NURS-6052 DISCUSSION: PATIENT PREFERENCES AND 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.
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Initial Discussion Post
Discussion: Patient Preferences and Decision Making
Incorporating patients’ preferences and values gives the patients an active role in their care. Enable patients to offer opinions and participate in their treatment-related decision-making—is needed and could lead to more efficient and effective health care (Siminoff, 2013). Studies show that effectively engaging patients in their care are essential to improve health outcomes, improve satisfaction with the care experience, reduce costs and even benefit the clinician experience (Krist et al., 2017). The authors added that patients who participate in their decisions report higher satisfaction with their care; have increased knowledge about conditions, tests, and treatment. In addition, they have more realistic expectations about benefits and harms; are more likely to adhere to screening, diagnostic, or treatment plans; have reduced decisional conflict and anxiety; are less likely to receive tests or procedures which may be unnecessary; and, in some cases, even have improved health outcomes.
In my professional practice, I have come across a scenario that highlighted the value of shared decision-making and providing patients with adequate information that led to quick medical intervention that saved the patient’s life. My personal experience is about a 34-year-old female patient who came to our office sometime early last year. Based on the patient’s history and other factors, I realized the patient might be at risk of developing breast cancer. We discussed the importance of breast self-examination and how it may be helpful in early breast cancer detection. No single test can detect all breast cancers early, but performing breast self-exam combined with other screening methods can increase the chance of early detection (Breastcancer.org, 2019). I taught the lady how to perform the examination. In the course of her self-examining of her breast, she discovered a lump in her left breast four months after. Without hesitation, the patient called the doctor’s office, where a physical examination of the breast was done. The doctor ordered breast imaging tests. In the end, the test revealed that the lump was cancerous. By involving the patient in her care, early detection was possible without any metastasis.
According to patient decision aids for women at high risk for breast cancer, she should get extra checkups and testing, take medicines as prescribed, have surgery to remove both breasts or have surgery to remove her ovaries. Presenting available breast cancer treatments to the patient will enable her to make the best decision once presented with all the necessary information. I will most definitely be using this decision aid checklist when assisting patients in decision-making in the future.
References
Breastcancer.org (2019). Breast self-exam. Retrieved May 12, 2021, from https://www.breastcancer.org/symptoms/testing/types/self_examLinks to an external site.
Krist, A. H., Tong, S. T., Aycock, R. A., & Longo, D. R. (2017). Engaging Patients in Decision-Making and Behavior Change to Promote Prevention. Studies in health technology and informatics, 240, 284–302.
Siminoff L. A. (2013). Incorporating patient and family preferences into evidence-based medicine. BMC medical informatics and decision making, 13 Suppl 3(Suppl 3), S6. https://doi.org/10.1186/1472-6947-13-S3-S6Links to an external site.
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Collapse SubdiscussionJordyn Simons Shelia,
Thank you for your post. It is awesome that you were able to identify needs, advocate, ,and help that patient with her care! Patient decision Aids (PDAs) are tools that help patients and providers talk together about care options. PDAs help patients understand their choices about whether to have a specific treatment or screening. This includes knowing the pros and cons of each available option. Exploring all options allows a patient to feel more relaxed and less anxious about any upcoming test or procedure. PDAs also provide patients with information needed to decide, based on their personal values and preferences, by exploring each option and how it relates to their values. Research shows that PDAs lead to increased knowledge and a more accurate understanding of risk. When using a PDA, more patients feel comfortable with the decisions they make and the care they receive (Washington State Health Care Authority, n.d.). For example, a PDA could help a pregnant woman decide whether to attempt a natural birth after having a cesarean. We can use PDAs to form meaningful connects with patients by allowing them to feel knowledgeable and heard.
Good luck with the rest of your journey at Walden!
Jordyn
References
Patient decision aids (PDAs) | Washington State Health Care Authority. (n.d.). Www.hca.wa.gov. Retrieved from https://www.hca.wa.gov/about-hca/programs-and-initiatives/making-informed-health-care-decisions/patient-decision-aids-pdas#can-i-use-the-pdas-on-this-page
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Collapse SubdiscussionLeslie Rasmussen Module 6 Discussion, reply 2.
Hi Sheila!
This one hit close to home as I wrote about my genetic testing done and risk for breast and ovarian cancer, I opted for a double mastectomy at 25 and a full hysterectomy at the age of 27. It was a lot, but you are correct, imaging does not always work and its important to know the risks and what to look for. Thankfully you took the time do complete this teaching because it could have been a lot worse for this patient, she may never of known her risk without you looking into it further. Some individuals don’t pay attention to that type of thing or know what really affects the different types of cancer before it is too late. Realizing patients have a higher risk of breast cancer due to their family history is one big step in planning their future care so that way they can go in the right direction (Huber-Keener, 2022). Completing a self-exam is at no cost and no risk to yourself to improve mortality when it comes to breast cancer (Huang et al., 2022). I have done so much research on breast cancer just due to my risk and genetic mutation, but it was so hard to believe that it’s the leading cancer in American women and that every 2 minutes someone is being diagnosed with breast cancer (Huang et al., 2022). I have found that involving patients directly in their care, teaching them hands on has had so much benefit for better adherence and compliance to their treatments and their health all together.
References:
Huang, N., Chen, L., He, J., & Nguyen, Q. (2022). The efficacy of clinical breast exams and breast self-
exams in detecting malignancy or positive ultrasound findings. Cureus, 14(2). doi:
10.7759/cureus.22464
Huber-Keener, K. (2022). Cancer genetics and breast cancer. Best Practice & Research Clinical Obstetrics
& Gynaecology, 82, 3-11. https://doi.org/10.1016/j.bpobgyn.2022.01.007Links to an external site.
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Collapse SubdiscussionChristiana Nuworsoo Sheila,
Way to go! With your diligence and assistance, you were able to help the patient help herself. Recent reports from several US studies show that coordinated care trials that actively involved patients with chronic diseases led to significant mortality reductions when compared to a control group that merely took the recommended drugs (Krist et al., 2017). I genuinely think that all patients should have some degree of control over their medical treatment. Even a patient who suffers from a mental illness is aware that they ought to be given the opportunity to make decisions, no matter how minor. When the patient is involved, medical information that is no longer pertinent to them may occasionally be changed. I’ve encountered a number of instances when a patient’s medication list still included an ineffective drug, but since the patient was not participating in their treatment, the drug was added to the daily list of medications. I learned that the patient no longer takes the drug through education before administering it.
References
Krist, A. H., Tong, S. T., Aycock, R. A., & Longo, D. R. (2017). Engaging Patients in Decision-Making and Behavior Change to Promote Prevention. Studies in health technology and informatics, 240, 284–302.
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Collapse SubdiscussionAmanda Sutherland Response #2
Hello Sheila, thank you for your post. I wanted to expand on your discussion of patient decision aids (PDA) by describing a major source where we can find a range of PDA as described by Melnyk and Fineout-Overholt (2018), the Patient Centered Outcomes Research Institute (PCORI). PCORI was created in 2010 with the Affordable Care Act and reauthorized in 2020. It receives funding through the federal government and a $2 charge per insured person on Medicare, private insurance, and self-insured plans. Every year it awards research funding primarily for patient-centered clinical effectiveness research (CER) where the outcomes of 2 or more interventions, practices, or services are compared (Patient Centered Outcomes Research Institute, 2023). When I searched ‘patient decision aid’ on PCORI’s internet site, I received 126 results and found an article by Gayer et al. (2016) which includes a listing of the 56 decision aids in a variety of practice areas created through PCORI funding at the time of publication. The article also discusses strategies for increasing dissemination and implementation of decision aids by institutions, which the researchers note lags behind government-funded creation (Gayer et al., 2016).
References
Gayer C., Crowley M., Lawrence W., Gierisch J., Gaglio, B., Williams, J., Myers,, E., Kendrick, A., Slutsky, J., Sanders, G. (2016). An overview and discussion of the Patient-Centered Outcomes Research Institute’s decision aid portfolio. Journal of Comparative Effectiveness Research. Jun 14. PubMed PMID: 27298206.
Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Wolters Kluwer.
Patient Centered Outcomes Research Institute. (2023). About PCORI https://www.pcori.org/about/about-pcori
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Collapse SubdiscussionCrystal Lewis Hi, Sheila,
As you have explored decison aids, do you believe decision aids have any impact on patient satisfaction? Why is this important to consider?
Great post!
Dr. Lewis
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Collapse SubdiscussionRita Osei Initial post
I recently witnessed a situation where a patient was not brought into the decision regarding their treatment plan. The patient was a young man in his twenties who had been diagnosed with a rare form of cancer that had an extremely poor prognosis. The patient’s family was very involved in the decision-making process, but the patient himself was not consulted. The family decided to go with the most aggressive treatment option, which was a risky and invasive procedure with a poor chance of success.
The lack of patient involvement in the decision impacted the outcome of the treatment plan in several ways. First, it led to an unbalanced decision-making process, where the patient’s wishes and values were not taken into consideration. Second, it meant that the patient did not have the opportunity to make an informed decision about the risks and benefits of the procedure, and the potential for a successful outcome. Finally, the lack of patient involvement in the decision led to a feeling of helplessness on the part of the patient, who was not given the chance to be part of the decision-making process.
Including patient preferences and values in the decision-making process would have had a positive impact on the trajectory of the situation and the treatment plan. The patient would have been able to make an informed decision about their treatment and the potential outcome, and they would have been more likely to adhere to the treatment plan if they had been allowed to be part of the decision-making process. Additionally, the patient would have felt more empowered and in control of their situation.
The value of the patient decision aid I selected is that it provides clear and concise information about the patient’s condition and the potential treatment options, as well as the potential risks and benefits of each option. This helps to ensure that the patient is making an informed decision and that the care provider is considering all of the patient’s wishes and values when making a recommendation. Additionally, the patient decision aid can help to ensure that the care provider is practicing evidence-based care.
I believe that the patient decision-aid inventory is an invaluable resource for both care providers and patients. For care providers, it provides a way to ensure that they are providing evidence-based care and taking into consideration the patient’s wishes and values in the decision-making process. For patients, it provides a way to make an informed decision about their care and to feel more empowered and in control of their situation. I plan to use the patient decision-aid inventory in my professional practice to ensure that I am providing evidence-based care and taking the patient’s wishes and values into consideration in the decision-making process.
