Discussion: Discussion: Patient Preferences and Decision Making
A couple of months ago, I had a young patient with necrotizing fasciitis due to Necrotizing fasciitis is a flesh-eating disease when bacteria break through the skin barrier and infect the tissue. This disease is sporadic and requires immediate treatment of intravenous antibiotics or surgical removal of dead or infected tissue in severe cases. The gentleman was a young man early 30s and had
necrotizing fasciitis throughout his entire right forearm, radiating slightly past his elbow. Due to coming from a small, rural hospital, all significant surgeries are usually shipped to larger hospitals in other states. However, the orthopedic surgeon believed he could tackle this surgery at our facility. The patient at first did want to be sent to a larger hospital specializing in skin grafts, plastic surgery, etc. However, after numerous conversations with our surgeon, the patient reluctantly decided to do the surgery at our facility. The first surgery was unsuccessful, and the patient underwent four more surgeries within a week at our facility before the administration stepped in and sent him to an appropriate facility that could accommodate all his needs. The patient did not receive proper treatment soon enough and ultimately had to amputate his arm.
It is crucial understand their patient’s beliefs, values, and preferences to promote effective communication to understand the patient’s role in decision making, the meaning of diagnostic information, and the treatment plan (Kennedy et al., 2017). In the previously described situation, the surgeon showed poor communication skills as the surgeon did not consider the patient’s wishes, preferences, and best treatment plans. As healthcare professionals, one of our primary roles is to advocate for our patients and incorporate them into the treatment plan as best as possible. Ultimately, we are treating their body. Therefore, the patient’s values, beliefs, and preferences should be the deciding factor in a treatment plan if alert and oriented. However, in this situation, the patient’s preference was disregarded and resulted in a medical consequence affecting his entire life. If the patient would have been sent directly to a tertiary center, the outcomes may have been significantly different.
According to Health Value Hub, shared decision-making has been shown to result in treatment plans that better reflect the patients’ goals, increase patient and physician satisfaction, improve patient-physician communication, and positively affect outcomes (Home, 2019). Physicians should be properly trained to communicate to facilitate treatment decisions to ensure patients are being heard effectively. The three significant components that make up the evidence-based practice are the best available evidence, the clinician’s knowledge and skills, and the patient’s wants and needs (APTA, 2020). By cooperating with all three elements, the patients will benefit greatly and be satisfied with their treatment plan.
The closest patient decision aid I could find about cosmetic surgery was utterly unrelatable. The decision aid was on making quality decisions about primary breast augmentation surgery. Therefore, I found the Ottawa Personal Decision Guide much more helpful for this situation. The guide allowed the patient to problem solve and visualize the entire treatment plan, including knowledge, values, support, and certainty, to make the patient decide ultimately. I would use this decision guide in my future practice to help my patients thoroughly understand their decision plan and make sure they are satisfied with their decision.
APTA. (2020, March 23). Components of evidence-based practice. https://www.apta.org/patient-care/evidence-based-practice-resources/components-of-evidence-based-practice
Home. (2019, May). @HealthValueHub. https://www.healthcarevaluehub.org/advocate-resources/publications/consumer-benefits-patient-shared-decision-making#:~:text=Research%20reveals%20that%20patients%20who,increased%20compliance%20with%20treatment%20regimens.
Kennedy, B. M., Rehman, M., Johnson, W. D., Magee, M. B., Leonard, R., & Katzmarzyk, P. T. (2017). Healthcare Providers versus Patients’ Understanding of Health Beliefs and Values. Patient experience journal, 4(3), 29–37.
Discussion: Discussion: Patient Preferences and Decision Making SAMPLE 2
At my facility, we provide patients an opportunity to express their choice or preference regarding their healthcare. I work in Case Management so when arranging post-acute care, we must provide our patients with a choice list and allow them to decide for themselves. Whether patient will discharge to a Skilled Nursing Facility, home with home healthcare, or will need Durable Medical Equipment (DME), we provide a preference list and allow patients to choose which facility or agency they would like to use. Respecting Choice is a model of advance care planning and something we follow religiously. According to MacKenzie et al., “Respecting Choices is a well-known model of advance care planning intended to assist individuals consider, choose and communicate these preferences to health care providers”. Recently, our palliative NP had to discuss end of life choices with a young terminal cancer patient. The patient seemed to accept his fate and decided to discharge home with Hospice. Patient’s wife on the other hand wanted her husband to keep fighting and accept any aggressive treatment. The palliative NP repeatedly informed the wife that the hospital will respect his choices and arrange Hospice at home. Wife continued to fight and attempted to have her husband deemed incompetent without success. Respecting patients’ choices is a way to demonstrate a way of acknowledging their moral status as individuals and their ability for self-determination (Beauchamp & Childress 2013). Patients’ wishes as well as their goals of health define the ethical obligations of health professionals (Zolkefli 2017).
MacKenzie, M. A., Smith-Howell, E., Bomba, P. A., & Meghani, S. H. (2018). Respecting Choices and Related Models of Advance Care Planning: A Systematic Review of Published Evidence. The American journal of hospice & palliative care, 35(6), 897–907.
Beauchamp, T.L., Childress, J.F. Principles of biomedical ethics. 7th ed. New York: Oxford University Press; 2013.
Zolkefli Y. (2017). Evaluating the Concept of Choice in Healthcare. The Malaysian journal of medical sciences: MJMS, 24(6), 92–96. https://doi.org/10.21315/mjms2017.24.6.11
Felisha, as you have mentioned in your post, the three fundamental components of Evidence-Based Practice are the best available evidence, clinician knowledge and skills, and patient’s wants and needs. Moreover, from your argument, one particular aspect is the third one, a patient’s desires and needs are mainly referred to as autonomy. Molina-Mula and Gallo-Estrada (2020) tell us that providing respect to a patient’s autonomy (the right to make their own informed decision about their medical care) means that we are acknowledging that the patient has full rights to which facility and doctor they believe will best provide them with proper care. Furthermore, according to this passage, the surgeon did not violate this right but instead put the patient into a life-changing situation. There is a rule that “healthcare professionals should not impose their own beliefs or decisions upon their patients” when the patients have made “informed decisions about their healthcare” (Pirotte & Benson, 2020). Understandably, the patient-physician relationship is unlike and distinct since the physician needs the patient to trust that he will do what is best for the patient’s wellbeing. However, unfortunately, in this case, the patient has the ultimate choice on the particular care they need, especially in emergent or urgent situations, such as the Necrotizing fasciitis, the flesh-eating disease.
Thanks for sharing, Felisha.
Molina-Mula, J., & Gallo-Estrada, J. (2020). Impact of nurse-patient relationship on quality of care and patient autonomy in decision-making. International journal of environmental research and public health, 17(3), 835.
Pirotte, B. D., & Benson, S. (2020). Refusal of Care.