Discussion: Patient Preferences Assignment
Discussion: Patient Preferences Assignment
Discussion # 1
Patient preferences are important to follow, especially when it comes to end of life choices and decisions. When I was a new nurse, I had an elderly lady who was admitted to my unit, she was in her mid-nineties, had a feeding tube, was not alert or oriented and had several large pressure ulcers on her sacrum. She had been a DNR and on hospice care when the family decided over the holiday season that they wanted to remove her DNR. During this time the feeding tube was accidentally pulled out, and she was experiencing some end-of-life symptoms such as severe bradycardia and was admitted to the hospital. There were different opinions of the family of this patient. Some of her children wanted to reinstate her DNR order and allow her to pass peacefully, while others wanted the hospital staff to do everything medically possible to keep her alive. This became a large issue that ended up involving nurse managers, physicians, social workers, and hospital administrators. “Often, DNR orders are the most controversial in family dynamics (Tajari, 2018). Families often try to convince the healthcare team to overturn the DNR directive. As a nurse, the patient is the priority of care and nurses are the patient’s advocate” (Haley, B, 2021). If a patient makes themselves a DNR when they are in their right mind, should someone at a later time be able to revoke this decision? As a healthcare professional, it is imperative that we provide patient-centered care, and not based on our feelings. “Failure to employ appropriate decision-making techniques can lead to significant problems” (Kon, A.A., et al., 2016). There are decision-making aides available for patients and family members to look over when making these end-of-life decisions (Healthwise Staff, 2021).
The use of nursing theories is critical to patient care because of the different purposes that they serve. Nursing theories assist in informing every interaction between nurses and patients. Through defining the features of the nurse-patient interaction, these theories shape how nurses develop relationships with patients (Wei et al., 2019). The purpose of most nursing theories is to help nurses identify care needs among patients, articulate what they can do for patients and why they do it, and determine the kind of information to collect to develop care plans. Through theories, nurses can comprehend and evaluate health situations, explain and anticipate certain responses from patients and map out objectives and anticipated outcomes (Bahabadi et al., 2020). These theories also help nurses determine the interventions to deliver, best practices, and selection of productive areas for research. The implication is that nursing theories are fundamental to quality care provision as they help nurses to possess background propositions to offer the best care.
After several meetings with the family and support staff, the family came to the agreement of reinstatement of the DNR order. “Patients rely on clinicians to be clinically wise and make sound judgment as experts in their profession. When clinicians do not meet this expectation, they fail patients and communities” (Melnyk, B. M., & Fineout-Overholt, E., 2018, p 224). Changing the code status takes away from the patients’ autonomy, and as healthcare providers we are to deliver patient-centered care.
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Aigielinn M
Discussion # 2
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One situation that I have experienced was with a patient who was diagnosed with diabetes but was noncompliant with insulin and was not living a healthy lifestyle. The patient was admitted because they had an infection on their foot which caused the foot to turn black in color and had extreme pain. The patient stated that they do not believe in doctors or medicine. Therefore, they were using herbal medicines from their country that they believed lowered their blood sugars. After being seen by the orthopedic doctor, the patient was advised to receive emergency surgery to remove the foot. Unfortunately, the patient refused the surgery and wanted to continue with the herbal remedies. I educated the patient, trying to explain that if not treated properly, the infection could spread to the bloodstream. However, the patient continued to refuse and wanted to be discharged home since I was not incorporating their preferences and values in the treatment plan.
Healthcare professionals should make a decision that “reflects their patient’s values and circumstances” (Hoffmann et al., 2014). However, in this situation, if I were to include the patient’s herbal remedies, it may have caused further damage to the patient’s injury because neither I nor the doctor was familiar with this particular natural medicine. Since the herbal remedies were not included, the patient was reluctant to participate in the treatment plan. Furthermore, by making treatment decisions “without attempting to understand the patient’s values, goals, and preferences, decisions will likely be predominantly based on the clinicans’ values” (Kon et al., 2016). Therefore, it was important to provide information packets and allow the patient to collaborate with the healthcare team about their plan of care to avoid unethical decision-making.