References
Melnyk. B. M. & Fineout-Overholt, E. (2018) Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Philadelphia, Wolters Kluwer Chapter 7, “Patient Concerns. Choices and Clinical Judgement in Evidence-Based Practice” Ipp 219-232)
Hoffman, TC, Montori, V. M. & Del Mar, C. (2014). The connection between evidence-based medicine and shared decision making Jour of the American Medical Association, 312113), 1295-1296, doi: 10.1001/JAMA.2014.10186 Kon, A. A. Davidson, J. E. Morrison W. Danis, M. & White, D. B. (2016). Shared decision making in intensive care units An American Collee Critical Care Medicine and American Thoracic Society policy statement Critical Care Medicine, 44(1), 188-201
doi:10.1097/CCM.0000000000001396
Opperman, C., Liebig, D. Bowling, J. & Johnson, C. S. & Harper, M. (2016) Measuring return on investment for professional development activities Implications for practice, Journal for Nurses in Professional Development, 3214), 176-184. doi:10.1097/NND.0000000000000483 Schroy, P. C. Mylvaganam, S., & Davidson, P (2014) Provider perspectives on the utility of a colorectal cancer screening decision aid for facilitating shared decision making & Health Expectations, 1711, 27-35. doi:10.1111/1369-7625.2011.00730.The Ottawa Hospital Research
Institute. (2019) Patient decision aids Retrieved from https://decisionaid.o
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Collapse SubdiscussionChristiana Nuworsoo Rita,
Your post brought back unpleasant memories for me because I had a similar situation but the patient did not make it. I completely agree that including patient preferences and values in the decision-making process would have a positive impact on the trajectory of the situation and the treatment plan. The patient was in his twenties, therefore, all he needed was information and education on treatment options and be allowed to make the decision for himself. Poor patient engagement can lead to higher rates of mortality, complications, readmissions to the hospital, and infections (Bartlett, 2020). Sometimes, family involvement can negatively affect the outcome of a patient’s treatment. Family members may also pester or quarrel with patients in an effort to encourage adherence, but this simply serves to lower patients’ self-efficacy and cause conflict within the family (Mayberry & Osborn, 2014).
References
Bartlett, W. (2020). The hidden cost of poor patient engagement in healthcare. Retrieved 2/9/2023 from https://www.intelichart.com/blog/the-hidden-cost-of-poor-patient-engagement#:~:text=Poor%20patient%20engagement%20can%20lead,care%20and%20population%20health%20initiativesLinks to an external site..
Mayberry, L. S., & Osborn, C. Y. (2014). Family involvement is helpful and harmful to patients’ self-care and glycemic control. Patient education and counseling, 97(3), 418–425. https://doi.org/10.1016/j.pec.2014.09.011
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Collapse SubdiscussionEsther Davis Main Post
Patient involvement and decision making
It is very important that patients be given the opportunity to get involved in their care. Patient centered care is respectful and responsive to patient preferences, values, and perspectives (Zizzo et al., 2017). So patient involvement is paramount in fostering quality care and patient satisfaction.
I worked with a patient with depression on my psych unit, who is also diabetic. In her story, she told me how she has been placed on insulin to control her blood glucose (BG). She further asserted that her provider thought she would benefit more and get a better control with the insulin. Her BG was not that bad with her A1C, and she did not think she needed Insulin at that point, but she just relied on what the doctor said. She believed she could control her BG with oral medication, diet, and exercise but her doctor was concerned the pt option may not work because she is obese and also hypertensive. She had to agree to the plan. The insulin drops her BG too low, as a result, she would skip the insulin at times, and this made her condition to get worse.
Inclusion of patient preference
Incorporating patient preferences in the decision-making process is beneficial to the patient wellbeing as it allows to build trust, and aid in the recovery process.
Yu et al., (2019) noted that when decision making is shared, it increases knowledge, increases risk perception, reduced decisional conflict and enhanced participation in care. In my opinion, the exception to the rules should be when the pt is uneducated, incapacitated or cognitively impaired. If this patient was given her treatment choice versus starting insulin, her BG could have been better controlled.
When the patients are treated with their preferred treatment option, the outcome is favorable (Vahdat,2014). This patient was not allowed to choose her preferred option. Instead, she had a treatment option she did not want and led her to unfavorable side effect. Pt should be given the opportunity to choose their treatment option. This allows for a better outcome and improved patient satisfaction.
Decision aid
Patient decision aids (PDAs) are tools that assist patients to make decisions and inform them about their treatment, cost, benefits, and risks during the clinical encounter (Yu et al., 2019). In my patient situation, patient decision aid gives her options to choose to take insulin or try other methods to keep blood sugar levels under control. The goal in treating type 2 diabetes is to keep blood sugar under control and decrease the risk for other health problems such as eye problems, kidney disease, and nerve damage. The decision aid I found for Diabetes is called the NICE guidance for Diabetes type 2. This decision aid is specific to diabetes. It is patient centered, goal setting, provide information and allows for communication between the patient and the health care team (The Ottawa hospital research Institute, 2019).
In my practice, I will use this decision inventory aid to help my patients make decisions about their health condition because this guideline covers care and management for adult with type 2 diabetes with focus on education, dietary advice, and long-term complications. This aid is also goal setting and allows for individualized care plan.
References
The Ottawa Hospital Research Institute. (2019). Patient decision aids https://www.healthwise.net/ohridecisionaid/Content/StdDocument.aspx?DOCHWID=ty756Links to an external site.
Vahdat, S., Hamzehgardeshi, L., Hessam, S., & Hamzehgardeshi, Z. (2014). Patient involvement in health care decision making: a review. Iranian Red Crescent medical journal, 16(1), https://doi.org/10.5812/ircmj.12454Links to an external site.
Yu, C.H, Ke,C., Jovicic, A, Hall, S & Strauss, S. E. (2019). Beyond pros and cons – developing a patient decision aid to cultivate dialog to build relationships: insights from a qualitative study and decision aid development. BMC Medical Informatics and Decision Making. 19(186). https://doi.org/10.1186/s12911-019-0898-5
Zizzo, N., Bell, E., Lafontaine, A.L., & Racine, E.(2017).Examining chronic care patient
Preferences for involvement in health-care decision making: the case of Parkinson’s disease patients in a patient-centered clinic. HealthExpectations,20(4),655-664. https://doi.org/10.1111/hex.12497Links to an external site..
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Collapse SubdiscussionBertina Boma Soh That’s excellent work you’ve done, Esther. That “it is vitally important that patients be given the option to get involved in their care” is something I fully agree with you on. Your piece was exciting and educational, so thank you for writing it! You made an excellent point when you stated that patients are becoming more active participants in their healthcare, beginning with the time they obtain a diagnosis from their doctors. Patient input and physician knowledge are crucial when making decisions about a patient’s or family’s health (Melnyk & Fineout- Overholt, 2018). In addition, the patient and doctor must be able to talk freely and respectfully to facilitate patient-centered decision-making. Patient-provider relationships strengthened through shared decision-making strategies benefit all parties involved. The clinician needs to ensure the surrogate’s choice for this model is not due to factors that may be changed, such as a lack of knowledge or professional support (Kon et al., 2016). Physicians who can support and listen to their patients while also providing them with high-quality care may find greater satisfaction in an approach encourages patients to have an active role in decision-making.
References
Kon, A.A., Davidson, J.E., Morrison, W., Danis, M., & White, D. B. (2016). Shared decision
making in intensive care units: An American College of Critical Care Medicine and American
Thoracic Society. Critical Care Medicine, 44(1), 188-201. Doi:10.1097/CMM.000000000001396Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing &
healthcare: A guide to best practice (4th ed.). Philadelphia, PA: Wolters Kluwer. -
Collapse SubdiscussionSheila Ankrah Response #2
Hi Esther,
Patient Preferences and Decision Making
I indeed agree with you that involving patients in their care makes patients and families feel empowered when making important decisions about their health and, in turn, can make them more compliant with their treatment regimens. According to Healthcare Value Hub (2019), shared decision-making has been shown to result in treatment plans that better reflect patients’ goals, increase patient and physician satisfaction, improve patient-physician communication, positively affect outcomes, and, sometimes, reduce costs. With enhanced patient participation and considering patients as equal partners in healthcare decision-making, patients are encouraged to actively participate in their treatment process and follow their treatment plan, resulting in better health outcomes (Vahdat et al., 2014). Giving patients information on the available treatment options allows them to choose a plan that best suits them. For those in critical condition, it is also necessary that their relatives assist them in making a sober decision.
References
Healthcare Value Hub (2019). The consumer benefits of patient shared decision making. Retrieved May 15, 2021, from https://www.healthcarevaluehub.org/advocate-resources/publications/consumer-benefits-patient-shared-decision-makingLinks to an external site.
Vahdat, S., Hamzehgardeshi, L., Hessam, S., & Hamzehgardeshi, Z. (2014). Patient involvement in health care decision making: a review. Iranian Red Crescent medical journal, 16(1), e12454. https://doi.org/10.5812/ircmj.12454Links to an external site.
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Collapse SubdiscussionSulaiman Yassin Jalloh In healthcare delivery, patient values and preferences are substantial elements of evidence-based practice. When making treatment decisions, clinicians must consider what the patient prefers based on their values (Melnyk & Fineout-Overholt, 2022). While working in an acute clinical setting, I came across a case that highlighted that underlined the significance of patient preferences in treatment planning. The case involved a Hispanic patient who was previously diagnosed with hypertension. Despite having received medications and instructions on healthy habits, the patient’s blood pressure was uncontrolled. The blood pressure reading at the time of the visit was 159/93 mmHg.
The patient acknowledged having failed to adhere to the recommended dietary plans because the changes were costly and could not be accommodated by the patient’s family. She preferred a low-cost diet plan that incorporated some of the Mexican diets. Having noted the patient’s preferences, I engaged her in developing a diet plan (Butler et al., 2018). The client received advice on ways of maintaining healthy eating on a low budget. The consideration of the patient preferences in the treatment plan improved blood pressure control (Xu et al., 2022). Thus, patients’ preferences are significant in treatment decision-making.
The Cardiovascular Risk Decision Support Tool is valuable in the management of patients with an elevated risk of cardiovascular diseases. The decision aid helps patients and nurse practitioners to make decisions regarding quitting smoking or taking statins to lower cardiovascular risk (The Ottawa Hospital Research Institute, n.d.). It offers solutions to complex cases of cardiovascular disorders, allowing nurse practitioners to provide effective personalized care. The objective of using the Cardiovascular Risk Decision Support Tool is to establish meaningful patient engagement and reduce the burden of cardiovascular disease on patients and health systems (The Ottawa Hospital Research Institute, n.d.). I plan to use the decision aid to provide patient-centered care to individuals with high cholesterol levels.
References
Butler, E. L., Laber, E. B., Davis, S. M., & Kosorok, M. R. (2018). Incorporating patient preferences into the estimation of optimal individualized treatment rules. Biometrics, 74(1), 18-26. https://doi.org/10.1111/biom.12743
Melnyk, B. M., & Fineout-Overholt, E. (2022). Evidence-based practice in nursing & healthcare: A guide to best practice. Lippincott Williams & Wilkins.
The Ottawa Hospital Research Institute. (n.d.). Patient Decision Aids; Cardiovascular Risk Decision Support Tool. https://decisionaid.ohri.ca/Azsumm.php?ID=1804
Xu, X., Guo, T., Liu, Z., Chen, P., Zhang, Y., Ji, Q., & Xie, H. (2022). A Systematic Review of Patient Preferences, Expectations, and Values for the Management and Treatment of Hypertension. Patient preference and adherence, 2867-2876. https://doi.org/10.2147%2FPPA.S388356
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Collapse SubdiscussionMleh Porter Patient Preferences and Decision Making
Access to information has led to more informed patients concerning their health life. This trend has resulted in patients being included in decision-making concerning treatment options, regarded as patient preference. According to Hoffman et al. (2014), active patient participation has become a priority in the healthcare sector. In addition to self-management, the choices are utilized to improve patient care experience and safety. Diabetes type 2 has become a common lifestyle disease, and its management is partially determined by patients’ ability to adhere to self-care plans developed by the care providers.
