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.
Personal experience with patient impact
I recently worked with an African female patient experiencing catatonia. She was not overly responsive to medications, so our next action plan was to incorporate electroconvulsive therapy (ECT). The patient could not make her own decisions, so we included her family members and husband as decision-makers. Her husband was informed of multiple options and provided education on ECT, ultimately deciding ECT was her best option, but due to cultural reasons, he was hesitant. She later had numerous family members visiting, encouraging her not to participate in the therapy or take medications because of their cultural beliefs. As a treatment team with her husband, we ultimately had to refrain family members from visiting because they impacted the patient. She eventually received ECT treatments and improved significantly from her catatonic state. It was a difficult decision for her husband to make, and it was difficult to keep family from visiting because of how important family is to her culture. While the family is an essential aspect of her life, we could provide quality, effective care the patient needs for recovery by restricting visitation.
Patient values and preference
Evidence-based medicine should be reflective of shared decision-making to improve the quality of healthcare. Decisions should reflect the patient’s values and circumstances (Hoffmann et al., 2014). While we provided opportunity for shared decision-making, her cultural beliefs became an obstacle when her family told her not to comply. We ultimately improved her healthcare outcome by improving her compliance with the treatment. It was important to incorporate her husband’s preference. ECT was ended early because the patient had exhibited improvement, and the patient could provide some insight. The treatment team provided care through patient-centeredness, which took into consideration the preference and values of this patient once she was more coherent in providing her opinion (Melnyk & Fineout-Overhold, 2018).
Decision aid inventory
The decision aid I decided to use was the Continue, adjust, or stop antipsychotic medications: Developing and user testing an encounter decision aid for people with first-episode and long-term psychosis. This patient suffered from chronic mental health issues, including psychosis. She had multiple life stressors and was noncompliant with medication. Through education efforts, we were able to provide the ECT treatments this patient needed for improvement. Her husband was very skeptical and unsure, but after proper medication and collaboration with healthcare staff, he identified her best interests and pursued treatment, despite her family’s beliefs. This encounter decision aid (EDA) provides patients and family members with information associated with their chronic psychosis about the importance of medication adherence and the potential side effects of abruptly discontinuing (Zisman-Ilani et al., 2018).
Introduction
Shared decision making is when the clinician and the patient work together by discussing options, the benefits and harms while considering the patient’s values. SDM is what links effective communications skills with the patient and EBM. (Hoffman et al 2014).
In this discussion, I am going to present a hypothetical patient having some similarities with the patients I encounter daily at work and how patients’ preferences might or might not affect their treatment.
Patient Experience encountered
Working in an inpatient psychiatry unit, we encounter patients in crisis and some having a psychotic breakdown. Some months back, we had a 59-year-old lady, Mrs. Maposa, (not her real name nor actual age), who had recently lost her husband of 30 years. Mrs. Maposa was grieving and did not want to eat or take care of herself, she lost weight, stopped taking her anxiety and depression medications, neglected her pets and her house became a mess. Family members and friends tried to encourage her to resume her medications and she simply could not hence the psychotic breakdown. Finally, the family and friends called the crisis center due to the patients’ deterioration and an involuntary commitment was initiated (302) due to patient being a danger to herself, poor self-care and endangering her own pets. (Parker et al 2020)
The first few days after admission into the behavioral health unit, Mrs. Maposa declined any kind of assessment, declined to talk to the doctors or anyone in the treatment team. Mrs. Maposa did not shower or perform hygiene, and her body odor worsened. She refused any offer for meals and only drank one packet of milk and 2 small juices a day.
At the end of the 302-involuntary commitment, which is the 5th day (120 hours), Mrs. Maposa had a Psychiatric Mental Health Hearing and was committed to a period not exceeding 20 days. (303-involuntary commitment). The attending Psychiatrist, Mrs. Maposa’s eldest Son and daughter both who lived out of state testified and confirmed that their mom needed treatment.
The attending doctor ordered inpatient psychiatric consultation, (second opinion), for medication over objection. On the same day, another psychiatrist reviewed Mrs. Maposa and a determination was made to restart Mrs. Maposa’s antidepressants and antianxiety medications with an alternative to get an injection if Mrs. Maposa refused to take her oral medication.
Within 3 days of restating her medication, Mrs. Maposa showed improvement, showered, and even ate a decent meal. Mrs. Maposa started attending therapeutic groups, and even talked to a few peers in the unit. By the end of the week, she had regained her insight and was visited by her family and plans were started on when to discharge her back home with helpful resources.
Incorporating or not incorporating patient preferences and values and the Impact on the outcome of patient’s treatment plan.
On admission, Mrs. Maposa was not cooperating with the treatment options she was being provided with and was not in the mental capacity to make a rational decision. The death of her beloved husband made her stop caring for herself and it took the intervention of her loved ones and friends to seek help even if she did not want it herself.
Fortunately, her children were on board with the treatment plan, and this made it possible for the proper intervention to be implemented and as much as it might have been against the patient’s preference, the result was acceptable.
Patient preferences and values and how they might impact the trajectory of the situation.
The patient was in a helpless, hopeless state and had given up as evidenced by poor self-care and no regard for her wellbeing and that of her pets. Had she been left like that; her state would have deteriorated further with worst case scenarios including being suicidal and or attempting suicide. This is why her loved ones and the treatment team intervened to give her the help she needed. This is why it is important for clinicians and patients/surrogates to use a shared decision-making process that is well defined with overall goals of care for the patient. (Kon et al 2016).
Decision Aid
Antipsychotic Medication Decision Aid.
I selected this Decision Aid because it aligns with the patient’s significant others decision for their loved one, who in this case is their mother. (Zisman-Ilani et al 2018).
This decision aid identifies the fact that not all patients need to be on antipsychotics forever, for someone having acute psychotic breakdown like Mrs. Maposa, started adjusting and even stopping some antipsychotics like the injectables for Mrs. Maposa is a wonderful way to get patient adherence to treatment.
All these years I have been working in the inpatient psychiatry unit, we have been using this model and I did not even know that it existed. I am glad and ready to embrace it in my daily work and disseminate it to my colleagues.
In conclusion, the quick and collaborative response of the family, friends and the treatment team helped restore Mrs. Maposa back to her normal state and she was discharged stable enough to resume her usual activities in the community.
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.
