Discussion: Patient Preferences and Decision Making

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

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.

• Links to an external site..
  • Choose “For Specific Conditions,” then Browse an alphabetical listing of decision aids by health topic.
• After you have chosen a topic (or condition) and a decision aid, consider if 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 

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