The Availability of Decision Aids

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.

Respond to at least two of your colleagues 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. 

Post #1

Working in the ICU and PCU settings in hospitals comes with its rewards and its downfalls.  One of the downfalls is not everyone follows the patient’s wishes when it comes to advanced care directives.  Clinicians and patients/surrogates should use a shared decision-making process to define overall goals of care (Kon, Davidson, Morrison, Danis, & White, 2016).  A patient of mine came into the hospital with an advanced directive already in place of DNR/DNI.  She was 91 years old, septic, and told us she just wanted to be comfortable.  We were following her wishes.  As the story usually goes, the children gather, and one can’t seem to let go and fights to make her full code.  We explain that is not her mother’s wishes, and we are making her comfortable.  This escalates, and one of the daughters rallies up the rest of the children and they guilt their mother into making her a full code.  This poor 91-year-old, frail woman, is now a full code.  Even if she were to make it through compressions, the healing process would be unbearable for her.  As the providers try to explain that to the patient and the children, they still proceed to make her a full code and want everything done to save their mothers life.  When I took over for night shift, visiting hours came to an end.  This lovely lady could barely move herself in bed.  The nursing assistant and I were cleaning her up and I asked her, “just out of curiosity, why did you change your code status?”  She said, “I couldn’t bare my children bickering and arguing with me about me leaving them.”  I explained to her that it was her choice, and she had the right to live the rest of her life the way she wanted to.  She told me and the nursing assistant, all she wanted to do was be with her husband up in heaven and that she was in so much pain she couldn’t bare it, but she didn’t want her kids to be mad at her.  I asked her if she wanted to speak with a chaplain.  She agreed.  I had a chaplain come to bedside.  About two hours later, the chaplain asked if a doctor could come to bedside, I said absolutely.  A half hour after that, her code status was changed to DNR/DNI and she wished to go on comfort cares.  The rest of my shift I helped make her as comfortable as possible, and she passed during day shift the next day.  If her family would have listened to her wishes to begin with, it wouldn’t have delayed the comfort cares and she would have gotten what she ultimately wanted sooner.  I took the time and listened to the patient, found out what her wishes were, and advocated for my patient.

            I chose the Ottawa Personal Decision Guide to reference.  It would contribute to effective decision making because it asks what the decision you are trying to make is, the pros and cons, to rate each pro

and con, what the other choices are, your support system and their choices, and your certainty (O’Connor, 2015).  In the above situation that I described, it would help because my patient would be able to write down the pros and cons of sticking with her original DNR/DNI status or switching to Full Code like her family wanted.  It would have helped her come to or stick to her decision quicker than prolonging it.  It could have also helped if her family saw the pros and cons as well, which would have helped them accept her wishes.  I would use this tool in my professional life if my patients were struggling with what decision they should make in their medical care.  I would make sure to talk about the natural history of the condition, the possible options, the benefits and harms of each, and a quantification of these must be informed by the best available research evidence (Hoffmann, Montori, & Del Mar, 2014).  By giving them this paper, it will allow them to write down their thoughts and feelings and help them come to a decision they are comfortable with.

references

Hoffmann, T. C., Montori, V. M., & Del Mar, C. (2014, October 1). The Connection Between Evidence-Based Medicine and Shared Decision Making. JAMA, 312(13), 1295-1296.

Kon, A. A., Davidson, J. E., Morrison, W., Danis, M., & White, D. B. (2016, June 15). Shared Decision-Making in Intensive Care Units: Executive Summary of the American College of Critical Care Medicine and American Thoracic Society Policy Statement. American Journal of Respiratory and Critical Care Medicine, 193(12), 1334-1336.

O’Connor, S. J. (2015). Ottawa Personal Decision Guide. Retrieved from The Ottawa Hospital Research Institute: https://decisionaid.ohri.ca/decguide.html

Post #2

It was an evening on Sunday when a young adult patient was accompanied by her mother for in-patient treatment due to self-harm and assaulting family members. Per the mother's report, the patient started exhibiting bizarre behavior, increased energy, and hearing voices telling her to hit herself. The patient presented with multiple cuts on her arms and legs. The mother added that the patient ran away multiple times and believes that the patient is currently "using drugs." When the mother was informed that the patient was diagnosed with schizoaffective disorder, bipolar type, the mother could not wait for further clarification. However, she screamed, "I do not believe that she is that sick" the mother was heard speaking in another language, panicking. The mother stated that the patient would not take medications, that "I have a friend who was on antipsychotic medications, and everything turned worst, that her friend rapidly decompensated and become dangerous to everyone." Unfortunately, the patient was autistic and unable to independently make her healthcare decision. The mother has been the patient's legal guardian. The mother's most significant concerns were fear of using antipsychotic medication. The mother reported that the patient was taking multiple medications already, and adding more will cause harm to the patient.

Adverse reactions begin much earlier, leading to recidivism because most antipsychotic drugs take

several weeks to manifest the desired effects. The mother was educated about the benefit of treating the disease at its early stage. The mother willingly participated in the treatment plan after being informed that she would be included in all stages of care, such as goal setting in treatment planning and decision about all interventions. The mother was also informed that antipsychotic medications would be reviewed accordingly.

 The treatment plan in the above scenario will involve using Shared decision-making (SDM) to support the mother, clinician, and patient in deciding on the treatment plan (Melnyk et al. (2018). The SDM is a collaborative process where patients and their clinicians make decisions using the best scientific evidence and integrating patient preferences. Like in the above scenario, many patients want more information and participation in the decision-making for quality of life during and after treatment. Disclosing potential benefits and risks of treatment is one of the ways to support the patient in making informed decisions while utilizing the best available evidence. The SDM follows the principle of patient-centered care, promotes informed choice, and results in care that patients value (Zisman-Ilani et al., 2018). Therefore, using SDM throughout the care process may improve the provider-consumer relationship. In this scenario, the mother will be given a choice to invite her friend or any other family member to participate in the SDM. The group members will be encouraged to participate actively because the SDM may not occur without mutual collaboration. Therefore, SDM will be used in every exchange with the patient as it will reduce adverse outcomes and improve patient adherence and quality of life (Melnyk et al. (2018).

Reference

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 fro

 https://decisionaid.ohri.ca/

Zisman-Ilani, Y., Shern, D., Deegan, P. et al. Continue, adjust, or stop antipsychotic medication:

developing and user testing an encounter decision aid for people with first-episode and long-term psychosis. BMC Psychiatry 18, 142 (2018). https://doi.org/10.1186/s12888-018-1707-x