In our assisted living we have a resident who was at high risk for falls due to diagnosis, medication, and use of a walker. She had 6 falls in three months. As her nurse, I looked at each fall, the time it took place, what she was doing, and what fall interventions we had put in place. Out of the 6 falls, five of the falls took place right before dinner and she was getting ready to ambulate down for dinner. A meeting was set up with her primary physician, her POA, (her niece), and myself. We discussed the falls and asked the resident what she thought she needed from us to be safe. The resident explained that she was feeling weak, and not as strong as she had been. It was discussed that her four-wheeled walker often rolled away from her and that a fall intervention had been put in place for education regarding the walker and keeping it close, however, the walker rolling ahead of the resident while ambulating and had been the cause of two falls. The resident was asked about using a front-wheeled walker instead. She did not like this idea. Her primary physician educated her on the risks and benefits of the front-wheeled walker and her overall safety. Her primary physician asked her if she would try it and work with PT on ambulation and exercises to strengthen her muscles. The resident thought that this could help and was open to trying it. Her primary physician put in a referral for PT to evaluate and treat the resident. The resident was asked how she felt about having staff walk with her to meals at the dinner hour until she felt stronger. The resident liked this idea. The resident’s niece brought a front-wheeled walker in for the resident and took the four-wheeled walker home. Nursing coordinated her appointments, updated her care plans, and educated staff on new interventions for the resident.
Then, explain how including patient preferences and values might impact the trajectory of the situation and how these were reflected in the treatment plan.
In this situation, the resident was identified to be at risk. The resident needed to be in control of her treatment plan, but she also needed the knowledge and evidence-based practice to make informed decisions for herself. By incorporating the patient and her primary care provider along with the people in her life who took care of her, the team was able to apply knowledge and visit with her about her personal preferences, to provide the best possible care (Melnyk-Overholt, 2018). By including the primary care physician and family, the nurse was able to have an impact on the treatment plan, with the resident’s response enhancing her own outcome (Kon et al., 2016). The risk of the resident not being educated could result in a fall causing significant harm or even death. A fall could also result in a hospitalization, but with her care team looking at her care and her safety, this helped in possibly reducing hospital admission (Schroy et al., 2014).
Finally, explain the value of the patient decision aid you selected and how it might contribute to effective decision-making in general and in the experience you described. Describe how you might use this decision-aid inventory in your professional practice or personal life.
A decision aid that I found useful was the Ottawa Personal/Family Decision Guides. This tool helps guide the nurse and the resident to make health decisions (Melynk & Overholt, 2018). This tool will help with my professional practice by using the evaluation tool kit to help guide decision-making and provide any barriers that may need to be looked at.
Importance of Shared Decision Making (SDM)
Shared decision making (SDM) is an important aspect of planning and coordinating patient care. Through SDM, patients and families have the opportunity to obtain and process information regarding their diagnosis and treatment. Patient involvement in the decision-making process is a critical component of patient centered care. As stated by Hoffman, Montor and Del Mar (2014), even if providers attempt to incorporate patient preferences into the decision-making process, they sometimes guess them wrong. Therefore, SDM should occur as often as possible when making critical care decisions.
Personal experience with SDM
One personal experience that comes to mind when I think about SDM occurred in the ICU. We had a young individual with a poor prognosis after cardiac arrest. The nurses, myself included, tried our best to educate and comfort the family. We held multiple family meetings in which we discussed the family’s wishes, the patient’s prognosis, and the (limited) treatment options. After months of weekly or biweekly family meetings and discussions regarding the patients care, the family came to a consensus, and we proceeded as they wished. The whole situation was honestly very sad.
In cases such as this, I always wish that everyone had an advanced directive so that we could know how to proceed and what their wishes are. Of course, that’s not always the case, especially with younger individuals. I believe that in this scenario, we respected the family’s wishes, and the plan of care was carried out per their request.
Decision Aid
The decision aid I chose was an ICD decision aid. Whether or not to get an ICD is a big decision to make for heart failure patients. The ICD decision aid chosen is available in video or booklet form, in both English and Spanish. It contains really great information about what an ICD is, why it has been recommended, and statistics on post implantation complications (Implantable Cardioverter Defibrillator [ICD] – Colorado Program for Patient Centered Decisions, 2019). This is valuable because it gives the patient something to keep and review during the decision-making process. They may want to share it with their family, so that everyone is on the same page.
In summary, SDM should be part of all critical care decisions. Including patients and families in the decision-making process can lead to more optimal health outcomes including less anxiety, quicker recovery, and increased compliance with recommended treatment (Shared Decision-Making, 2012). Resources such as decision aids should also be used whenever possible, as it gives patients and families something to review and use during the decision-making process.
As a registered nurse working with the younger population in behavioral health, there are instances where they are too young to make their own decision, one was a five-year-old kid who was normally aggressive to staff without reason due to being idle on the unit, he usually would tear up the unit because he was bored. I was able to talk with the doctors to enable the child to have some kind of incentive on the unit, this might allow the child something to do and be less aggressive to staff members. The incentives were agreed by the doctor, and this made a different in the patient life. One of the incentives was to allow patient extra sleep time in the morning to prevent aggression in the morning, also allow the use of coloring and games extra time for the kid as well. As nurses, our focus is on improving the well-being and comfort of our patients, including decreasing patient length of stay, decreasing risk of infections, and preventing pressure ulcers. As NPD practitioners, calculating the financial impact of educational interventions by measuring the outcomes can change the perspective of organizational leaders toward education from one of activities to meaningful accomplishments with great benefit to the organization (Opperman et al., 2016).
The patient treatment plan was impacted because within a two -week period of using the incentives for the five-year-old kid. We were able to see less aggression on the unit and better behavior by the kid. Evidence shows user-centered design approaches lead to higher-quality interventions, increased user acceptance, and improved efficiencies due to the early identification and rectification of usability problems before the launch of the intervention (Hussain et al.,2022).
The use of educational literature plays a role in patient decision making. I have seen this method effectively inform and encourage patient to making decisions that affect their lifetime. I love reading educational literature and have used it in many personal areas of my life. By building a realistic, collaborative maintenance plan with patients, goals can be reached with confidence and control. For the practitioner, utilizing appointment times for a better purpose ensures a holistic approach alongside patient compliance with every encounter. For the service, waste is reduced, variation considered, and non-attendance appointments reduced (Lawrence,2022).
Patient-centered care concept emphasizes the importance of including patient preferences, beliefs, and values when providing care. Notably, some patients today already understand their role in their care when they visit a healthcare facility. Some know they have the right to refuse treatment (Bombard et al., 2018). In this respect, healthcare providers should always involve patients in decision-making regarding their care to achieve the desired treatment outcomes.
A once-experienced situation involved a 78-year-old white male with Alzheimer’s disease. After evaluating the patient, it was established that his symptoms could best be managed using a combination of pharmacological and psychotherapy interventions. The choice of therapeutic interventions must always be supported by research evidence, and published literature supports the use of pharmacological and psychological interventions in managing symptoms of Alzheimer’s disease (Blackman et al., 2021; Melnyk & Fineout-Overholt, 2018). However, the patient did not want to use medications, indicating that they are associated with adverse side effects. While incorporating the patient’s preferences, I helped him understand the benefits of medications and psychotherapy. I even guided him on what to do if he experiences side effects after using drugs (Hoffmann et al., 2014). Incorporating patient preferences and values positively affected the treatment plan and the trajectory of the situation. For example, the patient agreed to use medication, which was reflected in the treatment plan.
