NURS 6052 Discussion Patient Preferences and Decision Making
NURS 6052 Discussion Patient Preferences and Decision Making
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Patient Preferences and Decision Making.
Promoting patient participation in care is a priority identified by the World Health Organization and various national bodies around the world. In Patient centered care, treatment decisions are made with the patient, with consideration to their preferences and values (Siminoff, 2013).
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My encounter was with a patient with Atrial fibrillation (A-fib) who was on Coumadin to prevent blood clots and subsequent heart attack or stroke. From reports, I got to know that patient has been refusing her Coumadin, she also has Warfarin writing boldly on her left arm, so before accepting any medication from the nurse, she would point to the inscription on her arm and tells you if that medication is amongst, take it out.
I interviewed patient to find out why her refusal of the anticoagulant, the reason given was that whilst on Coumadin she bled into her brain, so after that incident she keeps telling her doctors not to put her on any anticoagulant. According to her, she prefers to not take any anticoagulant. I explained the importance of needing the anticoagulant and that there are also different drugs beside the Coumadin. After much education and answering questions patient agreed to try a new anticoagulant. Physician was notified, discussion between physician, patient, and nurse resulted in patient taking Eliquis instead of coumadin, patient was really happy and satisfied with the outcome.
The patient’s preferences and values guided the trajectory of the situation. Initially, the patient did not agree to take Coumadin or any anticoagulant. Once I had the discussion with patient, she decided to have an anticoagulant. If the patient had chosen not to have the Eliquis, she could have had a heart attack which would result in a more extensive treatment plan or possibly death.
The patient decision aid used to educate the patient was, “AFIB Decision Support tool” and A- fib: which anticoagulant should I take to prevent stroke? (The Ottawa Hospital, 2019). The value of the decision aid provided easy to understand language, evidence-based decision making with rational explanations. The patient decision aid allowed me to thoroughly provide education to direct the patient in the most up-to-date best evidence as to the importance of taking an anticoagulant. In general, the decision aid is a good and effective tool to use to help people become involved in decision making, in order to help provide information about the options and outcomes (The Ottawa Hospital, 2019b).
The Ottawa Hospital decision aids is a great resource not only for patients but also nurses, doctors, and other healthcare professionals. The decision aids explain in plain simple language for any decision for specific conditions or in general decision making. In my professional practice I can use the inventory of decision aids to help my patients make decisions in making healthy choices and explain necessary treatment options in order to guide them to deciding based upon their preferences and values.
In conclusion, patient preferences and values should be included in decision making and treatment plan to ensure the best possible care (Melnyk & Fineout-Overholt, 2018). Giving the patient autonomy is an essential component in the choices made regarding their care. Nurses should also respond positively to patients attempts for communication.
References
Melnyk, B.M. & Fineout-Overholt, E. (2018). Evidence-based practice in nursing and healthcare: A guide to best practice (4th ed., pp. 219-222). Philadelphia, PA: Wolters Kluwer.
Laureate Education (Producer). (2018). Evidence-based decision making [Video file]. Baltimore, MD: Author.
Siminoff, L. A. (2013). Incorporating patient and family preferences into evidence-based medicine. BMC Medical Informatics & Decision Making, 13, S3-S6. https://doi.org/10.1186/1472-6947-13-S3-S6
The Ottawa Hospital. (2019a). Afib: which anticoagulant should I take to prevent stroke? Retrieved from https://www.healthwise.net/ohridecisionaid/Content/StdDocument.aspx?DOCHWID=hw267214
The Ottawa Hospital. (2019b). Patient decision aids. Retrieved from https://decisionaid.ohri.ca/
NURS 6052 Discussion Patient Preferences and Decision Making
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.
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/.
- Choose “For Specific Conditions,” then Browse an alphabetical listing of decision aids by health topic.
- 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 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.
By Day 6 of Week 11
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.
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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
NURS 6052 Discussion Patient Preferences and Decision Making
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.
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Submission and Grading Information
Grading Criteria
To access your rubric:
Week 11 Discussion Rubric
Post by Day 3 and Respond by Day 6 of Week 11
To participate in this Discussion:
Week 11 Discussion
Congratulations! After you have finished all of the assignments for this Module, you have completed the course. Please submit your Course Evaluation by Day 7.
Module 6: Changing the World Through Evidence-Based Practice (Weeks 10-11)
Laureate Education (Producer). (2018). Evidence-based Practice and Outcomes [Video file]. Baltimore, MD: Author.
| Due By | Assignment |
| Week 10, Days 1-3 | Read the Learning Resources. Begin to compose your assignment. |
| Week 10, Days 4-6 | Continue to compose your Assignment. |
| Week 10, Day 7 | Deadline to submit your Assignment. |
| Week 11, Days 1-2 | Read the Learning Resources.
Compose your initial Discussion post. |
| Week 11, Day 3 | Post your initial Discussion post. |
| Week 11, Days 4-5 | Review your Discussion posts.
Compose your peer Discussion responses. |
| Week 11, Day 6 | Post two peer Discussion responses. |
| Week 11, Day 7 | Wrap up Discussion |
Learning Objectives
Students will:
- Analyze opportunities for change within healthcare organizations
- Recommend evidence-based organizational changes using an evidence-based practice approach to decision making
- Identify measurable outcomes addressed by evidence-based changes
- Justify dissemination strategies
- Analyze the impact of patient preferences on clinical decision making
- Analyze decision aids
Learning Resources
Note: To access this module’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Required Readings
Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Philadelphia, PA: Wolters Kluwer.
