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
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).
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:
ACOG Committee
Opinion 439
http://www.acog.org/-/media/Committee-Opinions/Committee-on-Ethics/co439.pdf?dmc=1&ts=20150309T0843479479
http://www.acog.org/-/media/Committee-Opinions/Committee-on-Ethics/co439.pdf?dmc=1&ts=20150309T0843479479
AWHONN: Women’s
Health and Perinatal Nursing Care Quality Draft Measures Specifications
https://c.ymcdn.com/sites/www.awhonn.org/resource/resmgr/Downloadables/perinatalqualitymeasures.pdf
https://c.ymcdn.com/sites/www.awhonn.org/resource/resmgr/Downloadables/perinatalqualitymeasures.pdf
Health Care Consent Act 1996 https://www.ontario.ca/laws/statute/96h02
IOM Six Aims:
Crossing the Quality Chasm
https://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf
https://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf
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