Monday, November 07, 2016

What is Informed Decision Making?

One of the main constructs on which I have based my entire career, is informed decision making or informed consent.  What that means to me as a nurse, childbirth educator and doula is that I will, to the best of my ability, give to my client(s) understandable, current, accurate evidence-based information on a variety of topics pertaining to their impending childbirth experience.  I make it my job to empower them to understand completely and have an appreciation of the facts, implications and possible future consequences of their decision(s). 

In order for a person to be ready for informed decision making, they must first have the evidence-based information, be able to ask questions freely in a non-judgmental and unbiased environment, be able to list the pros and cons, discuss these findings not only with their support team but also their health care provider, have
time for their decision to be pondered, and then implemented.

Based on the many acronyms for informed decision making from BRAND (Benefits, Risks, Alternatives, Nothing, Decide) to BRAIN (Benefits, Risks, Alternatives, Instinct, Now decide), clients can get their information and study that information.  Ideally, the nurses and health care providers are responsible for obtaining the decision or consent; the consent must be informed, voluntary and not obtained through misrepresentation. Along with the ability to make this informed decision is also the right to the information necessary to refuse care – the implications of the right to refuse must also be clearly understood by the client.  According to the Health Care Consent Act of 1996 (Ontario, Canada), “medical care is wrongful and “battery” unless the patient has given consent to it.”

Consent must also be free from bias in that health care professionals should be insightful as to the power of their persuasiveness in either word, voice inflection, facial expression or presentation.  As mentioned in the ACOG Committee Opinion 439 (original date August 2009, reaffirmed 2015), “care should be taken that the physician’s perspectives do not unduly influence a patient’s voluntary decision making”.

Good communication is key to the success of informed decision making.  Collaborative relationships between expectant clients, nurses, physicians, midwives, childbirth educators, doulas and lactation consultants are unique and specifically designed for a central focus – optimum birth outcomes. Ongoing communication must be clear, distinct and respectful, focusing on the patient-centered care and impact on the mother/baby dyad.  To ensure that these collaborative relationships are powerful and serve the expectant client, the Institute of Medicine defines quality of care that improves outcomes  with Six Aims:

1. Safe – avoiding injuries to patients from the care that is intended to help them.
2. Effective – providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and over use).
3. Patient- centered – providing care that is respectful of and responsive to individual patient preferences, needs and values and ensuring that patient values guide all clinical decisions.
4. Timely – reducing waits and sometimes harmful delays for both those who receive and those who give care.
5. Efficient – avoiding waste, in particular waste of equipment, supplies, ideas and energy.
6. Equitable – providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socio-economic status.

For childbirth educators and doulas, nurses, lactation consultants, and midwives, our knowledge of the aspects of quality of care is imperative to drive the informed decision making.  Especially with doulas and childbirth educators who are often the “first responders” with whom expectant parents interact, we must stay focused on the latest information, what is and is not evidence based, and be able to respond to our clients’ needs for informational resources.  We cannot sit on our laurels and expect someone else to take up the mantel and provide our clients with information.  If our clients hear information multiple times from multiple sources, then so be it!  They will know that those sources are quality sources that can be trusted.

Study after study has proven that respectful care, and respect for decision making can improve birth outcomes and satisfaction.  And we as birth professional must continue to ask the hard questions about the iatrogenic rise in interventions, including cesarean section as compared to the rise of maternal/infant morbidity/mortality.  We must take care that there is not disconnect in the communication and care continuum.

For further review:

AWHONN: Women’s Health and Perinatal Nursing Care Quality Draft Measures Specifications
Health Care Consent Act 1996 

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