One of many situations I have encountered as a nurse involving a patient in a treatment plan entails a patient diagnosed with type 2 diabetes. While the care plan entailed healthy eating, exercising, reducing weight, and constant blood sugar monitoring, the situation required active patient participation. The patient was in denial that his life habits contributed to his condition, making him hesitant to be part of the self-care plan. However, after consultation and patient education, the patient embraced the chance to take care of his health life. Factoring patient preferences in the care plan resulted in establishing the best diet possible, affordable and easily accessible depending on his income and location.
Incorporating patient preferences and values into the identified situation helped the care provider develop a tailored self-intervention measure for the diabetic condition (Melnyk & Fineout-Overholt, 2018). For example, the patient understands his powers in addressing the issue by practicing the mentioned care interventions, including exercises, healthy eating, and time to time checking on his blood sugar. In addition to providing critical details about the patient, patient preferences and values offered a defined direction on the best care practice or interventions which would deliver the best experience for the patient. The care providers are informed by the preferences, hence developing care interventions that improve clinical intervention. In terms of utilizing this in professional practice, the presence would be critical in informing patients about the disease and their ability to adopt self-care practices effectively.
The selected decision aid contributes to effective decision-making regarding addressing the selected patient as it entails options between taking medication and changing lifestyle to prevent and reduce the menace effects of the disease (Patient Decision Aids – Ottawa Hospital Research Institute, 2020).
References
Hoffman, T. C., Montori, V. M., & Del Mar, C. (2014). The connection between evidence-based medicine and shared decision-making. Journal of the American Medical Association, 312(13), 1295–1296. https://doi.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.). Wolters Kluwer.
Patient Decision Aids – Ottawa Hospital Research Institute. (2020). https://www.healthwise.net/ohridecisionaid/Content/StdDocument.aspx? DOCHWID=abp5563Links to an external site.
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Collapse SubdiscussionStephen Chege Response 1
Great post Mleh.
Including the patient in decision-making is essential when establishing a care plan. Also, patients tend to be more compliant and involved in their care when involved in decision-making. Getting a new diagnosis comes with increased stress and the patient may not be fully aware of what lifestyle to adjust to stay healthy. Also, some illnesses may impact patients’ careers or other daily activities. Accommodating the concerns, the patients may have been critical to their recovery.
Kon et al. (2016) mention the importance of shared decisions between the medical team and the patients or family, and its impact on promoting recovery. I discussed with a provider who took care of a diabetic patient, and there is certain food the patient was not willing to let go of. To accommodate the patient’s wishes, the doctor discussed with the patient the risks associated with diet non-compliance. In this instance, the doctor agreed with the patient to establish an insulin sliding scale that is therapeutic and instructed the patient to reach out if the diet changes, to sustain a therapeutic blood glucose range. It is therefore important to work together with the patient in making a medical decision, to promote compliance and patient satisfaction.
Reference
Kon, A. A., Davidson, J. E., Morrison, W., Danis, M., & White, D. B. (2016). Shared decision making in intensive care units: An American College of Critical Care Medicine and American Thoracic Society policy statement Links to an external site. Critical Care Medicine, 44(1), 188–201. doi:10.1097/CCM.0000000000001396
Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Philadelphia, PA: Wolters Kluwer.
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Collapse SubdiscussionOdion Iseki Module 6 Initial Discussion Post
EXPERIENCE
As a nurse working in long-term care, we often must talk to the residents and their families about palliative care. Sometimes, all the decisions are made by the family because the patient cannot do so. Sometimes the person can still think, but their body is giving out. Every time, these talks are complex, but they are always necessary. Even though hospice care has many benefits, few LTC residents currently get it (Xiong, B., Freeman, S., Banner, D., Spirgiene, L., 2020).
One resident has a liver failure that has reached the end stage. The only treatment left is a liver transplant, but she is not a good candidate. This person has been in and out of the hospital because they have a high level of lactic acid and feels sick. She came home from the hospital and told us that they told her she wouldn’t get better without a new liver and that they wouldn’t even consider her for this surgery. This information was given to the staff but not to the resident, who is mentally healthy.
Then it was up to me to talk to this resident about her prognosis and what she could do. I told her the truth, and when we were done talking, she decided that hospice care would be best for her. Before COVID-19, this resident spent her days with family and friends. Now, she spends her time doing things and is happy and pain-free. Considering her values and wishes, we decided to bring in hospice care. She is no longer going to and from the hospital, is no longer in pain, is not limited in what she can drink or eat, and is happy. The resident knows what to expect with her prognosis and is satisfied with her treatment plan.
WHAT THE PATIENT WANTS
When a treatment plan considers what the patient wants and values, the patient is more likely to follow the procedure. When a patient can be cured, more compliance often means faster healing. When a patient can’t be cured, following their care plan makes them and their family happier and improves their relationship with the healthcare team.
Before she decided to be a hospice patient, she wasn’t supposed to drink as much coffee as she does now. She was in a lot of pain every day, and now that she is in hospice, more potent painkillers can be thought about. Pain is a common symptom in the last stages of a disease (Xiong, B., Freeman, S., Banner, D., Spirgiene, L., 2020). This resident is also diabetic and was on a strict diet. Now that she is in hospice care, she can eat whatever she wants, making her happier and easier for her to get along with the staff.
Her treatment plan works because it no longer focuses on keeping her as healthy as possible. Instead, it now focuses on making her as happy as possible. The resident is happy, her family is there for her, and she gets along well with the people who care for her.
DECISION AID
Looking Ahead: Choices for Medical Care When You’re Seriously Ill is a tool used to help people make decisions when they have a severe illness that is likely to end in death. This decision-making tool is often used with people who are staying in hospitals. This guide is mostly about making decisions about feeding, hydrating, breathing machines, and CPR. This DA was okay and helpful. Many of the participants said they wished this had been part of their treatment plan sooner because they had already made some of these decisions. With this tool, the patients felt like they had more control over their treatment plan and were more involved in it (Matlock, D. D., Keech, T. A. E., McKenzie, M. B., Bronsert, M. R., Nowels, C. T., & Kutner, J. S., 2014).
When used at the right time, this DA could help patients with terminal illnesses work with their healthcare team to make a treatment plan that considers all possible outcomes during their illness. When patients know what to expect and their choices, they can make more informed decisions. If this patient had been able to decide like this before she got sick, it could have saved her from some of the worry, fear, and uncertainty she went through (Matlock, D. D., Keech, T. A. E., McKenzie, M. B., Bronsert, M. R., Nowels, C. T., & Kutner, J. S., 2014).
PRACTICE ON YOUR OWN
Now, we use a questionnaire about advance directives that asks a few general questions about their wishes. Being in long-term care, it would be helpful to have a more advanced and detailed decision-making tool. A patient decision aid is a tool that can help the patient and their family understand the different options and talk about them. This lets the patient’s values be considered (Malloy-Weir, L. J., & Kirk, A., n.d.).
We could teach the residents about their specific diagnoses and outlooks and tailor the help to these facts and the residents’ needs. If this tool is used when a person with dementia is still in the early stages of the disease, their wishes can be carried out at every stage of their care and disease (Malloy-Weir, L. J., & Kirk, A., n.d.). It could take a long time to fill these out for all 80 residents, but they could be instrumental and helpful in the long run.
References
Malloy-Weir, L. J., & Kirk, A. (n.d.). Development and pilot testing of a decision aid for the initiation of antipsychotic medications in persons with dementia in long-term care using a systematic approach: a study protocol. BMJ OPEN, 7(10). https://doi-org.ezp.waldenulibrary.org/10.1136/bmj…Links to an external site.
Matlock, D. D., Keech, T. A. E., McKenzie, M. B., Bronsert, M. R., Nowels, C. T., & Kutner, J. S. (2014). Feasibility and acceptability of a decision aid designed for people facing advanced or terminal illness: a pilot randomized trial. Health Expectations, 17(1), 49–59. https://doi-org.ezp.waldenulibrary.org/10.1111/j.1…Links to an external site.
Xiong, B., Freeman, S., Banner, D., & Spirgiene, L. (2020). Hospice Utilization Among Residents in Long-Term Care Facilities. Journal of Palliative Care, 825859720907415. https://doi-org.ezp.waldenulibrary.org/10.1177/082…Links to an external site.
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Collapse SubdiscussionNtumba Kabongo Response #2
Hi Odion, I agree with you that advocacy is very important. I did experience the same situation working with patients going through the end of life. Although some patients, when given a gloomy prognosis, can still make a sound decision, some patients are mentally broken and give up on the little time that they have left. I have seen both situations. Despite the outcome of how patient received the information given to them, it is their choice to act anyway they want.
It is the provider’s responsibility to relay the information and include the patient in the decision making for their care. the medical provider must help the patient overcome the challenges that may exist when making medical decisions (Kon et al. 2016). Melnyk & Fineout-Overholt (2018) affirm the effectiveness of care and good medical outcomes when a patient is involved in medical decision-making. The American General Medical Council requires Doctors to respect patients’ autonomy over their lives (McAlpine et al., 2018). Involving the patient in decision-making is crucial in promoting optimal health service results and should be required by healthcare facilities.
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
McAlpine, K., Lewis, K. B., Trevena, L. J., & Stacey, D. (2018). What is the effectiveness ofpatient decision aids for cancer-related decisions? A systematic review subanalysis. JCO
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Collapse SubdiscussionCrystal Lewis Hi, Odion,
Excellent post! As a nursing leader, how would you educate your staff related to utilizing decision aids? What type of research data would your present?
Dr. Lewis
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Collapse SubdiscussionStephen Chege Main Discussion Post
Incorporating the patients when making medical decisions is essential and promotes compliance with the care plan and awareness of the disease or medical process management. The patients are barely involved when making medical decisions, and their values, preferences, or understanding of the circumstances surrounding their medical conditions get bypassed (Hoffman, Montori & Mar 2014).
Inclusive decision-making between the medical team and patients or individuals involved in patients’ care is crucial and demonstrates respect for the patient’s values, preferences, and goals. Including the patients in decision-making allows for a well-informed treatment plan and goals. Some decisions may be sensitive and challenging for the patient and medical team. In some instances, the medical provider must help the patient overcome the challenges that may exist when making medical decisions (Kon et al. 2016). Melnyk & Fineout-Overholt (2018) affirm the effectiveness of care and good medical outcomes when a patient is involved in medical decision-making.
In my experience, I encountered a situation where the family members had difficulty deciding to terminate high-flow Oxygen for the patient. The decision to stop the high flow of Oxygen meant the end-of-life protocol was to be implemented; however, the family lacked an understanding of the disease process. Culturally, the family perceived the decision as an act of killing. The provider spent much time educating the family on the quality of life and the medical prognosis. The patient persistently had difficulty sustaining adequate saturation, skin started breaking out, and the chances of survival were minimal. Eventually, the family agreed, and the medical team implemented comfort measures.