Patient decision aids are tools that help patients and providers collaborate together about care options (Washington Health Care, 2022). Brochures, an example of a patient decision aid tool, is effective in decision-making and incorporates information and teaching strategies. In this situation, the diabetes doctor and the patient reviewed a brochure that explained what diabetes is and how it affects the body as a whole. By reviewing the brochure together, the patient was more willing to cooperate and agree to the surgery. Using brochures can benefit patients admitted to the hospital because it provides information that keeps the reader engaged but does not overwhelm the reader with too much information. Lastly, brochures can benefit professional practice when implementing discharge plans for patients. For example, when this patient was able to be discharged, they were provided an additional brochure that educated them on how to monitor blood glucose at home and medication compliance. Therefore, brochures are a great patient decision aid tool that I can continue to use in professional practice when discussing new diagnoses with patients.
Social determinants of health (SDH) refer to the circumstances/condition in which a person lives, such as where a person was born, where a person lives, the education one receives, religion/worship, play, and age that affects an individual’s quality of life, function, and health (Melnyk & Fineout-Overholt, 2018). For example, a person from Africa who needs more education in the English language can experience difficulties when making healthcare decisions. This can be due to limited knowledge of the disease process or a lack of understanding of the treatment method. Also, lack of income, lack of social support, and lack of necessities such as food, housing, and transportation can impact a person’s health and the decision-making process, as in the case of the patient described below. When patients’ preferences, their social determinants, and their values are considered when making healthcare decisions, it can lead to better patient outcomes and health improvement overall.
As an ED nurse, most of the patients I care for are incredibly sick, and for many of them, their time in my care is the end of their lives. While nurses try their hardest to save every patient and nurse everyone back to health, they also have learned how to be realistic and know when to expect that the patient has reached the end. Sometimes, the patient’s prior condition is considered in decision-making, however. Clinicians must act in the patient’s best interests and use evidence-based decision-making, which includes using their judgment to help patients make decisions (Melynk & Fineout-Overholt, 2018). Just recently, I had a 92-year-old patient who, up until nine months ago, was walking several miles a day. He developed an aneurysm. The surgeon used his judgment in that this was an exceptional 92-year-old who was very active and could benefit from surgery. He went in for a stent placement through his left femoral artery. The nursing and medical staff were completely transparent with the family throughout the entire process and after several days of the most intense measures to save his life, including but not limited to CRRT, maxed-out vent settings, and the use of several pressors. Palliative care was consulted, and several discussions between the medical staff and family were made to determine the course of action.
Furthermore, despite the grim prognosis with almost no hope, the family kept pressing. Some family members stated they believed it was not right and that the patient was being “tortured.” When they finally decided to withdraw care, the patient died within minutes. Had a shared decision-making patient (surrogate) decision aid been used earlier in the process, the outcome may have differed.
Decisions on the continuation of life are ultimately the decision of the patient and surrogates. Nobody is comfortable making these decisions, and clinicians should be trained in communication to facilitate treatment decisions (Kon et al.,2016). Our job as healthcare professionals in shared decision-making is to offer the best scientific evidence available while considering the patient’s values, goals, and preferences (Kon et al., 2016). A decision-aid inventory may complement the clinician’s approach by increasing surrogate knowledge.
Kon, A. A., Davidson, J. E., Morrison, W., Danis, M., & White, D. B. (2016). Shared decision
making in intensive care units: An American College of Critical Care Medicine and American
Thoracic Society policy statement. Critical Care Medicine, 44(1), 188-201. doi:10.1097/CCM.0000000000001396.
Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing healthcare:
A guide to best practice (4th ed.). Philadelphia, PA: Wolters Kluwer
Hoffman, 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
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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/