This week we dig deeper into informed consent. How can all of us as birth professionals and consumers ensure that we understand each other and that care supports the client's values? Shared Decision Making!
This week we dig deeper into informed consent. How can all of us as birth professionals and consumers ensure that we understand each other and that care supports the client's values? Shared Decision Making!
Maggie, RNC-OB: 0:06
Hey there. Welcome to Your BIRTH Partners. We're here to break down barriers and cultivate community as we discuss issues that impact pregnancy, birth and postpartum. We welcome you no matter what your background is and are so excited to learn together. Today we are going to be discussing Shared Decision Making. And we're using this as a model to kind of give it a sense of how we want conversations to happen when we are discussing options with clients, ways that you can know if a provider is perhaps aligned with really supporting you and what your goals are during birth and give some tips and tricks for what we can do as birth professionals to help, to continue to elevate the conversation around birth and choices and options so that everyone feels inspired, respected, trusted and heard throughout their entire pregnancy, birth and postpartum journey. Onto the show!
Maggie, RNC-OB: 1:05
So if you are listening to this podcast live, in real time, we are smack in the COVID-19 pandemic. And this is obviously, it is on everyone's mind, and it's impacting all of our lives in a myriad of different ways, personally and professionally. And so we plan on discussing as a group a little bit more specifically about COVID-19 and how it's affecting our practices, our interactions with clients, how we're kind of seeing birth care being affected by this in one of our next episodes. But I wanted to take the time to share this particular message, which we recorded earlier in February before this was really reaching its peak. And I think Shared Decision Making and the idea of consent and being really clear about what options are available during labor and birth could not be more relevant than in a time where so many people are being swept up and feeling panicked and worried. And there is so much misinformation, and there's so many sources that we're getting our information from. I think it's very hard, it's very challenging to try to stay grounded in what you want and what matches up with kind of your personal philosophy for care. And I think that's on both sides; I think that's both as a birth consumer and as a professional trying to take the best care of people we can in really unprecedented circumstances. So all of that is to say that I hope this conversation really inspires you all to still continue to reflect best practices as you work to support birth, and as you work to give birth during COVID-19. And, you know, during any crisis, that can come up in our world, I know so many of us are concerned. We don't want to see just this huge, sweeping kind of return to really paternalistic care of birthing people. We want to be able to listen to experts and trust their recommendations. But we also recognize how important it is for the individual people, the families who are giving birth, to be able to make decisions that really best match-up with what their needs are, you know, within established safety parameters. And so I find this conversation to be extremely relevant, everything we're going through, everything I'm talking about with people who are pregnant right now, and really concerned about what is gonna happen to their care. And to so many of my colleagues in birth, from those who are operating out of hospital, those who are, you know, in hospitals and how we're balancing just the very quickly changing dynamic playing field we're in right now in terms of providing the best we can for birthing people. So with all that said, I am going to continue us onto our main discussion, and I really I look forward to hearing from you all about how you're really helping to navigate these kind of typical conversations and birth choice options, especially in the face of a really challenging time like we're in right now.
Maggie, RNC-OB: 4:24
How do we kind of get best practices there for how we talk to our clients about issues that come up or, you know, potential treatment options? So I want to highlight the idea of shared decision making as kind of the method for doing that. So typically, when we think about, you know, consent, we have kind of three different concepts; so there's informed consent where you know, in essence, it boils down to like, "Hello, I am the person providing care for you. This is the thing I think we should do, for this reason, do you agree?" And we're hoping that people say, like, "yes, that sounds great." And they sign that they've been consented to that. And, you know, during that process, we're certainly talking about, you know, the risks and the benefits and what you know goes into it. But potentially we're leaving out kind of what a lot of the other options are because we've kind of come in with a particular care, you know, treatment option plan that we're hoping I'll follow. And then there's kind of informed choice the idea that we just present everyone with "Okay, yes. In the situation, you could do A, B, C, or D, the world's your oyster here kind of the pros and cons of those," and, you know, informed choice is great because it's obvioulsy showing people more depth and breath of what they can possibly do. But it potentially misses out on, kind of the reason that people come to us for care is that they're looking to have an expert, you know, opinion, kind of that is helping them to evaluate their personal health history and what's going on with them and what we understand about them. And so a lot of times, people will feel like they're lacking a little bit with just getting, you know, all of these choices, that they still want someone to kind of help them guide their decisions a little bit more and so share decision making is the idea that we're kind of taking all of that and kind of meeting the middle. So we're telling people, "Hey, you have options. You could do A or B or C. Here are the risks and benefits of each of those, in your situation where I understand you have these values and you have this in your medical history, I would probably recommend B." And then we have a continued conversation. You know, beyond that, where we are able to kind of listen, you know, to the client and what their options are, um and that obviously, at the end of it, ultimately they may choose to do A or C, something that was different than what we thought. You know what's the best fit for them, but what helps him to have more autonomy about, you know, their health care. So I would like you all to kind of be able to speak to how this conversation goes and how we can kind of do that best to provide for safety while still really respecting people's, you know, individual choices and autonomy.