References
Hoffman, T. C., Montori, V. M., & Del Mar, C. (2014). The connection between evidence-based medicine and shared decision-making Links to an external site. Journal of the American Medical Association, 312(13), 1295–1296. doi:10.1001/jama.2014.10186
Kon, A. A., Davidson, J. E., Morrison, W., Danis, M., & White, D. B. (2016). Shared decision making in intensive care units: An American College of Critical Care Medicine and American Thoracic Society policy statement Links to an external site. Critical Care Medicine, 44(1), 188–201. doi:10.1097/CCM.0000000000001396
Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Philadelphia, PA: Wolters Kluwer
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Collapse SubdiscussionOdion Iseki Hello Stephen,
Great post i agree with you that Respect for the patient’s values, preferences, and goals can be shown through collaborative decision-making between the medical team and the patient or other individuals involved in the patient’s care. The treatment plan and outcomes are more likely successful when patients are involved in decision-making. The patient and the medical staff may find some decisions complex and emotionally fraught. Providers often need to coach patients through challenging moments while deciding on medical care (Kon et al. 2016). Melnyk and Fineout-Overholt (2018) state that patient participation in medical decision-making increases the quality of care and improves health outcomes.
References
Hoffman, T. C., Montori, V. M., & Del Mar, C. (2014). The connection between evidence-based medicine and shared decision-making Links to an external site. Journal of the American Medical Association, 312(13), 1295–1296. doi:10.1001/jama.2014.10186
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Collapse SubdiscussionCrystal Lewis Hi, Stephen,
How can decision support tools help improve patient safety?
Great post!
Dr. Lewis
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Collapse SubdiscussionVictavian Jackson Great Post Stephen!
I agree it is important to incorporate patients when making decisions because it promotes care plan compliance and disease awareness. Shared decision-making (SDM) is identified as a strategy to improve collaboration between clinicians and patients in achieving recovery (Fiorillo et al., 2020, p. 1). Whenever I have a patient that is newly diagnosed with diabetes, I ensure they understand the disease process and how it directly impacts their health. When patient understands their choices, it is easier for a clinician to help them through the decision process. According to the International Patient Decision Aids Standards (IPDAS) Collaboration, decision aids are evidence-based tools designed to help patients make specific and deliberated choices among healthcare options (Stacey, Lewis, et al., 2017, p. 10). Similar to your example, I had a patient who was transitioning and wanted to be DNR, yet there was a family member who was the DPOA who did not want to change the code states. After several meetings with the ethics committee, the family member agreed. During the ethics meetings, the patients family member had a hard time understanding the disease process of end-stage chronic obstructive pulmonary disease (COPD). The decision aid tools helped the patient and family members to make a decision even though it was up to the patient.
References:
Fiorillo, A., Barlati, S., Bellomo, A., Corrivetti, G., Nicolò, G., Sampogna, G., Stanga, V., Veltro, F., Maina, G., & Vita, A. (2020). The role of shared decision-making in improving adherence to pharmacological treatments in patients with schizophrenia: a clinical review. Annals of General Psychiatry, 19(1), 1–12. https://doi.org/10.1186/s12991-020-00293-4
Stacey, D., Lewis, K. B., Barry, M. J., Bennett, C., Eden, K., Holmes-Rovner, M., Llewellyn-Thomas, H. A., Lyddiatt, A., Thomson, R., & Trevena, L. (2017). Decision aids for people facing health treatment or screening decisions. The Cochrane Library, 2017(4), 1–287. https://doi.org/10.1002/14651858.cd001431.pub5
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Collapse SubdiscussionBertina Boma Soh Involving patients in the decision-making process regarding their treatment is crucial, as you obtain a sense of their perspective or viewpoint regarding the chosen treatment modality. The information offered by medical practitioners is essential for making sound clinical judgments. Additionally, it ensures the patient. Since the patient’s perspective will be considered in the decision-making process, satisfaction is obtained. Professional groups and government bodies support patient participation in life-decision making. A good example is the United States Preventive Services Task Force (USPSTF), which emphasizes the importance of cooperation between doctors and their patients in decision-making. The American General Medical Council requires Doctors to respect patients’ autonomy over their lives (McAlpine et al., 2018). Involving the patient in decision-making is crucial in promoting optimal health service results and should be required by healthcare facilities. Patients might be encouraged to engage in their care either orally or in writing. Educating patients about their illnesses enables them to collaborate with the hospital to address the situation.
Before making a decision, patients might also be encouraged to ask questions to comprehend their condition better.The Ottawa personal guide assists the patient in making decisions on their health condition, particularly delicate ones. It requires the patient to assess the benefits and risks of a given decision, including the option of doing nothing. A guide assisting the patient in decision-making can improve the treatment option since any adjustment to the treatment will be based on the patient’s values being acknowledged (Finderup and Stacey, 2021). Due to kidney failure, I previously worked with a patient who required dialysis. As the coordinator for dialysis, I provided the patient with a summary of their symptoms to ensure they knew why they would be required to choose between the available dialysis options. To ensure the patient made an informed selection, I assured them they knew each dialysis option’s benefits and drawbacks (Finderup and Stacey, 2021). After comprehending. The patient opted for the scheduled hemodialysis operation out of all available possibilities from the comfort of home. This patient’s response was crucial, as I had met their expectations and adhered to their core principles to achieve maximum patient happiness. The patient argued that a choice guide was essential since it helped them learn more about their health and the optimal dialysis procedure to fulfill their needs, values, and expectations.
Additionally, the patient appreciated the dialysis process since he knew what to anticipate from beginning to end. The dialysis choice tool ensures that patients select the modality they feel most at ease with, enhancing therapy. Outcome. PDAs do not interfere with the physician-patient relationship but facilitate decision-making conversations (Housten et al., 2019). To guarantee that the PDAs are of a high standard, they are evaluated using the IPAS standards as a guide. On what a typical PDA should consist of. It should offer a thorough discussion of the condition or the patient’s situation, the benefits and drawbacks of each decision, and the outcomes of each alternative. In conclusion, patient decision help is vital since it guarantees that the appropriate treatment is selected.
The doctor’s goals and the patient’s preferences and needs are in harmony, resulting in optimal treatment. Success rate amongst patients. Involving the patient in the decision aid can help reduce or eliminate potential biases.
References
Finderup, J., & Stacey, D. (2021). Quality patient decision aids to support healthcare decisionmaking. Medical Writing, 30, 38-44.
Housten, A. J., Lowenstein, L. M., Hoffman, A., Jacobs, L. E., Zirari, Z., Hoover, D. S., … &Volk, R. J. (2019). A Review of the Presentation of Overdiagnosis in Cancer Screening
Patient Decision Aids. MDM Policy & Practice, 4(2), 2381468319881447.
McAlpine, K., Lewis, K. B., Trevena, L. J., & Stacey, D. (2018). What is the effectiveness ofpatient decision aids for cancer-related decisions? A systematic review subanalysis. JCO
clinical cancer informatics, 2, 1-13.
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Collapse SubdiscussionMona Bourbour Shirazi Kordi Hi, thanks for sharing the great post. As you mentioned the involvement of the patients in the care plan plays an important role and in fact when patients are involved in decision-making, they feel a sense of control over their own health and treatment. This can lead to increased engagement in their own care, which can improve outcomes. In addition, patients who are involved in decision-making are more likely to understand their condition, treatment options, and the potential risks and benefit of each option
References
Finderup, J., & Stacey, D. (2021). Quality patient decision aids to support healthcare decision-making. Medical Writing, 30, 38-44.
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Collapse SubdiscussionMona Bourbour Shirazi Kordi Stiggelbout, A. M., Van der Weijden, T., De Wit, M. P., Frosch, D., Légaré, F., Montori, V. M., … & Elwyn, G. (2012). Shared decision making: really putting patients at the centre of healthcare. Bmj, 344.
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Collapse SubdiscussionCrystal Lewis Hi, Bertina,
Excellent post! Discuss how decison aids stimulate patients to be more active in decision making, without increasing their anxiety.
Dr. Lewis
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Collapse SubdiscussionAnupa Mukundram Mehta In medical step down, I took care of many patients who were sick beyond our ability to cure them. In most of the cases, the patient had never had an advanced directive, and their family was left with the difficult decision of what to do. I had one patient who was in her 70s with many comorbidities. She was already bedbound, semi-comatose, and on a chronic ventilator at baseline in her nursing home when she coded for the third time in her life. They were able to achieve return of spontaneous circulation and she was brought to my unit with anoxic brain injury and a Glasgow coma score of 3 (Nguyen et al., 2018). The patient did not have an advanced directive. Her daughter was her healthcare proxy and wanted all life-saving measures to be taken. The other siblings felt that their mother was suffering and tried to convince their sister that they should let their mother go to hospice. We were required by law to follow the daughter’s decision so the patient was full code and received all treatment. She had multiple drug resistant infections for which we tried a variety of antibiotics, a large stage 4 pressure injury that would not heal despite all measures due to the patient inability to heal, sepsis that required pressors and admission to the ICU on and off, kidney failure requiring daily dialysis, heart failure leading to stage 4 pitting edema throughout her body that was unresponsive to medications, frequent mucous plugging that required regular bronchoscopy, and more (Miguel et al., 2018). The ICU doctors, palliative care team, and nurses regularly spoke with the daughter, listened to her concerns, and educated her on how there was no treatment that was working for her mother. In the next 6 months on my unit, she coded several more times and eventually passed away. Including patient preferences and values was not possible due to the patient’s condition, but incorporating the daughter’s values led to continuing all care as described above on a patient that would receive no benefit from continuing care. It prolonged the inevitable result.
The decision aid I selected was “Advanced Care Planning: Should I Stop Treatment That Prolongs My Life?” (healthwise, 2018). It is valuable in how it contributes to effective decision making. First, it has you look at the facts and options regarding palliative and hospice care. It has you compare the options of stopping treatment to focus on pain relief in hospice, or continuing treatment despite side effects. It even has quotes from people who have chosen either side. It then has you rate your feelings on several questions such as whether you feel you have met the goals of your life, if you feel ready to face death, if you feel the treatment is helping you, and more. It then has you rate your decision to continue or stop treatment. At the end, there is a quiz to see if you understand what was discussed, such as understanding that stopping treatment involves focusing on pain relief and comfort through hospice, or that continuing treatment despite the side effects may help you live long enough to achieve any goals you have wanted to achieve.
Our palliative care team in the situation with my patient had gone through the type of questioning present in the decision aid with the daughter. The daughter could not imagine living without her mother and wanted everything done, no matter what the chances were. She was convinced we were all incompetent and uneducated because we were not making her mother better. She understood hospice but said it was for dying people, and that her mother was not dying. In my professional practice, I would certainly encourage patients to use this decision aid. Being told your disease may not be curable is difficult for patients and families, and this decision aid helps organize the main points to consider when deciding to continue or not continue treatment.
References:
Nguyen, K. P., Pai, V., Rashid, S., Treece, J., Moulton, M., & Baumrucker, S. J. (2018). Prognostication in anoxic brain injury. American Journal of Hospice and Palliative Medicine®, 35(11), 1446–1455. https://doi.org/10.1177/1049909118767881
Miguel, N., León, M. A., Ibáñez, J., Díaz, R. M., Merten, A., & Gahete, F. (2018). Sepsis-related organ failure assessment and withholding or withdrawing life support from critically ill patients. Critical care (London, England), 2(2), 61–66. https://doi.org/10.1186/cc127Links to an external site.
healthwise. (2018). “Advanced Care Planning: Should I Stop Treatment That Prolongs My Life?”. . Patient decision AIDS – ottawa hospital research institute. Retrieved February 8, 2023, from https://www.healthwise.net/ohridecisionaid/Content/StdDocument.aspx?DOCHWID=tu1430
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Collapse SubdiscussionCrystal Lewis Hi, Anupa,
Patients may not understand the evidence base underlying the decisions they are being offered. How do decision aids assist with this lack of understanding?