The use of patient decision aid enhances clinical decision-making and leads to positive health outcomes for patients. The chosen patient decision aid is “Alzheimer’s disease: should I take medicine?” This decision aid might contribute to effective decision-making in general and in the scenario described by guiding the clinician to treat Alzheimer’s disease using medicine when they are considered helpful. The clinician can also use other interventions to reduce confusion and improve memory (Ottawa Hospital Research Institute, 2022). The nurse will use this decision-aid inventory in professional practice when treating Alzheimer’s disease patients whose symptoms are interfering with daily living.
Providing patient-centered care entails interventions aimed at restoring a patient’s health by empowering him as a self-managing person and enabling him to take responsibility for his wellbeing (Lipovetski and Cojocaru, 2019). It is essential that patients are involved in their treatment plan. Including patients in their treatment plans gives them the opportunity to contribute to their own health care decisions. A patient’s involvement in the treatment decision-making process enhances health outcomes, improves compliance with the treatment regimen, and improves the quality of life of the patient.
The psychiatric facility where I work encourages patient participation in the treatment plan and allows them to participate in the decision-making process regarding their healthcare. The treatment team consists of multi-disciplinary healthcare professionals who are responsible for developing comprehensive treatment plans for each patient. Among the members of the treatment team, you will find a psychiatrist, a medical doctor, nurses, social workers, dieticians, advanced practice psychiatric nurses, psychologists, and patient advocates. Every morning, the team meets in collaboration with patients to evaluate their treatment progress and to make clinical decisions aimed at improving their health outcomes.
One of the experiences I had, involved a patient with bipolar disorder who refused to comply with his medications and unit activities despite extensive counseling by the nurses. The patient remained selectively mute and was always found in his room, not interacting with those around him. During the treatment team meeting, the patient alleged that he was sexually abused by one of his peers and was threatened never to speak out. As a result, the patient suggested that he should be moved to another unit where he would feel more comfortable. An investigation was conducted in order to find out what had truly happened. As a result, the perpetrator was returned to jail, and the patient (victim) was transferred to a different unit. This issue was appropriately addressed, and the patient was satisfied with the outcome. The patient felt safe once again and was more compliant with his medications as well as the daily activities of the unit.
By taking into consideration the patient’s preference for being transferred to a different unit, he felt more safe, which subsequently led to a better health outcome. Involving patients in their treatment plan allows healthcare professionals to identify their mental health needs and develop collaborative clinical decisions to meet their needs. Identifying patients’ mental health problems early facilitates the provision of early support services to prevent psychological deterioration (Wu, 2019).
According to the Ottawa Hospital Research Institute, 2019, patient decision aids are tools that help individuals become involved in decision-making by providing information about options and outcomes and clarifying personal values. Decision aids help the patient identify his needs in order for him to be able to determine the treatment options that are available to him, the questions that he may wish to ask his health care providers, and how he will make informed decisions that will serve his interests.
I will incorporate the decision aid inventory into my clinical practice in order to empower my patients to make informed healthcare choices. The decision aid tool will give patients an increased sense of control and provide a sense of satisfaction in being part of their own treatment. The decision aid tool will be included in their treatment plan, and I will provide the support necessary for them to successfully use it.
Patient Preferences and Decision-Making
I once worked as an ICU nurse. There is one instance involving an 84-year-old patient who was brought into the unit complaining about severe pain having developed gallbladder issues, and needing an urgent surgical procedure. Up until 12 months ago, the patient would walk up to 10 miles. Following the doctor’s assessment and judgment, it was decided that the patient was bound to benefit immensely from the procedure since the patient was still active.
I often experienced cases like that requiring the use of values and patient reference, which significantly influenced the treatment plan. Alfahmi (2022) observed that nurses do everything to save their patient’s lives, and ensure everyone is healthy. Following years of experience, nurses have learned to act realistically, and cognitively when such patients are brought to the unit. Thus, the treatment plan would benefit from incorporating preferences and outcomes.
Patient preferences and values would impact the situation trajectory, which is also reflected in the treatment plan. For instance, patient preferences and values, when combined with clinical guidelines, provide the needed direction to select viable treatment options, and tailor interventions for use in the treatment plan (Gruß & McMullen, 2019). These preferences and values can also be used to inform clinical decisions for healthcare problems plaguing the patient.
The value of the patient decision aid selected (palliative care aid) was one of the palliative care options, which included the option for euthanasia. The decision to allow end-of-life care or continue with the treatment ultimately rests on the patient and the surrogate. Making such a decision would be difficult for everyone, including the clinicians, and may require intense training for effective communication (Tringale et al., 2022). This facilitates treatment decisions.
I might use such a decision-aid inventory in my personal life or professional practice by considering values, goals, and preferences as part of the evidence-based decision and treatment. I would also use it to complement the clinicians’ approach to increase knowledge and experience.
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Description
The best story I know would be of an end-of-life/hospice care patient who chose to forego their ER visit/trip. Knowing that they had chosen hospice and that the ER visit could kick them off of hospice, they do not want strenuous life-saving measures anymore. This is such a difficult decision for the patient, their family, and even the staff because they know the ultimate cost of the decision. I feel it is vital that we involve patients in their care and, ultimately, their decision about their care. After all, do we want to be able to make our own decisions and be involved in our care?
Explanation
Research shows that involving patients in their care and allowing them in the decision-making process increases patient satisfaction levels, educates the patients on their disease process/prognosis, reduces anxiety, have a better view of what is necessary for their care, and in some cases increases outcome levels (Krist et al., 2017). Ultimately, this left the care decision in that patient’s hands, and they could choose. I feel it set their mind at ease that they were in control of their destiny and had limited time left here on earth. Not choosing to go to the ER and extending life-saving measures speeds up the transition process. Often, I feel like people forget that most of these patients have lived good, long lives and have come to terms with that when it is their time, it is their time. Coming from a long stretch of working in long-term care, patient-centered care is vital, and I am so grateful for the time I spent there to adopt that way of thinking into my practice.
Explanation of Trajectory
It is different in many settings, but in long-term care; the patients are fully engaged in their care plan/plan of care. They attended meetings and mostly had a decision in their care and what they did/didn’t want. The trajectory of the situation described above was ultimately a quicker death which can be difficult for the patient and family member. So, even though it may be hard for the family and what they may not be prepared for, the care we provide for patients should be patient-centered. Patient-centered care can be defined as providing respectful care to patients, specific to what the patient needs and wants, and ultimately, honoring what the patient holds the most important (MeInyk & Fineout-Overholt, 2018).