Ray, CBM: 6:46
Yeah. So I could talk about how this works in my home birth practice. So with all the like medical decisions like tests and procedures of pregnancy, I have informed consent document that I share with people before I talk about the test options that I typically like to do things a little bit before they happen. So, like with Group Beta Strep testing, I talk to people around 30-32 weeks about it, with newborn procedures. I talk around 34 weeks. Genetic screening, I talk at the first appointment because often times you know, when people established care of 12 weeks, one of their options is about to close, to do like a nuchal translucency. And, you know, when I share this document and then I talk about what the screening is. So I did a genetic screening inform choice yesterday, and I was like, "this is kind of what's available, was developed to screen for Down Syndrome. We now have all these other screens that are available. This is why people seek it, this is the information, there is the risk of having a negative positive screen and then like that, adding stress to a pregnancy and seeking diagnostic testing. There's risks if we don't have this information, like, if you choose to decline all genetic screening, including an anatomy scan and we don't know your baby has a heart defect that is born at home like that could affect life." And so we kind of hold all those things together and, like people sometimes like, reflects on the things that they're prioritizing, values and reflect that back and then we kinda have to make a decision together but allowing them to really be in the driver's seat. There are times that you know, as a provider, like I have boundaries around what I can and can't do so. Like if I have a concern about fetall growth and someone declines an ultrasound like I can't provide safety in that scenario without the tool of ultrasound, and that's like one of the boundaries I get to have because people are choose universe at home and then I need to determine that someone is a safe candidate for that, and we're entering into a partnership to do that together. But if someone does not want to have any ultrasounds in pregnancy and we're holding together that there's information we don't know, and they're accepting responsibility for that, like I can do that. And I think that kind of like having those conversations together from the beginning, helps to set the stage for home birth. And it allows for, like, more complex conversations, you know, around labor, like if someone's water was to break first, and they don't go into labor, to have a bigger conversation about risks and benefits, what's available at home, what's available to hospital, what we can do to reduce infection risk. And that the birth would change very significantly quickly if an infection developed and to hold the balance of both and tell them both, like what my comfort level is, and what my boundaries are and also, you know, help them kind of navigate, you know, like someone might choose to transfer way before I would. Or they might kind of push the limits and me being like, "okay, like I can do this for a little bit longer, but not forever. But like I could also respect your choices in this moment or in labor. You know, like if I've had someone who's like "Okay, you were seven centimeters at 10 a.m. And it's now like 4 p.m. And you're like seven and 1/2. You know, these are the positional things we haven't done that we could do. And then we can reassess and see if they work. You know, we could try and help you, like rest for a little while and then get the contractions a little bit more active or this is taking a long time, you know, like there is a balance where the time labor can take can start affecting baby's well being. And, like the intervention of the hospital might be able to hope more with that or are a lot stronger and so kind of having conversations like that and then making the plan to, like, re-evaluate to see if, you know, hanging upside down over this they're doing this, like, was effective or not, and then reevaluating and making another decision together.