Great post!
Dr. Lewis
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Collapse SubdiscussionMona Bourbour Shirazi Kordi Initial post
Patient preferences and decision making
Patient preferences and decision-making refer to the process by which individuals make informed choices about their health care. This process involves considering personal values, beliefs, and goals in addition to medical information. In the healthcare industry, patient-centered care has become increasingly important in recent years. This means that healthcare providers work with patients to understand their preferences, make informed decisions about their care, and ensure that their values and goals are integrated into their treatment plans. Patient preferences and decision-making can be influenced by a variety of factors, including cultural background, family values, personal experiences, and health literacy (O’Connor et al., 2004).
It is important for healthcare providers to take these factors into account when communicating with patients and helping them make decisions about their care. Effective communication between patients and providers is crucial in this process. Providers should provide clear and concise information about treatment options, risks, and benefits, and encourage patients to ask questions and express their concerns. Patients should also be encouraged to be active participants in their own care, and to take an active role in decision-making (Légaré et al., 2018).
Ultimately, patient preferences and decision-making empower patients to take control of their health and ensure that they receive aligned with their values, goals, and preferences. In my workplace, they involved patients in the care plan. One example of patient involvement in decision-making is shared decision-making (SDM). SDM is a process where healthcare providers and patients work together to make patient treatment decisions. It involves open and transparent communication, active patient participation, and the consideration of the patient’s values, goals, and preferences.
A patient is diagnosed with early-stage breast cancer and needs to make a decision about their treatment. The healthcare provider explains the different options, including surgery, radiation therapy, and chemotherapy. They also discuss each option’s benefits, risks, and side effects.
The provider then works with the patient to understand their goals and preferences. In this case, the patient placed a high value on avoiding surgery if possible and may prefer a less invasive treatment option. The provider takes this information into account and together, they come to a decision that best aligns with the patient’s values, goals, and preferences.
This example demonstrates how patient involvement in decision-making can lead to more personalized and effective care. By considering the patient’s unique circumstances and preferences, the healthcare provider is able to provide care that is tailored to the individual’s needs and goals.
References
Melnyk, B. M., & Fineout-Overholt, E. (2022). Evidence-based practice in nursing & healthcare: A guide to best practice. Lippincott Williams & Wilkins.
O’Connor, A. M., Llewellyn-Thomas, H. A., & Flood, A. B. (2004). Modifying Unwarranted Variations In Health Care: Shared Decision Making Using Patient Decision Aids: A review of the evidence base for shared decision making. Health affairs, 23(Suppl2), VAR-63.
Légaré, F., Adekpedjou, R., Stacey, D., Turcotte, S., Kryworuchko, J., Graham, I. D., … & Donner‐Banzhoff, N. (2018). Interventions for increasing the use of shared decision-making by healthcare professionals. Cochrane database of systematic reviews, (7).
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Collapse SubdiscussionCrystal Lewis Hi, Mona,
What might happen if we do not consider patient preferences or cultural beliefs? Will they be compliant?
Great post!
Dr. Lewis
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Collapse SubdiscussionStephen Chege Response 2
Great post, Mona,
The shared decision between the patients and the medical team is essential. The patient values and beliefs are respected when included in making decisions about their medical care. The medical section also discusses the medical goals with the patients and weighs in the preferences that the patient may have. Adder et al. (2020) emphasize the importance of including the patient in decision-making during admission and collaborating with all the disciplines involved in patient care. Hoffman, Montori & Del Mar (2014) affirms that “Evidenced-Based medicine should begin and end with the patient.”
I witnessed a patient and provider discuss advanced directives. In this situation, the patient had a knee replacement that has dehisced and required the patient to go back to the operating room. In the rehab course, the patient had an episode of Pulmonary Embolism (PE) and Deep Vein Thrombosis (DVT). Due to the medical complications, the patient was a high risk if operated on again. Present at this time were the patient’s son and the rest of the family members in a conference call. This situation stood out because the patient had much to discuss with the family members and even made peace with relatives with whom the patient had differences. The patient agreed to no resuscitation if the surgery is unsuccessful and stated, “it is a win-win situation.”. The circumstances surrounding this discussion were full of emotions; however, it was clear how the patient wanted her care handled if any complications occurred during the surgery. Also, the family seemed satisfied with the decision made.
Reference
Addario, B., Geissler, J., Horn, M. K., Krebs, L. U., Maskens, D., Oliver, K., Plate, A., Schwartz, E., & Willmarth, N. (2020). Including the patient voice in the development and implementation of patient‐reported outcomes in cancer clinical trials. Health Expectations, 23(1), 41–51. https://doi.org/10.1111/hex.12997Links to an external site.
Hoffman, T. C., Montori, V. M., & Del Mar, C. (2014). The connection between evidence-based medicine and shared decision making Links to an external site.. Journal of the American Medical Association, 312(13), 1295–1296. doi:10.1001/jama.2014.10186
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Collapse SubdiscussionJimmy Jesse Ortega Evidence-based medicine (EBM) and shared decision making (SDM) are both essential to quality healthcare. 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). Working in the ICU I experienced many instances where patients were able to incorporate their preferences for treatment, and many instances where they were not able to incorporate their preferences for treatment. One instance that stands out in my mind was when I responded to a rapid response up on the medical/surgical unit for a patient with COVID-19 that was in respiratory distress. He was on the BIPAP machine, unresponsive, breathing 40 breaths per minutes, with an Arterial blood gas reading pH of 6.9. We called his wife to let her know he was not doing good, and despite his wishes to be DNR/DNI, she told us to intubate him. The doctor followed the wife’s wishes and we transferred him to the ICU and intubated him. He did eventually recover and was one of the few patients we were able to extubate and send home during the COVID-19 pandemic. If the patient was responsive, we would have followed his wishes for the treatment plan, and he would have most likely succumbed to the virus. Having a decision aid would have been valuable in this situation because the patient would have been made aware of the pros and cons of intubation vs. non-intubation. This would have allowed the patient to make a better-informed decision regarding his treatment plan. Clinicians and patients/surrogates should use a shared decision-making process to define overall goals of care (including decisions regarding limiting or withdrawing life-prolonging interventions) and when making major treatment decisions that may be affected by personal values, goals, and preferences (Kon et al., 2016). The decision aid I chose was one that helped patients decide if they were going to agree with mechanical ventilation as one of their treatment options. After reviewing the decision aid, 31 participants (94%) reported that they had made a choice, which in 23 cases (74% of those deciding) was to forego MV. These choices were associated with more accurate expectations of MV outcome, and reduced decisional conflict (Wilson et al., 2005). Although it did help many of the patients make a decision, it also did prove to be stressful to the patients. This is good to know, because the nurse or healthcare provider educating the patient can show some compassion and patience for the patient during the difficult decision making process.
References
Hoffman, T. C., Montori, V. M., & Del Mar, C. (2014). The connection between evidence-based medicine and shared decision making. Journal of the American Medical Association, 312(13), 1295–1296. doi:10.1001/jama.2014.10186
Kon, A. A., Davidson, J. E., Morrison, W., Danis, M., & White, D. B. (2016). Shared decision making in intensive care units: An American College of Critical Care Medicine and American Thoracic Society policy statement. Critical Care Medicine, 44(1), 188–201. doi:10.1097/CCM.0000000000001396
Wilson, K. G., Aaron, S. D., Vandemheen, K. L., Hébert, P. C., McKim, D. A., Fiset, V., Graham, I. D., Sevigny, E., & O’Connor, A. M. (2005). Evaluation of a decision aid for making choices about intubation and mechanical ventilation in chronic obstructive pulmonary disease. Patient education and counseling, 57(1), 88–95. https://doi.org/10.1016/j.pec.2004.
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Collapse SubdiscussionMona Bourbour Shirazi Kordi Hi Jimmy,
I enjoyed reading your post and you mentioned great ideas and examples. Patient involvement in the care plan with increase the value and quality of care. The example you made was a great explanation of shared decision-making in the hospital.
References
Hoffman, T. C., Montori, V. M., & Del Mar, C. (2014). The connection between evidence-based medicine and shared decision making. Journal of the American Medical Association, 312(13), 1295–1296. doi:10.1001/jama.2014.10186
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Collapse SubdiscussionMona Bourbour Shirazi Kordi In addition, patient involvement in care plans is an important aspect of healthcare and can lead to improved outcomes and better patient satisfaction. Patients who are active participants in their own care tend to have a better understanding of their health status, treatment options, and the potential risks and benefits of different approaches (Emanuel & Ferris, 2000).
References
Emanuel, L. L., von Gunten, C. F., & Ferris, F. D. (2000). Advance care planning. Archives of Family Medicine, 9(10), 1181.
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Collapse SubdiscussionEsther Davis Hello Jimmy.
Great post. I agree that Evidence based medicine and shared decision making (SDM) are both essential to quality healthcare. EBP should begin and end with the patient. EBP is a patient-centered, holistic, problem-solving approach that combines the best available evidence, clinicians’ expertise, and patients’ values, to optimize patient outcomes ( Cleary & Fineout, 2021).
I have read many articles about Advance Directives (AD) in regard to autonomy and beneficence. Some authors believe in respecting the advance directives while some authors choose beneficence over AD. In this scenario you described, the act of beneficence has overridden the patient preference for directives. This situation had a great outcome because the patient ended up surviving the Covid-19 illness and I am sure his family would be happy at the decision they made even though there was an advance directive for a DNR/DNI.
I believe that when patients make AD in their capable mind, they may not envisage what the future preference might be. One of the ethics of nursing is Benevolence and I think this supports actions taken when a patient might be in need of life saving treatment regardless of their past decision against lifesaving treatment or AD. AD is a legal document which should be honored at all times but in many cases, there is always a conflict between what the principle of beneficence requires and what respect for autonomy requires. (The Principle of Determining Authenticity, 2022). Integrating patients into care teams’ decision-making processes offers clarity in plans of care and desired outcomes which can result in patient and family empowerment (Melnyk & Fineout-Overholt, 2018).
References.
Advance Directives: The Principle of Determining Authenticity. (2022). Hastings Center Report, 52(1), 32–41. https://doi.org/10.1002/hast.1338Links to an external site.
Cleary, H. J., O’Mathúna, D., & Fineout, O. E. (2021). Evidence‐Based Practice Beliefs, Implementation, and Organizational Culture and Readiness for EBP Among Nurses, Midwives, Educators, and Students in the Republic of Ireland. Worldviews on Evidence-Based Nursing, 18(6), 379–388. https://doi.org/10.1111/wvn.12543ClLinks to an external site.
Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice (4thed.). Philadelphia, PA: Wolters Kluwer.
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Collapse SubdiscussionDiana Boreland-Warden Throughout my nursing career I have worked in a range of settings. Each setting includes a melting pot of patients.Each patients background affords the patient the opportunity to make a decision based on the patients interpretation of the knowledge received. Decision making is also dependent on a range of the patients ability to self advocate to patients who needs assistance with advocacy. That being said , I have encountered both pros and cons of patients who are actively involved in their care.
