I just encountered a situation that may or may not be considered the patient being brought into their plan of care. I work mainly with adolescents and pediatrics in acute inpatient psychiatric care. These kids are very mentally ill. So, I was passing medications at dinner time, which is coincidentally change of shift. I was helping the other nurse on the pediatrics unit, I work the adolescents, by passing her medications while she was on the phone with a parent. One of the kids, maybe 13 years old female, was prescribed an SSRI for depression. She had no idea that she had it or what it did. I told her that of course she had every right to refuse the medication. She explained to me “I can do this on my own without medication”. I asked her if she knew about what the medication did and why she needed it. I went on to explain neurotransmitters and receptors and how the medication worked with them to boost her serotonin. She was shocked and immediately took her medication. After I told her that I wasn’t going to pressure her into taking it, but that she should always know why we take medication and what it does to our body. She shocked me and told me that no one had explained the medication to her, nor did they explain how they work. She told me that because I explained it to her in a way, she understood that she gladly took the medication. I found out later that she never refused that medication again and when I later asked her about it, she agreed that she needed it and was already starting to feel better.
Had I not explained to this adolescent why she was taking the medication, she may have refused multiple times or never taken it. This would have impacted her greatly in that she could benefit immensely from taking the medication. By explaining the medication properties to her, she was able to make an informed decision on her own. I treated her like a person, not just a patient or a child.
I spend a lot of time with my adolescent patients educating them on medications and neurology. I know that many of the nurses that I work with do very minimal education on medication as they don’t know much more than what the provider has told them or written in the medication indication section. ”Nurses have strong positive attitudes toward the necessity and processes underpinning successful patient medication education; yet, they may not act fully upon these beliefs” (Bowen et al, 2017). I think that the potential to want to educate patients is there, but many nurses lack the information and lack the motivation to seek it out. “Another significant finding from this study was that favorable treatment perception contributes to significantly higher rates of adherence to treatment with psychotropic medications irrespective of all other nonmodifiable demographic factors stated above” (Chawa et al, 2020). Knowing that by educating your patients, you can in fact help medication adherence and continued treatment following discharge. “Treatment efficacy, belief, and perceptions about the antidepressant were major influencing factors during the implementation phase of adherence” (Srimongkon et al, 2018). Knowing how best to talk to your patients starts with building trust.
References
Bowen, J. F., Rotz, M. E., Patterson, B. J., & Sen, S. (2017). Nurses’ attitudes and behaviors on patient medication education. Pharmacy Practice, 15(2), 930. https://doi.org/10.18549/pharmpract.2017.02.930
Chawa, M. S., Yeh, H. H., Gautam, M., Thakrar, A., Akinyemi, E. O., & Ahmedani, B. K. (2020). The Impact of Socioeconomic Status, Race/Ethnicity, and Patient Perceptions on Medication Adherence in Depression Treatment. The Primary Care Companion For CNS Disorders, 22(6). https://doi.org/10.4088/pcc.20m02625
Srimongkon, P., Aslani, P., & Chen, T. (2018). Consumer-related factors influencing antidepressant adherence in unipolar depression: a qualitative study. Patient Preference and Adherence, Volume 12, 1863–1873. https://doi.org/10.2147/ppa.s160728
Sample Answer 6 for Discussion: Patient Preferences and Decision Making
My work as a home hospice case manager has taught me a great deal about respecting patient preferences, even when it’s difficult as a clinician. I oriented to hospice many years ago and was shocked that my first hospice patient was also a full code. I was baffled how a patient could be both admitted into hospice yet still have active orders that ‘everything’ was to be done to save her life, which would inevitably lead to the hospital. It was incongruent. My preceptor whole-heartedly agreed.
We attempted to clarify what she wanted during our first several visits since the two facts were contradictory. However, we quickly learned that this patient was utterly unwilling to have any conversation that broached her coming death, either with her family or us. My preceptor attempted, several times and in the most skillful ways I’ve ever seen, to start difficult conversations, which included: the patient’s code status; a request from the patient’s daughter for a care conference to address family questions and concerns; and the hospice team’s strong expectation for how this particular patient might die (we anticipated a sudden bleed-out due to her sarcoma rapidly growing near her carotid). We also wanted to provide support, education, and preparation to the family to help answer their questions; support their anticipatory grief, and help prepare them for their loved one’s potentially dramatic death. However, the patient adamantly refused to allow us to discuss anything with them. She was also unwilling to speak about any of these concerns herself with any hospice team member. She would say things like ‘I just want to enjoy the day,’ and ‘You make me sad when you bring these things up.’ After several team members’ attempts, we had to acknowledge and accept that this patient was not ready (and never was prepared) to discuss or prepare for her death with her family or us.