Pansay, Doula: 10:29
Yes, within my practice, I feel as though it's my responsibility because it's so many decisions that has to be made throughout the pregnancy, you know, labor and birth. So I definitely provide the clients with all of the tests that might be recommended. What are some of the choices with that they'll come up with with labor, and then also you don't with the actual birth. What's important, I feel, is very important is giving them yes, the responsibility of research. Yes, I give them, you know, the risks & benefits on the choices. And I try to do that at the beginning of our relationship so that none of those decisions feel rushed, you know? So they have time to research with that, what I also like to do is have all of my clients join like, support groups, right? So they could see all these different scenarios of what these other women have gone for when they chose this particular, you know, action or did not and let them spend time. You know, with that before it comes before it comes up for them to actually make that decision. And then there is at least 2 to 3 visits that I attend the doctor's appointments, you know, with them so that we can all sit together, and it's, you know, to talk about the test to talk about the risks the benefits to get the doctors, you know, point of view. And most times they still have some time to think about it. Um, and make that decision. You know, with that, it seems that the client is much more secure and comfortable with it, with everybody, you know, playing a part and, you know, with a decision that they've chosen. You know, of course, you run into things that there needs to be a decision that has to be, you know, made quickly. I try my best to cover as much of those scenarios as possible, you know? Okay. And, you know, that's what if this this is a possibility. So they so you know, it's it's at least not the first time that they've even, you know, heard of it.
Maggie, RNC-OB: 12:45
Yeah, I think covering those possibilities absolutely, you know, helps. You don't want people to feel overwhelmed, you know, during the prenatal period, with everything that happened. But it's also important to be realistic about what you know, what we might see and how things could potentially, you know, involves that things aren't, you know, blindsided. I always I like the the BRAINS acronym as a way for kinda how you think about things. So there's, like, benefits, risks, alternatives, that sense like what is your intuition telling you? What does your values kind of line up. And then I was like that. The end is now, you know? So is this something that has to be made? A decision has been rain right now is their potential for time to kind of see what happens or let things evolve. Like, you know, Ray was saying, um and then the safety piece of it, Um and so I think it's very important to understand, you know, obviously that safeties are messy, you know, it's always gonna be a primary concern for us. We want to make sure that we're, you know, we're kind of allowing for things to evolve but also ultimately that we are doing everything in our power and, you know, within our scope to really protect for, you know, safety of, you know, the birthday person and their baby. And you know I would love for you guys too, if you can, um, kind of way in a little bit about how do you How do you deal with this topic of share decision making, especially when it comes into when people are making decision that you don't necessarily feel comfortable with or where you have safety concerns and what are kind of some ways you work around that.
Abby, MD: 14:07
I think the unfortunate thing in OB is sometimes these things come up as somebody who just wanted to really quickly. Um, you know, when things aren't going right, they sometimes aren't going right really very quickly. So I think having conversations in advance about everything that potentially could happen is an important part of our job. And then I think that also, um, I mean, it's hard if if somebody wants something that I don't think it's the safest thing or that I haven't necessarily recommended, my job is to educate, and my job is also to make sure that my patient understands the consequences of their decisions. But somebody very wise once said to me, If you're working a lot harder than the patient, you sometimes need to just step back and, like recognize that you know the patient's gonna make some of these decisions on their own. It's harder when there's a baby and it's harder when you've been doing this for a long time and you know that if you don't have a healthy baby at the end of this process, that ultimately tends to drive people's perceptions of their birth more than anything else.
Angela, CNM: 15:23
Usually what happens is when anyone presents something to me that I know is gonna put them at risk, or I know will lead directly to poor outcomes or potentially poor outcomes, I usually just investigate, you know, why they are feeling a certain way or why they think that they want to do a certain thing. Because most of the times it comes from just lack of knowledge, you know, not understanding completely, or maybe they've experienced some trauma in the past that has impacted the way they view their current situation. And usually what happens is I allow them to explain things to me, and I discover where the error in communication or education may have occurred. Or I discover that they genuinely just don't have trust anymore because of how things happen. Let's try to educate them about things and explain why and give them rationale, and I would say, man really, like 98% of the time, the patients are like, "Oh, okay. I didn't know that. No one's ever explained that to me. Okay, I think that's reasonable. I'm okay with doing that, or trying this for X,Y,Z reasons" or, you know, "Hey, I hear you, Angela. But I really want to try this way first. And if this way doesn't work, can we do it the way you recommend?" And usually, you know what, that's fine. Absolutely. That's fair. It's all about shared decision making, and I may not necessarily like those things, but you know what, if the patients is willing to listen to me and trust me enough and respect me enough to share and confide in me about the things that they desire then I just feel like you know what? Like I need to, I need to continue to promote this. And I will just document, you know, we discussed X,Y,Z, the patient still declined, but we are in agreement that if you know things, don't pan out that she will do this as recommended. You know, and that's it, and I don't lose any sleep over that. I usually feel pretty good about those conversations. I feel really good about those conversations because you made the decision together and the patient feels like they have autonomy. And I'll say, even in those rare cases, sometimes patients will call me back. Like, "you know what? Angela, I was really thinking about it. I talked to my spouse, et cetera. I think we do want to go ahead and do what you recommended." Yeah.
