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While I am fully supportive of incorporating patient preferences and values in their treatment plan, I also know from a medical standpoint that it is not always in the best interest of the patient. Throughout my years in medicine, I have witnessed many occasions where the patient arrived in labor and delivery with a very detailed birthing plan.
For example, I had a patient bring in a 4-page birthing plan with every little detail, including the essential oils she wanted to use during each phase of labor, music she wanted to play, noise level, refusal of a cesarean section, etc. Of course, this patient failed to progress and wound up with an emergency cesarean section causing the patient to have negative feelings about the birthing process and the labor and delivery staff. â€œFindings showed that women relied on many resources when planning a birth and that changes made to a womanâ€™s initial birth plan affected her recollection of the birth experienceâ€ (Cook & Loomis, 2012, p.158).
I think that it is fine for a patient to verbalize their preferences and values; however, it is important for them to be realistic about the fluidity of medicine, especially during labor. The patientâ€™s preferences and values impacted the trajectory of the situation because she wasnâ€™t willing to accept the doctorâ€™s recommendation to perform a cesarean section. The doctor had informed the patient that she was not progressing as expected, but she refused to accept a c/s and was focused on fulfilling her birthing plan. â€œDuring both the development and implementation of the birth plan, women must negotiate their expectations and make health decisions with their care providersâ€ (Cook & Loomis, 2012, p. 160). Had the patient accepted a c/s earlier on and realized that it was medically necessary, some of her preferences might have been fulfilled; however, since she refused a c/s until it became an absolute emergency, her preferences were no longer able to be incorporated.
â€œPatient decision aids (PDAs) have been developed as a way to support patient participation in the decision-making process and to increase the likelihood of reaching a treatment decision that is both clinically sound and in line with patientsâ€™ valuesâ€ (Ankolekar et al., 2018, p.Â 3). The patient decision aids on childbirth can help the patient make an informed and realistic decision about birth choices, pain management during labor, and spontaneous or induced labor (The Ottawa Hospital Research Institute, 2019). Using the decision aid inventory in my professional practice or personal life could be very helpful as it provides balanced information on a wide variety of topics and can aid in making an informed decision about treatment benefits and risks as well as help in identifying personal preferences and how they might impact healthcare choices.
Ankolekar,Â A., Dekker,Â A., Fijten,Â R., & Berlanga,Â A. (2018). The benefits and challenges of using patient decision aids to support shared decision making in health care.Â Â JCO Clinical Cancer Informatics, (2), 1- 10. https://doi.org/10.1200/cci.18.00013
Cook, K., & Loomis, C. (2012). The Impact of Choice and Control on Women’s Childbirth Experiences.Â Â The Journal of perinatal education,Â Â 21(3), 158â€“168. https://doi.org/10.1891/1058-1243.21.3.158
The Ottawa Hospital Research Institute. (2019, June 26).Â Â A to Z search results. Patient Decision Aids – Ottawa Hospital Research Institute.Â https://decisionaid.ohri.ca/AZsearch.php?criteria=childbirth
Patient Preferences and Decision Making
Working in the emergency room allows me to see so many different people every day and work with individuals with many different preferences and views on health. I believe incorporating patient preferences is so important and makes a difference in their overall outcomes. When reading the prompt for this weekâ€™s discussion, one scenario came to mind very vividly. While the end of life is unfortunately something we see in the emergency room often, this patient’s case hit me differently than others. A 67-year-old woman called 911 for shortness of breath around dinner, when on the scene she was told it was anxiety by EMS and decided with EMS that it wasnâ€™t bad enough to come into the emergency room. Early morning the next day the woman calls 911 again and is brought into the ER where I work in respiratory distress. On arrival, the woman was very pale, tachypneic, tachycardic, and hypotensive. We knew very quickly we needed to know what the womanâ€™s wishes were regarding resuscitation because of her rapidly deteriorating condition. The woman said she did not want us â€œto put a tube down her throat because I know I wonâ€™t survive itâ€. We educated the patient on how taking this portion of the resuscitation process away, limits our ability to bring her back if she were to stop breathing. The woman continued to decline. We medicated the woman with many different things and placed her on BiPAP to attempt to regain stable vitals, continuing to educate her along the way. Her brother was at the bedside when we got to the point of knowing she wasnâ€™t going to make it much longer without further respiratory support. The doctor at the time explained that he felt she was not able to think clearly due to the low oxygen circulation and needed the brother to tell us if we would be intubating her within seconds. The brother said he wanted us to do everything in our power to save her, and we did. We intubated and coded this patient for over an hour with the return of ROSC 3 times. This woman passed away that night and, in my opinion, was denied the ability to pass based on her preferences. Was the woman capable of making her own decisions at this moment, or was her hypoxia changing her decisions? I donâ€™t know,Â Â but I know reflecting on the situation, every nurse and tech in the room was thinking the same thing, why did we intubate her when she did not want it? I cannot say that the woman would still be alive if we had not intubated her, the end was inevitable with or without intubation, but I still wish we could have respected her preferences in the moment and simply made her comfortable.
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