- Chapter 7, “Patient Concerns, Choices and Clinical Judgement in Evidence-Based Practice” (pp. 219–232)
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
Note: You will access this article from the Walden Library databases.
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
Note: You will access this article from the Walden Library databases.
Opperman, C., Liebig, D., Bowling, J., & Johnson, C. S., & Harper, M. (2016). Measuring return on investment for professional development activities: Implications for practice. Journal for Nurses in Professional Development, 32(4), 176–184. doi:10.1097/NND.0000000000000483
Note: You will access this article from the Walden Library databases.
Schroy, P. C., Mylvaganam, S., & Davidson, P. (2014). Provider perspectives on the utility of a colorectal cancer screening decision aid for facilitating shared decision making. Health Expectations, 17(1), 27–35. doi:10.1111/j.1369-7625.2011.00730.x
Note: You will access this article from the Walden Library databases.
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Content
Name: NURS_6052_Module06_Week11_Discussion_Rubric
| Excellent | Good | Fair | Poor | ||
| Main Posting | Points Range: 45 (45%) – 50 (50%)
Answers all parts of the discussion question(s) expectations with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources.
Supported by at least three current, credible sources.
Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. |
Points Range: 40 (40%) – 44 (44%)
Responds to the discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module.
At least 75% of post has exceptional depth and breadth.
Supported by at least three credible sources.
Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. |
Points Range: 35 (35%) – 39 (39%)
Responds to some of the discussion question(s).
One or two criteria are not addressed or are superficially addressed.
Is somewhat lacking reflection and critical analysis and synthesis.
Somewhat represents knowledge gained from the course readings for the module.
Post is cited with two credible sources.
Written somewhat concisely; may contain more than two spelling or grammatical errors.
Contains some APA formatting errors. |
Points Range: 0 (0%) – 34 (34%)
Does not respond to the discussion question(s) adequately.
Lacks depth or superficially addresses criteria.
Lacks reflection and critical analysis and synthesis.
Does not represent knowledge gained from the course readings for the module.
Contains only one or no credible sources.
Not written clearly or concisely.
Contains more than two spelling or grammatical errors.
Does not adhere to current APA manual writing rules and style. |
|
| Main Post: Timeliness | Points Range: 10 (10%) – 10 (10%)
Posts main post by day 3. |
Points Range: 0 (0%) – 0 (0%) | Points Range: 0 (0%) – 0 (0%) | Points Range: 0 (0%) – 0 (0%)
Does not post by day 3. |
|
| First Response | Points Range: 17 (17%) – 18 (18%)
Response exhibits synthesis, critical thinking, and application to practice settings.
Responds fully to questions posed by faculty.
Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.
Demonstrates synthesis and understanding of learning objectives.
Communication is professional and respectful to colleagues.
Responses to faculty questions are fully answered, if posed.
Response is effectively written in standard, edited English. |
Points Range: 15 (15%) – 16 (16%)
Response exhibits critical thinking and application to practice settings.
Communication is professional and respectful to colleagues.
Responses to faculty questions are answered, if posed.
Provides clear, concise opinions and ideas that are supported by two or more credible sources.
Response is effectively written in standard, edited English. |
Points Range: 13 (13%) – 14 (14%)
Response is on topic and may have some depth.
Responses posted in the discussion may lack effective professional communication.
Responses to faculty questions are somewhat answered, if posed.
Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. |
Points Range: 0 (0%) – 12 (12%)
Response may not be on topic and lacks depth.
Responses posted in the discussion lack effective professional communication.
Responses to faculty questions are missing.
No credible sources are cited. |
|
| Second Response | Points Range: 16 (16%) – 17 (17%)
Response exhibits synthesis, critical thinking, and application to practice settings.
Responds fully to questions posed by faculty.
Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.
Demonstrates synthesis and understanding of learning objectives.
Communication is professional and respectful to colleagues.
Responses to faculty questions are fully answered, if posed.
Response is effectively written in standard, edited English. |
Points Range: 14 (14%) – 15 (15%)
Response exhibits critical thinking and application to practice settings.
Communication is professional and respectful to colleagues.
Responses to faculty questions are answered, if posed.
Provides clear, concise opinions and ideas that are supported by two or more credible sources.
Response is effectively written in standard, edited English. |
Points Range: 12 (12%) – 13 (13%)
Response is on topic and may have some depth.
Responses posted in the discussion may lack effective professional communication.
Responses to faculty questions are somewhat answered, if posed.
Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. |
Points Range: 0 (0%) – 11 (11%)
Response may not be on topic and lacks depth.
Responses posted in the discussion lack effective professional communication.
Responses to faculty questions are missing.
No credible sources are cited. |
|
| Participation | Points Range: 5 (5%) – 5 (5%)
Meets requirements for participation by posting on three different days. |
Points Range: 0 (0%) – 0 (0%) | Points Range: 0 (0%) – 0 (0%) | Points Range: 0 (0%) – 0 (0%)
Does not meet requirements for participation by posting on 3 different days. |
|
| Total Points: 100 | |||||
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