Maggie, RNC-OB: 18:19
Yeah, I think that, I love just the idea of just giving more time. You know, I think so many times we're busy as birth professionals, and you're just trying to kind of check, check, check and move things along and really have any time to have that conversation. And also then giving your client reminding them that they too have time. You know, every decision is not doesn't have to be made, you know, right now, and that that's something that's beautiful, that then they have time to actually, you know, process and think and, you know, evaluate what makes sense for them.
Angela, CNM: 18:46
Yeah!
Maggie, RNC-OB: 18:46
So yeah, you know, I think those conversations it's hard, though it's hard to have. I think there's that little piece, that ego that's in all of us, who, you know, we know we experienced a lot and we feel like we know you know so much and that sometimes we really just need to take a step back and, you know, realize we know so much about birth, but we don't know, obviously, as much as that that client does about themselves and about what makes send for for them, and it's really hard to kind of have that dissonance. But we have to live in that space sometimes.
Angela, CNM: 19:13
You know, I think the thing that's interesting to me is that, and I still don't quite get this, we have so many people, providers, and when I say providers, I am including every level of provider anyone who provides a service or health care to a client, nurses, techs, CNAs. It does not matter. Physicians, nurse practitioners, social workers, everyone. I don't understand how it is that we get so upset when people say no to what we recommend or suggest. I never feel that way. I genuinely don't feel that way. I genuinely don't get worked up personally when someone says "I'm not vaccinating my kid," for example, or "I don't want to do the GPS swab" or "I don't want to take antibiotics." I don't get, I don't get angry. I just ask "okay, tell me what's going on? Tell me, why do you feel that way?" And when they say no because of this, this, and this I I educate them and they still say no. I say ok. I don't like walk out of the room feeling upset. And I don't understand the emotional response that people get over people choosing what happens to their body. I don't get it. And it makes me completely insane. Your life would be so much better if you just minded your own business. Honestly, even in health care, you know. It's just people have the right to say what happens to their body, and just because they're seeking health care from you does not mean that you are now in charge of them. Are you're offering them a service? They may or may not like all of the service, which is their choice. You certainly have the right to say, You know what? I don't feel comfortable as the clinician. I don't feel comfortable with this. Um and I am going to have to dismiss you as a client because this does not align with my personal practice philosophy. And that's okay, too. Patients can fire practitioners. Practitioners can fire patients if the relationship is not, um it's not cohesive, you know.
Maggie, RNC-OB: 21:40
Right. No it isn't. It's important to realize that just exactly what you're saying. Like you said it so well, that just it. It's not up to that care provider what happened, and that's hard. And I get it cause we do, we get very invested, obviously, in the outcomes of our clients, which is good. That is appropriate. Of course, you want to care about what happens
Angela, CNM: 22:01
I go home thinking about these people. Good or bad outcomes, I go home thinking about them, you know.
Maggie, RNC-OB: 22:08
But realizing that you sometimes have to kind of pocket that up and separate that from your feelings and then what is actually happening and being able to to step back a little bit and just recognize that you absolutely should care about your client. But you can't care more. You can't. You know, you have to let any time that you feel like you're creeping over and you're trying to impact, like overpower their feelings and their thoughts about a thing you have to realize, like "whoops. Oh, I got too invested in that." And that's not appropriate because it is not my experience on that, is it? I mean, it's obviously it's harder than something with so many of us, we have to actively work against, you know, and get yourselves in those moments when we realized like "oh, hmmph. I'm going the wrong direction with that..."
Angela, CNM: 22:52
Yeah, absolutely, absolutely.
Maggie, RNC-OB: 22:54
So I wonder, Ray, if you could speak. I don't know how much of this is kind of being fueled by most of my experience coming from being in hospital births and cut into the more paternalistic setting of, you know, hospital policy and how much that kind of dictates that feeling that you know, that kind of investment or fear piece goes into it. If you want to speak a little bit more to kind of the community birth/home birth setting.