Decision Aid
A decision aid is a helpful way for patients to be involved in their care and make choices for their future and care. The tool shows what will happen if you forego one route vs. the other. The specific one I found was titled: “Advance Care Planning: Should I stop treatment that prolongs my life?” (The Ottawa Hospital Research Institute, 2019). I had never heard of this service, but I suppose it could help a patient see both views of what it could be if they chose one route over the other. For example, a patient could reflect on if I choose hospice, choose not to go to the hospital, and could experience worsened symptoms of this disease process. But ultimately, I am at peace and choose quality over quantity in my last days. Or the patient could choose to continue treating the disease process and use the ER for life-saving measures to extend their life. The patient must be somewhat tech-savvy or have assistance accessing this website. I feel this could be helpful in my practice in the future with helping a patient deal with anticipated grief related to death and dying. This could be a way to show a patient the cause and effect of their choices as well. I would describe this aid as cause and effect and could be used in anyone’s personal or professional life for many health problems or scenarios.
Incorporating Patient Preferences
I had a scenario once in which a patient was faced with the decision to have a pacemaker/ICD placed. This patient had poor quality of life at baseline, with several comorbidities including kidney failure requiring hemodialysis. The patient’s ejection fraction (EF) was around 20-25%, which is the reason for considering a pacemaker/ICD. Patients who have a low EF are at risk for sudden cardiac arrhythmias, and an ICD is one way to prevent cardiac death from lethal arrhythmias. This patient discussed with their family and decided not to have the pacemaker/ICD placed. They felt that the addition of an ICD would lead to more hospitalizations, more issues, and prolong suffering.
Physicians and nurses felt this would’ve been an easy decision to make; having an ICD placed would prevent this patient’s death from a cardiac arrhythmia, however they did not take into consideration quality of life. They tried counseling the patient that the procedure would not take long and is not complicated. Physicians struggled when the patient and family asked for a consult with our Palliative Care Team. The patient ultimately decided not to have the ICD placed, and code status was changed to DNR/DNI – do not resuscitate/do not intubate. Our Palliative Care Team is wonderful and helped the patient to understand that the ICD would not change current health state, it would only prevent sudden cardiac death.
Patient Decision Aid and Shared Decision Making
The patient decision aid I chose in this situation that I feel would be most helpful is “Heart Failure: Should I Get an Implantable Cardioverter-Defibrillator (ICD)? This decision aid is a very straightforward and informative guide. I feel that physicians are not always as honest with patients as they should be, and this decision aid puts information into simple and honest terms that patients and their families can easily understand.
Shared decision making is also an important aspect of treatment plans. SDM is when physicians and patients/families work collaboratively to make healthcare decisions based on evidence-based practice, while incorporating the patient/families’ values, opinions, and views (Kon, Davidson, Morrison, Danis & White, 2016).
Decision Aids in Everyday Life
I feel that the Ottawa Personal Decision Guide would be helpful to incorporate into complex life decisions. This decision aid is like a fancy pros and cons list. I often make pro/con lists whether it be mentally or writing out a list when I’m faced with difficult decisions in life. Sometimes physically seeing the decision at hand, written out makes it better than just thinking about things in your head. This decision aid also incorporates the values of others, like family and friends if you choose to include them when making decisions.
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Introduction.
Patient decision aids assist patients in becoming more active participants in making healthcare choices by providing up-to-date information that helps them communicate or seek clarification on treatment options to make more informed decisions (Li et al., 2021). Decision aids include information on the clinical problem as well as outcome probabilities. However, to deliver patient-centered care, it is essential to understand the type of patient that has the disease so that evidence-based practices and treatments can be integrated into the patient’s care only after congruency between decision and personal values and preferences has been clarified and accepted by the patient (Melnyk& Fineout-Overholt, 2019; Stacy et al.,2017).
Situation I experienced.
When admitting a patient into the older adult behavioral health unit, they are to be offered a voluntary admission if they are cognitively able to make that decision. Suppose the patient cannot; this decision is given to their power of attorney (POA). The patient or PAO acknowledges how the unit works, agrees to treatment, and understands their rights. Understanding the life of the patient helps in many ways in behavioral health. Therefore, we lean on the patient and their power of attorney to provide us with information about them so that the healthcare team can help care for and understand the patient. Although POAs make decisions for the patient, regardless of their cognitive impairment, the patients keep all their rights except to bear arms. Constant communication and reminder of the set goal and clarifying their priorities helps guide the treatment plan. Older adults with dementia have trouble remembering, learning new things, concentrating, or making decisions. Therefore, utilizing their priorities helps patients and PAO make decisions to achieve the outcome goal.
An example is a patient referred to us who was originally from home with combative behavior, a family member who is the POA wanted the patient to be placed into a facility because it was too much for her without admitting to inpatient psych. She was educated on the purpose of admitting her mother and accepted to admit. However, she did not want to give consent for any antipsychotic medication. It was explained to her that her loved one would not be accepted by a facility with combative behavior and refusing care because it would be a risk to herself and others. Education was given on the signing-in process, resources available, her and her loved one’s rights, the follow-up call to get psychosocial information, her decision of preferences on emergency interventions, medications use, side effects, and how it related to her mother’s conditions. Our common goal was to stabilize her mother’s behavior so that we could place her in a facility close to home. During the patient’s stay, we found common ground where we could get consent for some medications and try alternative treatments that honored her values and preference. We also identified patterns associated with her behavior so that the new facility could better care for her at discharge. In the end, the patient was cooperative and pleasant, and the family was grateful and satisfied with the decisions made as a collaborative team.
Decision Aid.
The decision aid I chose was the Ottawa’s hospital research institute “mild problems with thinking or memory: options to maintain mental skills in older adults.” This decisional aid allows individuals to clarify their priorities and choose from different options to maintain their mental skills and develop mechanisms to compensate for them that match their values and preferences. Identifying what is important to each patient is essential to help them stay focused during a frantic time and understand how their decision affects their priorities. In the future, I will implement this decision aid with families and patients to help them identify their priorities and what is important to them. Therefore, they can see how their decisions, values, and preferences are reflected in their care plans to help them reach their goals.
Personal experience with the patient
I am an Emergency Department nurse with 3+ experience, and I recently I started a travel contract as an Urgent Care Nurse. As much as I don’t see critical patients in urgent care, I do see patients needing further evaluation and treatment. Last week, I had a 67-year-old Hispanic female patient who came in c/o of recurrent fevers. After drawing basic blood work and obtaining her urine, it was significant that she was either septic or at risk of developing sepsis as artificial intelligence helped to flag potential risks in our system. Due to limited resources at Urgent Care, it was our duty to offer and encourage transport to the emergency department for further evaluation because as the provider stated, “She might be septic and should go to the hospital”. Unfortunately, the Patient seemed to be in denial and declined transport to the hospital and requested take-home treatment which the physician agreed to after having the patient sign the leave against medical advice (AMA) form. I witnessed a lot of patients being in denial of their own condition, and I was very aware that patients in denial should be approached in a different way as they are not thinking clearly. I, unfortunately, witnessed many providers unemphatically approach the shared decision-making process leading to minimal effort in helping the patient understand the severity of their condition, and giving up on care if the AMA form is signed.