My current practice allows me to work with developmentally disabled patients who function in a mild to profound range. All patients are allowed to make self informed decisions as long as they are deemed capable to provide consent. if the patient is not capable of making decisions on their own a family member may be deemed their advocate or a decision can be made in surrogacy court. A family member or surrogacy court may have limited information in order to make an informed decision. 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, T. C. , Montori , V. & Del Mar , C. , 2014. )
It is widely recognized that best possible clinical care is tailored to individual patient characteristics ( Butler et al , 2028 ) . The use of a decision making aid and health care technology can be beneficial to all parties involved inpatient care. Not only does it promote self independence but also individualization of car. Patients’ participation in decision making in health care and treatment is not a new area, but currently it has become a political necessity in many countries and health care systems around the world ( Vahdat et al , 2014).
References
Butler, E. L., Laber, E. B., Davis, S. M., & Kosorok, M. R. (2018). Incorporating patient preferences into the estimation of optimal individualized treatment rules. Biometrics, 74(1), 18-26. https://doi.org/10.1111/biom.12743
Hoffman, T. C. , Montori, V. M. & Del Mar, C. (2014). The connection between evidence-based medicine and shared decision making Jour of the American Medical Association, 312113), 1295-1296, doi: 10.1001/JAMA.2014.10186 Kon, A. A. Davidson, J. E. Morrison W. Danis, M. & White, D. B. (2016). Shared decision making in intensive care units An American Collee Critical Care Medicine and American Thoracic Society policy statement Critical Care Medicine, 44(1), 188-201
Vahdat, S., Hamzehgardeshi, L., Hessam, S., & Hamzehgardeshi, Z. (2014). Patient involvement in health care decision making: a review. Iranian Red Crescent medical journal, 16(1), https://doi.org/10.5812/ircmj.12454Links to an external site.
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Collapse SubdiscussionAmanda Sutherland Hello Diana, thank you for your post and for drawing attention to the example of patients living with various levels of developmental disability. Many of the patients I care for also have developmental disability and co-occurring mental illness (for example, autism and schizophrenia) with varying decision making capacity.
Patient engagement in care is a goal that has the potential to improve healthcare quality when patients ‘buy in’ to their treatment (Melnyk & Fineout-Overholt, 2018). Many of the examples of patient involvement in care assume that patients have the practical and personal infrastructure available to access their health information in order to make informed decisions, or that they have families or guardians who are engaged in their care who will do so.
In their systematic review of over 100 articles, Grossman et al. (2019) examine interventions to increase patient portal use in vulnerable populations. This is a practical consideration when caring for seriously mentally ill (SMI) patients in the community setting, as they may experience barriers that cause decreased health literacy such as: lack of housing, transportation, a mobile phone, reliable internet access, family involvement, flexible work hours, consistent health insurance, consistent appointment attendance, fluctuations in executive function, and other issues in terms of reviewing their health information so that they are able to incorporate that information as they use patient decision aids.
The authors found that there are well documented disparities in terms of the use of patient information portals, but that systematic research regarding ways to address the disparities is lacking. They found that interventions were mostly directed toward individual patients and that they therefore have the best evidence base for increasing portal use. They note that further research is needed in order to assess the efficacy of portal changes, specific task changes, changes to the care environment, or institutional supports rather than placing responsibility on the individual patient.
References
Grossman,L. Masterson, R., Creber, N., Benda,D. Vawdrey, D., Ancker, J. (2019) Interventions to increase patient portal use in vulnerable populations: A systematic review, Journal of the American Medical Informatics Association, (26), 8-9. https://doi.org/10.1093/jamia/ocz023
Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Wolters Kluwer.
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Collapse SubdiscussionCrystal Lewis Hi, Diana,
How do decison aids stimulate patients to be more active in decision making, without increasing their anxiety?
Good post!
Dr. Lewis
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Collapse SubdiscussionCassie L Bozard Diana,
I enjoyed reading your post!
You brought up a good point about patients that are deemed to not have capacity to make their own medical decisions. Working in behavioral health, I interact with patients that don’t have capacity. Even though they are deemed not to have capacity for medical decision, it is still important to keep them engaged in their day-to-day care. Some of these individuals can still make the day-to-day decisions for themselves. The Mental Capacity Act protects people who may lack the mental capacity to make their own decisions (Nicholson et al., 2008). The act has policies and procedures in place to protect the patient that was deemed incompetent. The Mental Capacity Act outlines the following laws; the person’s past and present wishes and feelings must be considered, the beliefs and values of the patient should be considered as if the patient decision had capacity, and other factors that the patient would like considered if they were able to have capacity (Wade and Kitzinger, 2019). Having these policies in place ensures that all patients are receiving the care desired based on the patients’ values, beliefs, and preferences.
References
Nicholson, T. R., Cutter, W., & Hotopf, M. (2008). Assessing mental capacity: the Mental Capacity Act. BMJ (Clinical research ed.), 336(7639),
322–325. https://doi.org/10.1136/bmj.39457.485347.80Links to an external site.
Wade, D. T., & Kitzinger, C. (2019). Making healthcare decisions in a person’s best interests when they lack capacity: clinical guidance based on
a review of evidence. Clinical Rehabilitation, 33(10), 1571-1585.
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Collapse SubdiscussionChristiana Nuworsoo Initial Post-Patient Preferences and Decision Making
The whole idea of evidence-based practice (EBP) is to use available data to guide decisions that will enhance outcomes for patients and their families. EBP refers to the integration of clinical knowledge, patient values and preferences, and rigorous research to create decisions that improve outcomes for patients and their families (Melnyk & Fineout-Overholt, 2018). Patient-centered care is defined as care that respects and responds to each patient’s unique preferences, requirements, and values while ensuring that patient values inform all therapeutic choices. Therefore, although there are challenges, there is research that proves that patient involvement in clinical decision-making leads to efficient and optimum patient care.
I once encountered a very sad circumstance where the patient’s and family’s priorities differed. The patient had stage four lung cancer, brain metastases, ascites, and intermittent disorientation. His outlook was pretty dismal. The patient requested to be given a do not resuscitate (DNR) order when he was conscious, but his family preferred that he be given a full code. The patient named a family nurse practitioner as his legal power of attorney (POA), and the patient concurred with everything the POA said. To cut a long story short, after he underwent a number of tests and procedures and coded four times in two weeks, the family ultimately opted to give him DNR status when he had to be placed on a ventilator after he coded for the fourth time. The ventilator was turned off once he was declared DNR, and by morning the patient had stopped breathing.
When the POA entered the picture, the patient and occasionally the physicians lost all control. With the clinical team, the POA was adamant about getting her way, thus she anticipated having her requests fulfilled. The patient’s requests should have been considered in order to prevent his suffering and agonizing death, which were out of his control and could have been stopped. I believe the POA’s choices were not rational but rather emotional.
According to Vahdat et al. (2014), patients who participate in their care typically experience better treatment results. In addition, this involvement leads to greater physical functioning in rheumatic diseases, increased patient compliance with secondary preventative measures, and an improvement in the health of myocardial infarction patients (Vahdat et al., 2014).
Patient decision aids (PDAs) were created to encourage patient involvement in the decision-making process and to raise the chances that a treatment choice will be both clinically sound and consistent with the patient’s beliefs (Ankolekar et al., 2018). Any resource whether it be a booklet, website, or application that enables the patient to fully comprehend the range of available treatments and make an informed choice is considered a PDA. A PDA with a good design offers patients balanced information on the advantages and disadvantages of the treatment and can aid patients in recognizing and considering their own preferences (Ankolekar et al., 2018).
In the scenario described above, I think it’s essential to provide both written and vocal information. Additionally, since the patient’s family is involved, it would be advantageous to educate them all rather than enabling one family member, whether a physician or not, to decide on behalf of everyone, including the patient. Verbal information will provide the patient and family with the opportunity to clarify any issues. In the event that the patient and their family require additional information, written information should be given.
It can be challenging to separate emotions from reality when a physician is also a family member, which can either be a benefit or a drawback. Although I would like to believe that the decisions were made with the greatest of intentions, I cannot conclusively conclude that the family member in question made the wrong choice. Furthermore, the person you choose to serve as your POA must be given careful consideration because they may decide whether you depart this world peacefully or painfully. Even if what the patient wants may not be in line with what the family wants, the patient’s voice needs to be heard and taken into consideration.
References
Ankolekar, A., Dekker, A., Fijten, R., & Berlanga, A. (2018). The benefits and challenges of using patient decision aids to
support shared decision-making in health care. JCO clinical cancer informatics, 2, 1-10.
Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice (4th
ed.). Philadelphia, PA: Wolters Kluwer.
Vahdat, S., Hamzehgardeshi, L., Hessam, S., & Hamzehgardeshi, Z. (2014). Patient involvement in health care decision
making: a review. Iranian Red Crescent medical journal, 16(1), e12454. https://doi.org/10.5812/ircmj.12454Links to an external site.
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Collapse SubdiscussionJimmy Jesse Ortega Christiana,
I too encountered a patient’s family member going against their wishes in terms of their treatment plan. Clinicians and patients/surrogates should use a shared decision-making process to define overall goals of care (including decisions regarding limiting or withdrawing life-prolonging interventions) and when making major treatment decisions that may be affected by personal values, goals, and preferences (Kon et al., 2016). By doing this, it is less likely for a family member to go against the wishes of the patient and change the plan of care when the patient can no longer decide for themselves. 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).
References
Kon, A. A., Davidson, J. E., Morrison, W., Danis, M., & White, D. B. (2016). Shared decision making in intensive care units: An American College of Critical Care Medicine and American Thoracic Society policy statement. Critical Care Medicine, 44(1), 188–201. doi:10.1097/CCM.0000000000001396
Hoffman, T. C., Montori, V. M., & Del Mar, C. (2014). The connection between evidence-based medicine and shared decision making. Journal of the American Medical Association, 312(13), 1295–1296. doi:10.1001/jama.2014.10186
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Collapse SubdiscussionJaushai Henry During my nursing career, I worked in oncology and hospice. When an individual has cancer, it is very important to know their culture, and their values of how they would like their treatment. It is important to ask the patient their thoughts, and values to plan a treatment that will be suitable for their life. Chemotherapy can be hard on one’s body and several individuals discontinue chemotherapy, or there may not be able to continue treatment due to progression of their illness, or they might want to take the holistic route instead of being in the hospital or in outpatient clinics. There values and preferences are very essential because they need to be in control of their lives. One article discusses that “It is imperative that we take into account the different patterns of transition and their unique patient and caregiver needs near the end of life” (Norton et al, 2018). I will always incorporate patient values when become a nurse practitioner by always asking my patients what they would want to gain from me being their doctor. Also, the values that are most important to them. I will use those values to establish a treatment plan. “Patient participation is regarded as a legal right of the patient as well as an international gold standard for healthcare systems, and health professionals strive for this standard. Patients must participate in decisions associated with planning, performance, and evaluation of healthcare” (Vahdat et al, 2014).