Ray, CBM: 23:17
I have my like kind of how I transfer in my like consent to home birth. And so for me, like I outlined from the beginning, being like, you know, like you're hiring me, you know, to provide safety and for my judgment to and, you know, I've never been in a situation where I've recommended transport for a medical concern and someone has declined. But I have in my consent that if you, if I think about a transport for medical reasons, is necessary and you declined, like, I'll transfer care EMS. Like, I do think people have the right to make decisions that might harm theirselves and their babies. You know, in saying that it sounds judgmental. I think people have the right to make decisions that make me uncomfortable and I disagree with. But it does not mean I need to attend their birth at home. And yeah, it's kinda like holding that balance of like, you know, for me so much of like, you know, home birth midwifery is like building deep trust with my clients. So you know by the time we get to the birth, most things can be unspoken and also like they really do trust my judgment and trust that I have their best interests at heart and respecting their values. And if there's a sudden shift, it's okay and they are going to go with me or like you know, I have the answer. Remember a head of someone where you're like, What do you do if the bull Santa doesn't comment on bleeding a lot? I'm like, I get it and you know I like, and that's a situation where I can't like. You're like, May I do this? It's like I'm sorry. This is an emergency. I need to do this right now And we built the trust that it's not like it sucks, but it's not like maybe as traumatic as it would be if you don't understand why it was happening of you didn't have a relationship with a provider kind of thing.
Maggie, RNC-OB: 24:57
Yeah, absolutely, I think that as we continue, you know, it always keeps circling back that that piece that we really want to have those strong relationship so that, I think as we work to improve, you know, perinatal care and especially the care that we're able to give during that prenatal period that ideally, we would have a shift that, you know providers have longer appointment times, you know, to talk about some of these issues and to develop that trust and to go through more of these questions so that in those those really tricky, you know, situations where you start to feel like these very of life and death issues, and they need be acted on now that there's more kind of understanding and there's more of a history there, you know, between the client and provider and I know Pansay was speaking to that, you know, earlier that you had a chance. People talk about it a lot earlier on so that you have a little bit more background and it doesn't come across, you know, quite as jarring and traumatic as it could otherwise,
Pansay, Doula: 25:52
With my position, I have to be very clear and comfortable that these aren't my births. So, you know, with that, doing my part very diligently to educate, you know, once I deliver that information and they have studied and researched, you know themselves they then it is their birth. So it's, you know, sometimes clients do want an epidural, you know, sometimes they want a c-section, and I have to be comfortable that I've done my part, and it's their right to make that to make that decision. Yeah.
Maggie, RNC-OB: 26:28
Yeah, absolutely. And I think you know that the key, please, about your decision is that we're involving. You know, the client in that we're really listening to their values, which might be very, of course, completely different than our own. Also providing, you know, providing for safety and providing, you know, like Ray was saying that we're, you know, we're meeting them, you know where they are. But part of why they've chosen, you know, to seek out care is that they want, you know, someone else to be there to help, to guide and provide safety. And, you know, for all that. So I do. I hope, as we you know, as we move forward that we are able to just have more time to have these conversations, you know, with our clients and that, you know, there's increased education for consumers about options and in the role that they have, you know, as autonomous people you know, in their health care. People feel more able to to ask questions and to get into discussions, you know, with birth professionals and and feel really empowered about what's going on with their body. I liked a quote from Larry Morrissey: "until we help people think about decisions and what's important them? We're not getting at the problems they face." And so I like that idea that we're helping people to really see, you know, to see themselves and see what's going on and then be able to make their own decisions just like we want to do with, you know, everything else that happens in our life. Thank you all so much for weighing in on this today. We'll talk soon.
Maggie, RNC-OB: 27:49
Thanks for tuning in. We love to talk birth and would love to talk about it with you. Please join the conversation by finding us on Facebook, Instagram or Twitter, we're Your Birth Partners on all platforms. We also recommend you check out our show notes blog on our website, yourbirthpartners.org. We'll be getting into some of the fun topics we've discussed today, including a really great video about your decision making and how it might look in health care setting. And we also ask, as we continue to spread this message far and wide, that if you agree and support our mission, you would share this with your friends and colleagues or consider donating to our non-profit. Thanks so much for your support until next time.