Instead of getting the AMA form signed, I printed the blood work and urine results and went inside the patient’s room to once again speak to her about her decision. I presented the definition of Sepsis, its signs, and symptoms, as well as its rapid progression and potentially lethal threat. As I was giving her information little by little, I stopped and made sure that she understands. The more information I shared, the quieter and more anxious the patient got. Finally, I asked if the patient is still declining transport for further evaluation, and thankfully the patient said NO and agreed to be transferred to the main Emergency Department (same organization as Urgent Care).
Patient values and preference
The provider’s brief statement that she “might be septic and needs to go to the hospital” wasn’t enough for the patient to fully understand the severity of the situation. Because of that, the patient preferred to be discharged home with medications instead of being further evaluated. The patient’s values and preferences were initially valid as the patient was under the wrong impression of her own condition. Therefore, the patient is a good candidate to provide shared decision-making, the obstacle in this situation lies within the provider and his inability and lack of motivation to ensure the patient is aware of her condition (Shared Decision-Making, 2012). After providing adequate education, patients’ preferences and values changed accordingly, where health was a priority.
Decision aid inventory
The decision aid I chose is adequate patient education about the patient’s condition to allow the patient to make a conscious decision about transfer for further treatment at an Emergency Room. As an Emergency Room nurse, I am fully aware of how lethal sepsis can be, and how early treatment is crucial. It is my obligation to ensure that patients have the same knowledge and understanding so they can make their own conscious decision about their health (Funnell, 2014). In this case, the patient ended up being transferred to the hospital for further testing, including lactic acid levels, which were abnormal. Appropriate antibiotics and fluid replacement protocol were initiated, and the patient was admitted to the intermediate care unit. Had the proper education and understanding of Sepsis not been properly transmitted, the patient would’ve gone home just to further develop sepsis at home, which could’ve resulted in patient’s death.
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Situation experienced
Throughout my working experiences as a registered nurse, I had an opportunity to work in different specialties of my choice, including pediatric burn trauma center, extensive metropolitan emergency department, neurology/orthopedics floor, and general medical surgical units. Of these experiences, one patient encounter I had in Emergency Room stands out. The hospital I worked at was a designated trauma center for ophthalmology in the city. On this particular day, I was the assigned nurse for the area coverage for the ophthalmology room. I had a 50 -year old male patient who came in via ophthalmology referral for bleeding in his retina. The immigrant gentleman with limited English as a second language with no insurance and access to healthcare sensed that his vision was blurred, and he saw spots of redness around his sclera lately. He assumed his vision was worsening due to age and didn’t think much of the fact. He went to an optometrist for a new glasses prescription. The optometrist found something abnormal about his eyes and immediately referred him to an ophthalmologist. When the patient visited the ophthalmologist, he found significant pools of blood sitting on the back of his retina and asked him to go to the Emergency Room. The emergency department doctor saw the patient, and soon, a retina specialist consult was placed. The patient had uncontrolled diabetes and never had access to healthcare, so the diabetes was poorly managed, which affected vessels in his eyes. The on-call retinal specialist came, and the patient received emergent surgery to remove the blood in his eye and was able to regain his vision. The emergency department doctor set him an appointment with the primary care doctor.
Patient preferences and values
The patient was afraid of the medical bills and refused treatment. The doctor and I had to explain to the patient that he might lose eyesight if he avoided the procedure. Then as a team, we had placed a consult for a social worker who came and explained to the patient his options to get coverage for his medical bills. The patient’s preferences and values were validated at this time. The patient was concerned about paying medical bills, so the team addressed this issue by consulting a social worker, who could find a solution for him. “In evidence-based practice, integrating patient preferences and values, clinical expertise and …research to make decisions lead to improved outcomes for patients and families.” (Melnyk, B. M., & Fineout-Overholt, E. (2018).
Decision aid Inventory
Hoffmann et al. state that evidence-based practice starts and ends with the patient. It shares that clinicians’ decisions should reflect patients’ values and consider their circumstances. The decision aid inventory I chose for this patient was Type 2 diabetes in adults: controlling your blood glucose by taking a second medicine-what are your options? As the patient follows up with a primary care doctor, he will address the target HbA1c level with him and discuss medicines that they might try to achieve this target. Following up with a primary care doctor will help keep his blood glucose under control and prevent future chronic diagnoses.
Culture and technology are two areas of healthcare that makes healthcare to be constantly changing. Culture is defined as learned patterns of behavior and values practiced through social interaction, shared by members of a particular group, and transmitted from generation to generation (Baker, 2020). Cultures are diverse, and healthcare professionals must be open to the values and beliefs of others in order to provide the best possible care for each patient. A person’s culture influences their life experiences and, therefore, their perceptions of health, illness, and treatment (Baker, 2020). One of the things I have learned during my long career as a nurse is that as a nurse, you need to learn and understand the cultural contexts of others which helps to facilitate communication and helps create an effective nurse-patient relationship (Baker, 2020). We learn about cultures through education and training, but the best way to learn is from patients as we work with them to determine the best course of treatment and care.
Along with culture, the technology significantly impacts the healthcare sector, increasing opportunities to provide the best possible care to patients. Not only does it help patients learn more about their health, but it also facilitates care collaboration between providers and medical professionals. Increasing culture and technology in everyday life, along with evidence-based medicine, has put the patient in the treatment plan; because the treatment plan is about the patient and must continue after discharge, it makes sense to let them participate. Optimal patient care requires a combination of evidence-based medicine and patient communication (Hoffman et al., 2014).
At my current job, we seek to incorporate all patients’ values and beliefs into treatment plans by asking for their input, making it difficult to describe an experience. I work in a crisis stabilization center. Many patients are in a mental health crisis when they come to the hospital, and many of them are not at a level where they can decide on a treatment policy at the time of their visit, so the staff begins to develop a treatment plan themselves. It is best not to include the patient in the treatment plan because they are mentally unstable at this time. When the patient is more stable, we bring them in and include them in the planning process. Research shows that patients who participate in health care decisions are more likely to continue to make those decisions after they leave the hospital, which is our facility’s belief. A Nurse Practitioner sees each patient on the care team daily to review the patient’s medications, general condition, and post-discharge care plan. They involve patients in discussions about medication regimens that help or may help improve their mental health, which is reasonable to follow. Ask the patient to create a safety plan to refer to if they are in crisis again. We do not decide for the patient but let them choose the best for their life. Another part of the treatment plan that includes them is the treatment follow-up plan. We assisted them in looking for the phone number of providers in their local area, but they chose which provider to call and book a follow-up. I have seen that this brings better results. Their participation helps us understand their values and beliefs along the way. Patients have the right to be involved in their treatment plans, and we, as providers, try to involve them in all decisions as much as possible.
