, but patients’ health literacy will impact their capability to use patient decision aids (PtDA). Few current patient PtDAs have addressed lower health literacy users’ needs, and the impacts of PtDAs intended to diminish the effect of low health literacy are unknown (McCaffery, et al., 2013). PtDAs can be a beneficial tool for higher health literacy patients, but care needs to be taken with lower health literacy users.
I think nurses are educators at heart. We are always in information exchange with our patients. I explain what and why I have to complete an action, the patient asks questions, and again I provide more clarifying information. The doctor leaves the room, and the patient looks to their nurse for a more understandable explanation of the dialogue. Patients need to be informed well so that they can make the best decisions for themselves. Providing education on PtDAs to nurses on how and when to implement sensitive topics would be fitting (Pyl & Menard, 2012). Patients need to learn on their own timeline. We need to offer opportunities for PtDA use but not be pushy. We need to assess the patient’s readiness to learn.
The patient I spoke of may have benefited from a PtDA before becoming too ill. Once someone is on my unit, they likely would be too ill and fatigued to use this type of tool without family assistance. Advanced directive PtDAs could be introduced at PCP offices very effectively as the best time to make these types of decisions are when you are healthy and can think clearly. In my own practice, PtDAs would need to be submitted to the facility for approval. Speaking to the unit coordinator would be the first step. In my personal life, I think a decision tree would be helpful. Nurses tend to put off self-care. Using a tree might make some nurses, myself included, become more proactive in their health.
References
- Healthwise.org. (2020). Advance Care Planning: Should I Receive CPR and Life Support? Retrieved from Healthwise.org: https://www.healthwise.net/ohridecisionaid/Content/StdDocument.aspx?DOCHWID=tu2951
- McCaffery, K., Holmes-Rovner, M., Smith, S., Rovner, D., Nutbeam, D., Clayman, M. L., . . . Sheridan, S. L. (2013, Nov). Addressing health literacy in patient decision aids. BMC Medical Informatics Decision Making, 13(s10). doi:10.1186/1472-6947-13-S2-S10
- Pyl, N., & Menard, P. (2012). Evaluation of Nurses’ Perceptions on Providing Patient Decision Support with Cardiopulmonary Resuscitation. International Scholarly Research Network, 2012. doi:10.5402/2012/591541