Our facility had a belief in the shared-decision making model, described by Melnyk & Fineout-Overholt (2019), in which research, clinician knowledge, and patient preferences are equally considered. In this situation, the patient’s preferences overrode the other two. So, we changed our approach at visits, and instead of focusing conversation on her code status or concerns from her family, we instead honored her desire to have pleasant talks, complete wound care, and manage her pain. Her treatment plan encompassed what she wanted, and these goals became what we wanted on her behalf.
Ultimately, she entered the actively dying phase very quickly (no bleed out), and her husband was able to call us to the home when she became unresponsive. He signed off on the DNR 45 minutes before she died. In the end, as frustrated as her family was that she had refused to allow them to communicate with hospice, they also stated this was precisely her personality in life. They appreciated that we had respected her ‘feisty and independent’ nature (their words), even though it had been difficult for all involved. By including her preferences and values in a shared-decision making approach, this scenario’s trajectory held risk for a potentially traumatic experience for her family had she bled out. It also created the possibility that she wouldn’t die at home, which had been her initial expressed desire on admission to hospice. However, in the end, her wishes for ‘pleasant’ visits from hospice were met by the team, and we also managed her wound care and pain quite well. It was a successful patient care experience that taught me a great deal about respecting patients’ rights and desires.
The patient decision aid that I found through the Ottawa Hospital Research Institute (2019) is called the Plan Well Guide. It helps guide difficult conversations related to planning for severe illness and medical treatment options (Heyland, 2019). I don’t believe that this patient decision aid would have made a difference for the scenario I described above – she knew what she wanted and had no problem relaying that to us. Still, I think this tool could be an excellent option for future patients and even friends and family. The site has short videos showing actual patients and their loved ones discussing their experiences with having hard conversations about care, but realizing that they felt better afterward, having made their wants known to their family.
The critical point for clinicians to understand when considering patient preferences in the shared decision-making model is that patients may make decisions that we disagree with or that we feel are ill-informed, as in the example I describe. Our team never had a chance to discuss with our patient what our concerns were or explain how we wanted to support her family; she refused it all. Clinicians have to be prepared to present information in several ways (direct conversations, written materials, websites, videos) and then be ready for the patient to reject this information or not use it in the way we expect. We may have strong feelings about how the patient should decide their treatment plan and who they should include in that decision. In the end, it is what the patient decides that guides the treatment plan. It is the most ‘challenging’ patients that can teach providers the most because if they are indeed in control of their treatment, then we must be ready and willing to accept what they decide…even when we disagree.
Changes in culture and technology have resulted in patient populations that are often well informed and educated, even before consulting or considering a healthcare need delivered by a health professional. Fueled by this, health professionals are increasingly involving patients in treatment decisions. However, this often comes with challenges, as illnesses and treatments can become complex.
What has your experience been with patient involvement in treatment or healthcare decisions?
In this Discussion, you will share your experiences and consider the impact of patient involvement (or lack of involvement). You will also consider the use of a patient decision aid to inform best practices for patient care and healthcare decision making.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
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/
- Links to an external site. were considered in the treatment plan Social determinants of health can affect a patient’s decision as these are conditions in the patient’s environment, such as economic stability, education access, health care access and quality, neighborhood, and social and community context.
- 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, social determinants of health
Links to an external site., and values impacted the outcome of their treatment plan. Be specific and provide examples. Then, explain how including patient preferences, social determinants of health, 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.
(Please Note: The underlined “social determinants of health” in the above content is meant to hotlink to the following Walden webpage and content:
Social Determinants of Health – Social Determinants of Health – Academic Guides at Walden
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.