References:
Norton SA, Wittink MN, Duberstein PR, Prigerson HG, Stanek S, Epstein RM. Family caregiver descriptions of stopping chemotherapy and end-of-life transitions. Support Care Cancer. 2019 Feb;27(2):669-675. doi: 10.1007/s00520-018-4365-0. Epub 2018 Jul 28. PMID: 30056528; PMCID: PMC6338326.
Vahdat S, Hamzehgardeshi L, Hessam S, Hamzehgardeshi Z. Patient involvement in health care decision making: a review. Iran Red Crescent Med J. 2014 Jan;16(1):e12454. doi: 10.5812/ircmj.12454. Epub 2014 Jan 5. PMID: 24719703; PMCID: PMC3964421.
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Collapse SubdiscussionMellissa Rodriguez Jaushai,
great post! You mentioned that you worked in oncology and hospice and that was crucial that you incorporated patients values into their treatment plan. Patient decision aids could play an essential role in a situation as tough as this. In a research study by Mc Alipine et al., (2018), patient decision aids “were superior to usual care for improving the quality of decisions as evidenced by increased patient knowledge, the accuracy of patient risk perception, and decisions congruent with patients’ personal values”. By taking into account patient value and providing them with proper resources and tools such as decision aids we are ensuring that we include them in their own treatment plan as well as ultimately let them decide what decisions will be best for them.
McAlpine, K., Lewis, K., Trevena, L., & Dawn, S. (2018). What is the effectiveness of patient decision aids for cancer-related decisions? Clinical Cancer Informatics. https://ascopubs.org/doi/full/10.1200/CCI.17.00148
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Collapse SubdiscussionAnupa Mukundram Mehta Hi Jaushai,
I enjoyed learning about your experience with oncology and hospice patients. The patient’s values are paramount when deciding when to continue treatment. As a medical step-down nurse, I have also worked in end-of-life situations. When the patient is able to make decisions for themselves, they often choose hospice. Often, family members disagree with that decision. The decision aid on Advanced Care Planning is very relevant to the situations we both experience regarding the decision to continue or withdraw medical treatment (healthwise, 2018). In cases of anoxic brain injury, severe stroke, sepsis, or other conditions, the patient can no longer make decisions, and the family has to decide what would be best (Nguyen et al., 2018). As the nurse I try to support them by understanding their values and educating them on all their options.
References:
Nguyen, K. P., Pai, V., Rashid, S., Treece, J., Moulton, M., & Baumrucker, S. J. (2018). Prognostication in anoxic brain injury. American Journal of Hospice and Palliative Medicine®, 35(11), 1446–1455. https://doi.org/10.1177/1049909118767881
healthwise. (2018). “Advanced Care Planning: Should I Stop Treatment That Prolongs My Life?”. . Patient decision AIDS – ottawa hospital research institute. Retrieved February 8, 2023, from https://www.healthwise.net/ohridecisionaid/Content/StdDocument.aspx?DOCHWID=tu1430
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Collapse SubdiscussionCrystal Lewis Hi, Jaushai,
As you have explored decison aids, share your thoughts as to how decision aids could affect patient satisfaction.
Good post!
Dr. Lewis
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Collapse SubdiscussionAmanda Sutherland Initial Post
During my experiences working first as a nurse assistant and now as a nurse, I have been struck by the differences in the way that patients diagnosed with dementias are regarded versus seriously mentally ill (SMI) patients in terms of their involvement in their own treatment despite similarities in their behaviors. In my experience in general, SMI patients are given many more patients’ rights and autonomy in medical decision-making than patients with dementias: the right to refuse psychiatric treatments if they are not a danger to themselves or others (and sometimes even when they become so), the right to refuse medical treatments even if they are lifesaving like diabetic care, the right to refuse daily hygiene, visits with family members, and daily programming activities. In contrast, patients with dementias were frequently forced to get up, wheeled into the showers to bathe against their will and change clothing, attend daily activities, and take medications, to the point that medications were crushed and fed to them in food without their knowledge.
When my grandmother was diagnosed with Alzheimer’s disease, her doctor and my extended family decided that it would be best not to inform her of the diagnosis because, “she might lose hope.” She died years later never knowing her diagnosis. I have never heard that rationale for not sharing a patient’s diagnosis of schizophrenia or bipolar disorder even though patients with dementias and patients with serious mental illness both have chronic progressive neurological disease resulting in behavioral changes and usually lack insight into the need for treatment. We have laws that protect the rights of institutionalized SMI patients to be involved in treatment decisions, but there is still a paternalistic attitude toward the involvement of institutionalized elders with dementia when it comes to involvement in making healthcare choices.
There are benefits and disadvantages of involvement or lack thereof for both patients and healthcare providers whether the patient suffers from dementia or serious mental illness. It is incredibly difficult to convince a person who does not believe that they are ill to undergo treatment. Does that justify hiding a dementia patient’s medications by crushing them and putting them into food? At what point does medical or psychiatric treatment refusal become self-harm? For example, should bipolar patients be allowed to refuse medications even though it is known that repeated mood episodes cause deterioration over time? Do we as a society have a moral imperative to house unhoused psychiatric patients who might die due to extreme weather even if they are refusing to leave the street to enter treatment? These are frequent ethical dilemmas faced by dementia and mental healthcare providers that do not have easy answers.
When I searched the Ottawa Hospital Decision Aid for Alzheimer’s Disease, there were several helpful links including Alzheimer’s disease: Should I take medicines? As well as Deciding Whether or Not to Stop Driving Following a Diagnosis of Dementia and an article regarding whether or not to undergo genetic testing for late-onset Alzheimer’s Disease. Davies et al. (2019) note that many decision support tools for dementia address single topics even though there is a need to address many interrelated issues. There is an effort to create more decision making tools for mental health, including development of a tool for young adults with first-episode psychosis (Zisman-Ilani et al., 2021). This tool could be helpful to use in practice in order to encourage autonomy and the formulation of a supportive safety plan in case the patient experiences another psychotic episode. I wish my grandmother had had the opportunity to use decision assistance like this while she still was still able to live independently. I think that it might have reduced her anxiety to be able to have a degree of control, knowledge that her path had been traveled by others, and that research exists to assist patients to make the best choice for themselves. She may have felt more empowered and at peace had she been able to educate herself and make a plan before her illness progressed. I think that this tool could be a helpful reference for patients with a family history of the listed conditions to make lifestyle choices to reduce aspects of risk within their control. Knowledge is power and a tool like this gives that power to patients.
References
Davies, N., Schiowitz, B., Rait, G., Vickerstaff, V., & Sampson, E. L. (2019). Decision aids to support decision-making in dementia care: A systematic review. International psychogeriatrics, 31(10), 1403–1419. https://doi.org/10.1017/S1041610219000826
Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Wolters Kluwer.
Zisman-Ilani, Y., Hurford, I., Bowen, A. Evaluating the feasibility of a decision aid to promote shared decision making among young adults with first-episode psychosis: Protocol for a pilot study. Pilot Feasibility Studies 7, 22 (2021). https://doi.org/10.1186/s40814-020-00757-0
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Collapse SubdiscussionEsther Davis Hello Amanda,
I enjoyed reading your post. It’s a practical example but I would also like to share my understanding of both conditions, Alzheimer’s, and schizophrenia. Clinical competence is the ability of a patient(pt) to make decisions related to clinical treatments and research protocols (Moro et al., 2020).
Before any medical treatments, it is necessary that the provider of care ascertain that the pt has capacity to make decisions regarding their care. When this ability declines, there will be a legally appointed representative or power of attorney (POA) who is authorized to make medical or financial decision (Moro et al., 2020). Decisions regarding care can be made in collaboration with the provider. Alzheimer’s and Schizophrenia are common neuropsychiatric diseases but Alzheimer is associated with neurodegenerative disease that advances with age where cognitive function declines and pt is not able to make informed decisions.
In the case of Schizophrenia, improving insight is often a therapeutic target ( Kaneko & Okamura, 2019). Illness management and recovery are part of the treatment plan and goal is successful integration into the community. Their cognitive function and mood are assessed daily and when they are not symptomatic, they are expected to have more insight and judgement into their mental illness.
During our team meeting today at my job, I asked our psychiatrist if it is okay to print the medication list for my bipolar disorder pt that was requesting for it. I asked this question because of my concerns. Answer was yes, and to my dementia pt, no. My dementia pt has memory loss, she is very confused, forgetful, and intrusive. My schizophrenia pt acts out his behavior which we were able to manage with PRNs. I believe I have a reason to agree when decisions regarding care were not shared in the situation you described but is this a patient-centered care?
Patient centered care is respectful, responsive and guides all clinical decisions (Melnyk & Fineout-Overholt, 2018). Clinicians should not think for the patient as to their desire for physical or psychological care need, but I see this as common in practice. Is this a patient-centered care?
References
Cui, Z., Meng, X., Zhuang, S., Liu, Z., Zhou, F., &Tian, Y. (2020). Schizophrenia, Bipola Disorder, and Alzheimer’s Disease are not Causal Factors of Bone Mineral Density: A mendelian Randomization Analysis. Calcified Tissue International, 106(2), 131-146. https://doi.org/10.1007/s00223-019-00625-xLinks to an external site.
Kaneko, F., & Okamura, H. (2019). Discrepancies between Self and Clinical Staff Members Perception of Cognitive Functioning among Patients with Schizophrenia Undergoing Long-Term Hospitalization. Occupational Therapy international. 1-10. https://doi.org/10.1155/2019/6547096
Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Wolters Kluwer.
Moro, v., Valbusa, V., Corsi, N., Bonazzi, A., Condoleo, M.T., Broggio, E, & Gambina, G. 92020). Comprehension of written texts for the assessment of clinical competence and decision making in people with mild to moderate Alzheimer disease. Neurological Sciences. 41(5), 1225-1231. https://doi.org/10.1007/s10072-019-04228-0Links to an external site.
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Collapse SubdiscussionMellissa Rodriguez Incorporating patient preferences and values into their treatment plan is crucial. Patients in any type of healthcare setting may be in a vulnerable spot and it is imperative that we as nurses consider their values and opinions in their treatment plan to ensure positive patient outcomes and positive patient experiences. “Shared decision making is the process of clinician and patient jointly participating in a health decision after discussing the options, the benefits and harms, and considering the patient’s values, preferences, and circumstances”. (Hoffman et al., 2014).
One situation I experienced in which incorporating a patient’s preference opted for a positive experience smooth transition from their treatment plan to their discharge was with a patient who was admitted for asthma exacerbation. Patient was requiring oxygen, but the patient was adamant about going home. The patient was refusing medication and simply did not want to be in the hospital. As a result, he was developing anxiety and becoming more non-complaint. We did not feel it was safe for the patient to go home and would essentially be leaving AMA, so the team decided to intervene, have a stern one to one with the patient and get the physician in the room, get all concerns and questions answered. We talked to the patient, and collaborated as a team, incorporating the patients’ thoughts and opinions and were able to come to an agreement. The patient was under the impression he would need to stay for a few days and did not want to miss the birth of his son but the physician cleared up that he only needed to stay if he was requiring high amounts of oxygen. The patient was now at ease, compliant and ended up being discharged the following day.