Incorporating patient preferences and values does not always lead to the best results. What the provider feels is the right course of action to treat someone, together with clinical expertise, has been effective (Melnyk & Fineout-Overholt, 2018). A patient may disagree with this course of treatment. For example, schizophrenia patients do not believe in drugs for some reason, which may lead to frequent readmission due to the return of symptoms. When discharged, they stop taking medication, against medical advice, thus ending up in another hospitalization. Therefore, when planning a treatment plan, we need to think outside the box and find ways for patients to seek help before they are hospitalized, like symptoms or clues to watch out for. I chose Patient Decision Support for Panic Attacks (Ottawa Hospital Research Institute, 2019). Besides schizophrenia, there are often patients who do not want to take medicine. This help provides information about the disease and the medicines needed to treat it. It explains what to expect and what will happen if you do not take medication to treat it. It also explains why healthcare provider recommends medications, what medications are available, and what medications are used as treatments, and shares other patient personal stories about their thoughts and decisions on medication. Patients’ thoughts and decisions about taking these aids give you a complete view of all aspects of the disease so that you can make an informed decision about any issue.
As nurses, we know and are taught that patient education is one of the most important things we do as nurses. These aids can be used as educational tools to present facts to patients. This helps patients to be informed about their care and make confident decisions. This tool can be used in our personal life to deal with our health care and the problems of loved ones. The website provided by The Ottawa Hospital Decision Support Resources has a lot of valuable and educational information to share with others.
I experienced quite a few situations where patient preferences played a huge role in their treatment plan. One situation while working in the ICU there was a patient that was a Jehovah’s witness and did not want to receive blood products for their gastrointestinal bleed. The patient has a hemoglobin of 6 and blood was ordered STAT. Time after time physicians and nurse practitioners entered the room trying to explain to the patient that receiving the blood products would help in saving their life and the patient adamantly refused the blood because it was against their religion. Although frustrating and a highly challenging situation, the doctors respected the patient’s wishes and tried to aid in saving their life in other ways (DeLoughery, 2020). The patient accepted scopes and procedures to try to find the source of the bleeding and hoped their body would regenerate the blood cells once the source was discovered. The patients’ plan of care took many different turns and as providers we were biting our nails in hopes they would make a full recovery, but their treatment plan was based on their values and not ours. After much debate it remains true that evidence-based medicine begins and ends with the patient and their wishes come before ours (Hoffman et, 2014).
Decision Aid
As I began to watch the patient decline and the family ask for help, the decision aid I chose was patient and family education. I used material printed from our facility which provided information on GI bleeds and treatment options, giving this to the patient and their family allows them to make an evidence-based informed decision (Schroy et.al, 2014). I am fully aware that the decision was made not to receive blood due to religious reasons but after getting to know the family and speaking to them about the disease process, a lack of understanding regarding the benefits of blood products was apparent. I provided education on GI bleeds and what are the options. We went over the options and all the ones we have attempted. I assured them I fully support their decision and realize it is going against their religious beliefs, but it is the only option to save the patient’s life. Once the patient realized they were rapidly declining and I provided the education to the family, I was asked to leave the room while the family discussed options. It is imperative during these times that the burden of decision making is equal amongst family members (Kon et al., 2016). After time passed and the family discussed their decision, much to the provider and my surprise, they decided to accept the blood transfusions that were needed to help save their life. We all made sure the family was clear that all other options had been exhausted and we were extremely hopeful for a positive outcome. Thankfully, the patient did well after a few units of blood, the family was hesitant but thanked us for the understanding and education that was given to them during this challenging time. As providers, we saw just how much education is imperative during these times and a there was a positive outcome for this patient.
Patient Preferences and Decision Making
Healthcare has developed and changed in many ways, including shifting its focus from clinicians to patients. Melynk and Fineout-Overholt (2018) outlined that patient-centeredness is essential for incorporating patients’ values and preferences into evidence-based practice and decision-making. Every element of a patient’s treatment is decided in collaboration with the patient, and the healthcare team should be sensitive to the individual’s wants and requirements as they make decisions (Melynk & Fineout-Overhold, 2018). Patients actively involved in their care decision-making have better outcomes and perform better in their everyday activities due to their care (Vahdat et al., 2014).
Once during my time working at a hospital in Arizona, I was able to consider patient values and beliefs in a way that ultimately improved the quality of care provided to the patient. A woman in her late twenties presented with dizziness, headaches, and extreme exhaustion. She was scheduled for a heart catheterization, during which her cardiologist established the need for a pacemaker. Upon hearing the news, she was overcome by various conflicting feelings. I, along with her loved ones, tried to convince her that accepting the pacemaker would help save her life. Before making any significant choices in her life, she researched the topic thoroughly and weighed the benefits and risks. I gave her booklets explaining pacemakers and reassured her that her doctors would support her choice. To cut a long tale short, she went through with the operation and afterward expressed her appreciation for the assistance and knowledge she received in making her choice.
People whose heart rates are problematic but have not been diagnosed with heart failure may find this patient decision guide helpful (Ottawa Hospital Research Institute, 2022). In addition, it has a wealth of information on pacemakers, including how to acquire one, what to expect from it, and how to deal with any issues that may arise. In addition, this resource would have been helpful for my patient since it would have prompted her to learn more about pacemakers, reduced her worry, and given her the most trustworthy information from which to make an informed choice. As my career develops, I can provide my present and future patients access to even more valuable learning materials.
N6052 Module 6 Week 11 Main discussion post by Leslie Davis
Dear Dr. Frazer and colleagues,
I work on a cardiac unit and have cared for a lot of patients that are admitted for chest pain. Many of these patients have tests ordered, such as an echocardiogram and a myocardial perfusion test (nuclear stress test). If the patient is found to have a critically low ejection fraction (EF), steps must be taken to protect that patient from life-threatening cardiac arrhythmias. It is imperative to include the patient in shared decision-making (SDM) and determine their preferences in order to prescribe the appropriate treatment.