Sample Answer 7 for Discussion: Patient Preferences and Decision Making
Patient preferences mean a patient’s choice to decide about their health and treatment based on their experiences, beliefs, and values. However, these choices and preferences are not left entirely to the patients, and there is a need for a shared decision-making process between the providers and the patients (Gurmu, 2022). In my previous practice, a 36-year-old male presented with complaints of insomnia that had lasted for about four months. The patient stated that he had been prescribed Benadryl at a community clinic but stopped taking it due to next-day drowsiness. He had researched about Benadryl and learned that it is an antihistamine. He, therefore, asked if he could get a prescription without an antihistamine.
The NP informed the patient of the available medication options, which included Trazodone, Vistaril, and Ambien. They discussed the benefits and side effects of each medication and established that Trazodone would be the most beneficial due to its established tolerability and efficacy in reducing insomnia. After four weeks, the patient reported that his sleep quality had significantly improved and had no issues initiating or maintaining sleep. He also reported that the medication had no side effects. Respecting the patient’s values and treatment preference contributed to positive outcomes since he adhered to the treatment, resulting in the desired outcomes (Russo et al., 2019).
The patient decision aid appropriate for this scenario is the “Insomnia: Should I Take Sleeping Pills?” The target audience for this decision aid includes persons thinking of taking sleeping pills for insomnia. It offers two choices: Use sleeping pills in a short time in addition to lifestyle modification or manage insomnia with only lifestyle interventions (Ottawa Hospital Research Institute, 2019). The aid can guide clinicians in making appropriate decisions when treating patients with insomnia as it guides one to initiate pharmacotherapy or sleep hygiene interventions. I can utilize the aid in my future nursing practice when managing patients with sleep disorders and identifying cases to prescribe pharmacotherapy or lifestyle interventions.
References
Gurmu, Y. (2022). Patient Preferences in Shared Decision Making During Healthcare and Associated Factors Among Adult Admitted Patients at Public Hospitals of West Shoa Oromia, Ethiopia. Patient preference and adherence, 16, 1781–1786. https://doi.org/10.2147/PPA.S376600
Russo, S., Jongerius, C., Faccio, F., Pizzoli, S. F. M., Pinto, C. A., Veldwijk, J., Janssens, R., Simons, G., Falahee, M., de Bekker-Grob, E., Huys, I., Postmus, D., Kihlbom, U., & Pravettoni, G. (2019). Understanding Patients’ Preferences: A Systematic Review of Psychological Instruments Used in Patients’ Preference and Decision Studies. Value in health : the journal of the International Society for Pharmacoeconomics and Outcomes Research, 22(4), 491–501. https://doi.org/10.1016/j.jval.2018.12.007
Ottawa Hospital Research Institute. (2019, June 26). A to Z summary results. Patient Decision Aids – Ottawa Hospital Research Institute. https://decisionaid.ohri.ca/AZsumm.php?ID=1085
Sample Answer 8 for Discussion: Patient Preferences and Decision Making
Introduction
This paper will provide examples of how incorporating or not incorporating patient preferences and values impact their outcomes. Then, we will explain how including patient preferences and values influence their health situation and are reflected in their plan of care. Finally, we will discuss decision aid support and its impact on patient decision-making and use in professional practice.
The situation related to patient preference and value impacts outcomes in the plan of care.
The National Kidney Foundation (2020) state that, in the United States, 37 million adults are estimated to have chronic kidney disease, and approximately 90 percent don’t know they have it. Risk factors associated with CKD are diabetes, high blood pressure, heart disease, obesity, and family history. According to Hoffman et al. (2014), evidence-based medicine should begin and end with the patient. For example, when a patient transitions from chronic kidney disease (CKD) to end-stage renal disease (ESRD), the patient is faced with several treatment options that are critical to their survival. These treatments are necessary for the rest of their lives, so patients need to choose the most suitable treatment for them. According to Green et al. (2018) many patients are unprepared for kidney failure treatments—even when they have been under nephrology specialty care for years. Nephrologists are often unable to predict the timing of kidney failure. Sometimes patients with advanced kidney disease experience rapid decline in kidney function, which leaves little time for a nephrologist to help patients prepare in advance (p. 2). With electronic health records (EHR) and analysis, algorithms predict CKD patient characteristics and laboratory measures. The nephrologist can recognize patient needs or prognosis of kidney transition based on age, gender, eGFR, urine albumin, creatine ration, calcium, phosphorus, albumin, and bicarbonate focus, providing patients with the knowledge, skills, and support in shared decision making (p. 5). Kon et. (2016) note three elements of a shared decision-making (SDM) approach include information exchange, deliberation, and making a treatment decision addressing the patient preference, values, and goals of care (p. 1334). The impact in outcomes is that patients and families who are educated, informed, and supported throughout their diagnosis can better participate in SDM, accommodating their medical needs and preferences, leading to more satisfying outcomes and relationships.