Including patient preferences impact the trajectory for the situation because patients who are not in agreement with their treatment plan do not result in positive outcomes. Patient will be upset, non-compliant, and develop stress and anxiety if they feel they are not being heard. On the other hand, if you communicate and include patients in their treatment plan, they are more likely to trust you and comply with the plan, resulting in happy patients. Furthermore, patient decision aids are able to play a role in patients’ knowledge and understanding of their own treatment plan. “Patient decision aids are tools that help people become involved in decision making by making explicit the decision that needs to be made, providing information about the options and outcomes, and by clarifying personal values” (The Ottawa Hospital Research Institute, 2019). In my experience, that same upset, non-complaint patient could use a decision aid to see the benefits of staying the night in the hospital greatly outweighing the cons of him leaving against medical advice.
References
Hoffman, T. C., Montori, V. M., & Del Mar, C. (2014). The connection between evidence-based medicine and shared decision making Links to an external site.Links to an external site.. Journal of the American Medical Association, 312(13), 1295–1296. doi:10.1001/jama.2014.10186
The Ottawa Hospital Research Institute. (2019). Patient decision aids Links to an external site.Links to an external site.. https://decisionaid.ohri.ca/
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Collapse SubdiscussionJimmy Jesse Ortega Mellissa,
I strongly agree with you that incorporating patients in their treatment plan is essential to ensure that the best healthcare is being provided. Without the patients input or involvement, patient care cannot be patient centered. 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). In the critical care unit, patients are often times unresponsive or unable to make decisions for themselves. This has led to many patients family members making decisions for them that go against what they would want as their treatment. Clinicians and patients/surrogates should use a shared decision-making process to define overall goals of care (including decisions regarding limiting or withdrawing life-prolonging interventions) and when making major treatment decisions that may be affected by personal values, goals, and preferences (Kon et al., 2016).
References
Hoffman, T. C., Montori, V. M., & Del Mar, C. (2014). The connection between evidence-based medicine and shared decision making. Journal of the American Medical Association, 312(13), 1295–1296. doi:10.1001/jama.2014.10186
Kon, A. A., Davidson, J. E., Morrison, W., Danis, M., & White, D. B. (2016). Shared decision making in intensive care units: An American College of Critical Care Medicine and American Thoracic Society policy statement. Critical Care Medicine, 44(1), 188–201. doi:10.1097/CCM.0000000000001396
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Collapse SubdiscussionSheena Grays Patient Preferences and Decision Making
Involving the patient in the decision-making process for medical treatments has always been the primary focus of patient-centered care (Melnyk & Fineout-Overholt, 2018). Current studies show the advantages of utilizing patient participation in decision-making and state how it increases patient satisfaction and outcomes (Why patient-centered care is so important, 2022). Involving patients in the decision-making process has also been shown to reduce costs for patients and healthcare facilities and improve the quality of care. Patient decision-making is a crucial factor in overall treatment planning (Why patient-centered care is so important, 2022). The patient-centered care model states, “Patients should always be in complete control when it comes to making decisions about their care and treatment” (Why patient-centered care is so important, 2022). Furthermore, patients should completely comprehend the procedures and treatments they may experience. At the same time, clinicians must educate the patient and family and make them as comfortable as possible. However, there are some circumstances where utilizing patient decision-making and evidence-based practice may not line up, but as clinicians, we must value the patient’s wishes (Melnyk & Fineout-Overholt, 2018). In my experience of working on the medical-surgical unit, I remember utilizing patient preferences and values in their treatment plan. A symptomatic patient needed a heart catheterization. It was then revealed that a pacemaker was necessary. Once the patient received the results, the patient became very emotional and unsure of how to proceed. I offered support and allowed the patient to express her feelings towards the procedure. After listening to the patients’ point of view, it was determined that the patient required more information and education on the subject matter. As the nurse, I educated her on the reasoning for the pacemaker and how it would aid in her quality of life. The patient had many questions regarding the procedure. Furthermore, I provided her with educational handouts regarding pacemakers and gave her time to think about it and discuss options with her family (Patient Decision Aids – Ottawa Hospital Research Institute, 25). After providing education and reassurance, the patient decided that the procedure was the best thing she could do for herself and her family and voiced her appreciation for supporting her decision. The patient decision aid I selected was Heart Rate Problems: Should I Get a Pacemaker? (Patient Decision Aids – Ottawa Hospital Research Institute, 25). The chosen patient aid aims to provide information to parties that may be thinking about getting a pacemaker, provide resources and possible options, and answer any common questions. Additionally, I do believe that the use of a patient decision aid would have benefited this patient by decreasing her anxiety related to the procedure and providing her with the latest resource of information, in the beginning to assist her in making a conscious decision (Patient Decision Aids – Ottawa Hospital Research Institute, 25).
References
(25, 2). Patient Decision Aids – Ottawa Hospital Research Institute. https://decisionaid.ohri.ca/Links to an external site.
Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice. Lippincott Williams & Wilkins.
Why patient-centered care is so important. (2022, October 5). Wolters Kluwer – Combining Domain Expertise With Advanced Technology | Wolters Kluwer. https://www.wolterskluwer.com/en/expert-insights/why-patientcentered-care-is-so-important?Links to an external site.
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Collapse SubdiscussionAnupa Mukundram Mehta Hi Sheena,
Nice post. I agree that patient-centered care, in which the patients are given knowledge about their condition and fully understand their options, is crucial to patient safety and modern medicine. Unfortunately, in my experience, the patient is often in a condition in which they can no longer make decisions for themselves; this leaves their remaining family with the difficult decision of deciding what they would have wanted (Miguel et al., 2018). We educate the family just as we would the patient and help them understand all aspects of the condition so they can make the best decision. A relevant decision aid is the Advanced Care Planning tool to help decide whether to continue treatment that may or may not prolong life (healthwise, 2018).
References:
Miguel, N., León, M. A., Ibáñez, J., Díaz, R. M., Merten, A., & Gahete, F. (2018). Sepsis-related
organ failure assessment and withholding or withdrawing life support from critically ill patients. Critical care (London, England), 2(2), 61–66. https://doi.org/10.1186/cc127Links to an external site.
healthwise. (2018). “Advanced Care Planning: Should I Stop Treatment That Prolongs My Life?”. . Patient decision AIDS – ottawa hospital research institute. Retrieved February 8, 2023, from https://www.healthwise.net/ohridecisionaid/Content/StdDocument.aspx?DOCHWID=tu1430
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Collapse SubdiscussionCrystal Lewis Hi, Sheena,
Have you had access to any of the decison aids we reviewed this week? Excellent example!
Dr. Lewis
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Collapse SubdiscussionSheena Grays Hello,
Unfortunately, in my experience, I have not had any access to the patient decision aids that we have discussed. In places where I have worked, we utilized the patient education that was incorporated into our electronic medical record system (EMR). Within the EMR, we would select the health issue the patient was experiencing, and then the system would connect us to a credible site where we could print off health education to provide to the patient. This was very helpful because the information was in great detail, and the information could be printed out in any language.
References
(25, 2). Patient Decision Aids – Ottawa Hospital Research Institute. https://decisionaid.ohri.ca/Links to an external site.
Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice. Lippincott Williams & Wilkins.
Why patient-centered care is so important. (2022, October 5). Wolters Kluwer – Combining Domain Expertise With Advanced Technology | Wolters Kluwer. https://www.wolterskluwer.com/en/expert-insights/why-patientcentered-care-is-so-important?
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Collapse SubdiscussionJasmine London The incorporation of patient’s values and preferences is an essential part of patient centered care. Patient preferences in treatment and healthcare decisions are influenced by religious and spiritual values, personal priorities and beliefs about health (Armstrong & Mullins, 2017). Often times, healthcare providers do not take patients’ values into account because of barriers such as time constraints, sociocultural influences and previous knowledge (Armstrong & Mullins, 2017). I have been in scenarios where I had to prioritize a patient’s preference in their care. I had a patient recently diagnosed with diabetes type 2 and had developed DKA. The diagnosis was all really new to her and she was very overwhelmed with all the information she was consuming. As her nurse, I included her in the assessment and interventions by speaking with her regarding her wants in regards to her care. She expressed that she really didn’t want to start using insulin even though the physicians had ordered it for her. I explained to her that it would take lifestyle changes but she can control it through diet, exercise and oral medications. The physicians were now aware of the patient’s preferences and were able to act according to what the patient wanted.
The patient decision aid are tools that help patients in making decisions by providing information on options and outcomes, and clarifying personal values (Melnyk & Fineout-Overholt, 2018). I chose the Ottawa Personal Decision Guide which is designed for any health related decision. It is essential to helping people plan next steps, track their progress and share their views about their decision. This tool aims to help patient’s make decisions that they are comfortable with (The Ottawa Hospital Research Institute, 2019). Healthcare organizations should adopt decision aids because it can provide direction for selecting interventions to meet patients values.
Armstrong, M. J., & Mullins, C. D. (2017). Value Assessment at the Point of Care: Incorporating Patient Values throughout Care Delivery and a Draft Taxonomy of Patient Values. Value in Health, 20(2), 292–295. https://doi.org/10.1016/j.jval.2016.11.008
The Ottawa Hospital Research Institute. (2019). Patient decision aids.https://decisionaid.ohri.ca/Links to an external site.
Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice. Lippincott Williams & Wilkins
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Collapse SubdiscussionCrystal Lewis Hi, Jasmine,
As you have explored decison aids, do you believe decision aids have any impact on patient satisfaction? Why or why not?
Great post!
Dr. Lewis
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Collapse SubdiscussionCheron Massonburg In my care setting, a patient came to the hospital complaining of dizziness. She was diagnosed with HBP. The nurse in charge of the patient included her in the assessment and treatment of the illness. After diagnostic results came out, the nurse discussed with the patient the results, and together they developed a treatment plan. Incorporating patient values and preferences profoundly helped the nurse tailor intervention for the disease. For instance, the nurse and the patient agreed that the patient would be exercising a least three times a week and would eat a balanced diet in a move to curb the disease.
Engaging the patient in the treatment plan increased her satisfaction towards the nurse and the intervention.The patient’s values and preferences impacted the course of this situation. The first impact of the incorporation of the preferences into treatment plan is improved quality of clinical intervention. The nurse was able to develop a response that enhances the patient outcome (Kon et al., 2016). Another impact is about the efficiency of the treatment. The patient happily followed the prescribed medication because she was consulted before the prescriptions given to her. Lastly, she took long to come back to the hospital with regards to HBP. In other words, the strategy reduced hospital readmission (Schroy et al., 2014).The decision aid used in this scenario was the Ottawa Personal/Family Decision Guides(OP/FDG). This model was valuable because it helped the nurse together with the patient to make either social or heath decision (Melnyk & Fineout-Overholt, 2018). The tool was also helpful because it helped the patient decide the next step about their health. I can use this tool in my professional development by planning goals.ReferencesKon, A. A., Davidson, J. E., Morrison, W., Danis, M., & White, D. B. (2016). Shared decision making in intensive care units: An American College of Critical Care Medicine and American Thoracic Society policy statement. Critical Care Medicine, 44(1), 188-201.doi:10.1097/CCM.0000000000001396Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Philadelphia, PA: Wolters Kluwer.Schroy, P. C., Mylvaganam, S., & Davidson, P. (2014). Provider perspectives on the utility of a colorectal cancer screening decision aid for facilitating shared decision making. Health Expectations, 17(1), 27-35. doi:10.1111/j.1369-7625.2011.00730.x