Many of the patients I have encountered with low EFs have shown an eagerness to be involved in their plan of care. As Melnyk & Fineholt-Overholt indicate, patient preferences and clinical expertise are essential to making clinical decisions that promote the health and well-being of their patients (Melnyk & Fineout-Overholt, 2018). I believe that an informed patient will be more likely to follow through with the treatment plan. Once it is determined that a patient is at risk due to a low EF, our cardiologists always inform the patient (and family where applicable), thus allowing the patient to become an active participant in the decision-making process. One particular case stands out. A female, in her mid 50’s, with a long history of drug abuse, was found to have an EF of 20%. She was shocked to learn the extent of damage the drug abuse had on her heart. She was very eager to learn all she could about ICD placement and Lifevests, and asked many questions when the physicians made daily rounds. This woman was admitted to my unit for 63 days, because she also required long-term antibiotics for an infection due to IV drug use. She was engaged in her plan of care and always asked questions. She was discharged with a LifeVest and is waiting for an ICD placement.
Providing information and education to the patient is essential. Patient decision aids (PDA) are valuable tools that can be used for effective decision-making. I would present these patients with the PDA titled: “Heart Failure: Should I Get an Implantable Cardioverter-Defibrillator (ICD)?” I have cared for several patients that have needed an ICD and wish I knew about this PDA. Patients are often overwhelmed with information when they are discharged. This PDA would be a good reference to take home.
The patients that were waiting for an ICD were sent home wearing a Lifevest. With our cardiologists’ approval, I have used a Lifevest patient education guide from the Cleveland Clinic. This comprehensive guide provides a Lifevest overview and answered many frequently asked questions (Cleveland Clinic, 2022). Using evidence-based medicine with SDM is essential to quality health care. It should begin and end with the patient (Hoffman, Montori, & Del Mar, 2014).
Shared decision-making (SDM) is a healthcare decision-making model in which clinicians and their patients work together to develop a deeper understanding of the patient’s situation and decide how to proceed (Rabi et al., 2020). In SDM, both the patient and the clinician share information and expertise—the clinician brings to the table medical information about their options, risks, and benefits, and the patient brings to the table their personal preferences and values (Den Ouden et al., 2022). Utilizing both aspects allows for patient-centered care, which is required to integrate patient preferences and values in evidence-based decision-making (Melnyk & Fineout-Overholt, 2018). This discussion examines the impact of incorporating patient preferences in values in their treatment plan through shared decision-making to provide quality patient-centered care.
Personal Experience with Shared Decision Making
A recent situation I encountered was a conversation I had with a 66-year-old female patient regarding her concerns about osteoarthritis of her left hip. She stated that she and her husband try to be fairly active and enjoy bike riding and kayaking often. However, due to the worsening of her condition, it had been very difficult to enjoy the things she had once loved. In addition, she stated she had terrible days where her pain was incredibly intense. After trying multiple therapies and corticosteroid injections, which seemed to help for only a short time, the orthopedic surgeon spoke to her about possibly getting a total hip replacement. Although she was initially agreeable, a few weeks prior to surgery, she grew increasingly concerned. She did not feel like she had adequate support at home during the postop period and preferred to manage her osteoarthritis through continued medication and an alternate physical therapist. In addition, she described her desire to lose weight for the potential improvement of pain and to possibly improve outcomes if she had to go the surgical route in the future.
The patient verbalizing her preferences and values changed the trajectory of the treatment plan as it was shifted back to medical and therapy management from surgical. The patient stated she initially agreed to the surgery because she did not feel like she had any other choices and felt pressured. After speaking with another healthcare professional and her orthopedic surgeon again before her preop appointment, she made an informed decision she felt comfortable with. Not listening to the patient’s preferences and values in this situation could have led to the patient making an undeveloped decision to get surgery and feeling unsupported during a lengthy postop period.
Impact of Including Patient Preferences and Values to the Treatment Plan
Patients constantly make decisions throughout their whole healthcare journey. As nurses, we are patient advocates who strive to protect our patients’ rights. This includes the patient’s right to choose their own journey. Nurses are in an excellent position to provide patients with the information and knowledge necessary to make informed decisions regarding care and treatment; ultimately, the decision lies with the patient, who is the central focus of our care.
Patient Decision Aid
The patient decision aid I would utilize in this situation would be the Arthritis: Should I have Hip Replacement Surgery? Aid which is found on the A to Z Inventory of Decision Aids on the Ottawa Hospital Research Institute page (The Ottowa Hospital Research Institute, n.d.). This was an excellent decision aid, as it was very clear and easy to understand. It allowed the audience to get facts, compare their options, and analyze their feelings to reach a decision. It even allowed the audience to review a brief quiz to test their knowledge (Healthwise, 2022). This helps individuals considering a total hip replacement to make an informed decision that is right for them.
Recent patient experience
Medication adherence has become as important as a patient’s lab work trends. One of our care management duties at our health center is to follow up on patients who are not getting medications filled as prescribed and evaluate the barriers such as cost, accessibility, understanding of prescription directions, etc. I recently experienced a patient not getting his cholesterol medication filled as prescribed. His fasting lipid panel had not improved on the statin therapy even after a recent increase in the medication strength. The lab work was significantly worse.
I called the patient to inquire about these trends. I started the conversation with the patient by introducing myself and the reason for my call. I then presented the information as stated above. I asked the patient to help me understand, “why do you think your cholesterol has worsened even after your medication was increased?” I noted silence but decided to allow the patient time to respond versus continuing the conversation for him. The patient finally responded and said
you’re the first to ask me what I think. I think it’s not improving because I’m not taking it at all and never have. I don’t want to be on those medications; they made my brother sick and weak. He no longer goes fishing with me because he can’t walk, and his legs always hurt him. His doctor said he would die if he didn’t take the medications, but he’s not living life taking them. I’m not going to take it, but my doctor keeps refilling it.”
Patient-centered
I often use motivational interviewing tools when discussing self-management care with patients. I reflected on what the patient had told me and validated his concerns that he feared the medication would make him sick and he would not be able to fish again. Unfortunately, this case is an example of what happens when shared decision-making is not used. To achieve optimal patient care, evidence-based medicine and patient-centered care must be parallel. (Hoffmann TC, 2014) The patient was encouraged there are other options, and I agreed to talk to his physician for him. Integrating the patients’ preferences and values and enlisting everyone from the care team is a focus of patient-centered care. (Melnyk & Fineout-Overholt, 2019)
Decision Aid
A decision-making aid that would be valuable with this patient is Beyond Statins and other LDL Lowering Treatments tools. (Cardio smart, n.d.) This tool would be helpful to review with the patient and to visit options other than statins. There are a lot of patients who are unable to take statins. We need to reassure them it is not the end of the road. There are other options, such as lifestyle changes and different medications that are not statins. We utilize many similar decision-making tools, such as this embedded in the evidence-based protocols of our electronic health records.
Patient involvement drives wise clinical decision-making and subsequent care delivery. One of the key provisions in the definition of evidence-based practice (EBP) is the use of patient preferences along with clinical expertise and academic knowledge to guide decision-making and care delivery processes (Melnyk & Fineout -Overholt, 2018). Therefore, exploiting patient preferences and engaging patients in the healthcare process are credible techniques for achieving EBP outcomes. Analysis of correlations between patient preferences and clinical decision-making will provide essential insights for the implementation of her EBP in clinical practice.