Patient preferences and values
Evidence-based practice requires a patient-centered approach when it comes to decision-making. The Institute of Healthcare Improvement (IHI, 2013) describes “patient-centered” as placing an international focus on patients’ cultural traditions, values, personal preferences, family issues, social circumstances, and lifestyle. This approach leads to better patient engagement and outcomes (Melnyk & Fineout-Overholt, 2019, p.227). The evaluation of factors related to home and family life can make or break a successful care plan; for example, a young family of four with two children under the age of four recently found out that the husband/father needed to start dialysis therapy. This family has already been dealing with financial hardship, unstable marital concerns, and the responsibility of raising two small children. The husband reports a lack of support once starting treatment from his wife, who feels burdened and unappreciated. He is afraid of losing her and his children and feels burdened with guilt and worry. The family needs a transdisciplinary care plan that focuses on the patient’s best options for treatment (given his current circumstances), including transplant and home therapies. This care plan would include counseling support to help save their marriage and adjust to this new chronic health diagnosis, care management to help provide support, financial guidance and options, and dietician to ensure the patient has the knowledge needed to optimize his therapy. William Osle’s quote, “It is much more important to know what sort of a patient has a disease than what sort of disease a patient has (Melnyk & Fineout-Overholt, 2019, p. 229) embodies the reason why patient preferences and values determine clinical decisions and outcomes.
Decision-Aid Support and Impact on Decision-Making
Decision aids are a valuable tool in helping patients make the right decisions based on their values and needs. The Ottawa Hospital Research Institute (2019) provides an A-Z inventory of decision aids. For example, when searching the term, “Kidney”: multiple decision aid tools populate to relating to chronic kidney disease, end of life issues, and kidney failure to include dialysis choice, dialysis; doing the right choice, My life, My dialysis choice, advanced care planning: should I stop kidney dialysis, Kidney Failure: Should I start dialysis? This tool provides patients with treatment options, pathways, and outcomes. Clinicians use it to support patient preference and guide patient and provider decision-making (Melnyk & Fineout-Overholt, 2019, p. 228). In the example of the kidney patient who has multiple barriers to achieving optimal care, this information would have provided him with the options needed before starting dialysis. It would give a platform of shared decision between himself, his wife, and his provider. Clinicians should use decision aids in their daily practice with patients newly diagnosed or with patients who are not managing their diagnosis well. These aids will support active engagement by the patient and lead to both an improved patient and provider experience and outcomes.
References
Green, J. A., Ephraim, P. L., Hill-Briggs, F. F., Browne, T., Strigo, T. S., Hauer, C. L., Stametz,
- A., Darer, J. D., Patel, U. D., Lang-Lindsey, K., Bankes, B. L., Bolden, S. A., Danielson, P., Ruff, S., Schmidt, L., Swoboda, A., Woods, P., Vinson, B., Littlewood, D., Jackson, G., … Boulware, L. E. (2018). Putting patients at the center of kidney care transitions: PREPARE NOW, a cluster randomized controlled trial. Contemporary clinical trials, 73, 98–110. https://doi.org/10.1016/j.cct.2018.09.004
Hoffmann, 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: Executive summary of the American College of Critical Care Medicine and American Thoracic Society policy statement. Critical Care Medicine, 44(1), 188-201. Doi:10.1097/NND.0000000000000483
National Kidney Foundation. (2020) NKF statement on the ESRD treatment choices model
(ETC) and policies to improve kidney patient choice: Kidney disease facts. https://www.kidney.org/news/nkf-statement-esrd-treatment-choices-model-etc-and-policies-to-improve-kidney-patient-choice
The Ottawa Hospital Research Institute. (2019). Patient decision aids. Retrieved from
https://decisionaid.ohri.ca/