Incorporating the patient’s preferences and values can influence the course of the situation. Reflect positively or negatively on your treatment plan. Patient participation ensures quality and a culturally appropriate, patient-centered approach that improves the quality of life (Ashrafzadeh & Hamdi, 2019). For example, for a diabetes mellitus patient, the inclusion of patient preferences regarding diet, physical activity, and general flexibility resulted in optimal outcomes for patient health. Cultural competence means accepting patient preferences related to their cultural background and using them to improve treatment plans (Jongen et al., 2018). For example, a Muslim patient may prefer halal food in their DM management plan, so the nurse should create a meal plan that favors the patient’s beliefs. Patient values and preferences improve treatment approaches by ensuring that patients are optimally involved in improving their health.
Patient decision support facilitates information delivery and allows patients to reflect on their thoughts and values in the healthcare process. A selected decision aid on the Ottawa Hospital website reads: Taking a Second Medication to Control Blood Sugar—What are the options for adults with type 2 diabetes who are taking a single medication? Other drug options include DPP-4 inhibitors, metformin, pioglitazone, SGLT-2 inhibitors, and sulfonylureas (The Ottawa Hospital Research Institute, date undated). This decision support is treatment focused and includes patients with type 2 diabetes. Many patients could benefit from learning about other alternatives that support disease management and improve overall health.
Patient decision-making aid and inventory influence my professional practice. They help the patient Make informed decisions about health care, taking into account individual preferences and values (Chenel et al., 2018). Decision support increases patient engagement in healthcare, improves patient knowledge, and increases realistic perceptions of outcomes following informed value-based decisions. Empowered patients work with healthcare professionals to improve health outcomes. Patient decision support improves professional nursing practice. Patient preferences and clinical decisions are directly related to the impact of EBP in the clinical setting. Patient engagement streamlines care delivery through support and a patient-centered approach. The use of decision aids increases patient involvement in the care process and facilitates EBP outcomes.
When I was in nursing school, I had a patient who was 93 years old. She was coming in for heart related issues (can’t remember the specific diagnosis) and her family was very involved in her care. one day, I walked in to take vitals and she was alone with her cardiologist, and he was explaining that she needed to have heart surgery, she was a healthy woman who had never really been sick. Once the physician left, she seemed very upset about their conversation, so I took a moment to speak with her about it. She stated that if it was up to her, she wouldn’t have heart surgery at her age, she was content and said she lived a pretty amazing life. She emphasized that her children would be upset if she did not have the surgery, but she was tired and just wanted to be home in her comforts.
After I left her room, I saw that the cardiologist was sitting at the desk documenting, and I interrupted to speak with him. I explained who I was (just a student at the time) and I shared with him the patients’ concerns. After the conversation the cardiologist went back to her room for further understanding, she explained everything to him, and he eventually agreed especially considering her age. He then called her family and informed them of the patients’ decision to not have the surgery, it seemed like a tough conversation, but they eventually respected their mothers wishes. In this moment I learned the true meaning of advocating for my patient.
A decision aid I found useful is the Ottawa Personal/Family Decision Guides, in this instance the risks we’re too great and the patient found the surgery unnecessary considering her age and other circumstances (Melynk & Overholt, 2018). I realized the need for a further conversation, the patient felt like she did not have say in her own care, but this was based off pressure coming from her family. This tool will help me in the future with conflicts regarding family centered care and decision making (Spijkers et al, 2022).
A male patient once presented to our clinic complaining of chest pains. This patient was originally from a male dominated culture that did not permit women to be in the workplace but instead should be in the home taking care of the children and family. One of our female nurses attempted to perform the assessment on this particular patient however, the patient refused to have her conduct the assessment. As a male nurse, I had to take over this responsibility and had to complete the patient assessment. I observed that the patient possessed strict values concerning women and their role in society. I had no choice but to respect this patient’s values and interacted with him in a very respectful and sensitive manner (Melnyk & Fineout-Overholt, 2018). This interaction allowed my patient to completely communicate his symptoms and issues to me, as I returned sensitivity and respect to him as a patient. This promoted a positive impact on the patient’s care and also on patient outcome. It is important that patients values are respected and patients are treated in a culturally sensitive manner (Kaihlanen et al., 2019). This will promote positive patient outcomes, as the patient feels fully integrated as a part of their own healthcare team.
Ironically enough, a patient recently came in for a procedure in my department, and it was quite clear that she did not want the procedure that she was getting that day. She has a condition called Atrial Fibrillation (AF or A-Fib). We routinely see patients that have AF and perform a varying array of procedures to either get them out of AF and/or get them off of anticoagulation medication. In her case, she is on anticoagulation due to Paroxysmal A-Fib (pAF). PAF is a type of A-Fib that comes and goes on its own. Patients must be anticoagulated to prevent blood clot formation in the heart during episodes of A-Fib. A-fib increases thromboembolic stroke risk by fives times, and 40% of strokes in patients over 80 years old are attributed to A-Fib (Piccini & Fonarow, 2016). The patient that I am referring to was nearly 90 years old and refused to take anticoagulation due to multiple falls. Serious bleeding (internal and external) can occur due to a fall when a patient is on anticoagulation. The procedure that she was having done is referred to as a Left Atrial Appendage Closure (LAAC). This procedure prevents clot formation during episodes of A-Fib and negates the need for anticoagulation. The procedure does have risks, which include death. The risk of major complications is 0.5% per the device manufacturer (Boston Scientific, n.d.)
The patient was with her daughter, and it was obvious that the family wanted her to have the procedure and the patient was against it. I have a strong feeling that the patient had little to no say in the decision to have the procedure. I looked up A-Fib on the decision aid site and found several treatment options, but LAAC was not a treatment option. However, other A-Fib treatments that we commonly perform were on the site. The treatment options on Patient Decision Aids for A-Fib are: Do nothing, treatment with medications, left atrial ablation, and atrioventricular (AV) node ablation with pacemaker implant (Ottawa Hospital Research Institute, 2022). The patient that I am referring to declined all of the treatments and the LAAC, except the “do nothing” option. That was her treatment decision. Nonetheless, due to family pressure she went ahead with the LAAC. The procedure was successful. To my knowledge, the patient spent a complicated-free night in the hospital and went home the next day. Despite the positive results, I cannot help but feel as if the patient was not a part of her own care decision and that is not right. This seemingly took away the right that she has to make her own healthcare decisions.
The decision aid tool has the option to do nothing for a reason. The patient can opt for this, and despite how difficult it might be for the family, this is an option that their loved one can choose. This patient aid tool would have been great for the patient, but in the end, her decision did not matter. I hope this is a situation that I am rarely (if ever) a part of again.