Perviable Decision Making

How I Practice Video Series 
Brownsyne Tucker Edmonds, MD, MPH, MS, FACOG – Indianapolis, IN


Transcript: Periviable Decision Making

I study periviable decision making and obstetrical care in the setting of periviable delivery. It’s really probably one of the most difficult and challenging areas, I think, for obstetrician gynecologists and for neonatologists even to communicate in. I’ve watched with my research I’ve observed a number of attending physicians, OBs, neonatologists, residents, I’ve watched them counsel standardized patients who are portraying this role of having ruptured their membranes at 23 weeks and they tend to get stuck in the same places again and again. So if I had advice to help OB/GYNs enter into that interaction with patients and have more success at making it kind of a more patient-centered interaction, I’d probably give them three points to consider. The first is that I’d avoid going in with a spiel. I think that since we’re a little uncomfortable in that setting that people just tend to go in, they have their thing that they say, they are trying to go in there, get it said, and get out.  But I would really recommend starting off with this ask-tell-ask technique that there is a great deal written about. It really starts with what the patient understands and knows already. It’s a tenant of adult education that if we sort of tailor our message to where people start, I think it can save us time, but it can also help patients to feel heard and engaged. So just asking patients: What have the other doctors told you? What do you know about this situation? I think one of things that I have seen doctors say that is most effective is: What experience do you have with premature babies or do you know anyone who has broken their water this early in pregnancy? So starting out with a question that helps you to understand what the patient know, where they are starting I think can help before we sort of jump into just unloading all of the information that we think is important for them to hear. On the back end, the reason it is ask-tell-ask is that a lot of times after we’ve given the information a lot of times we use our classic “do you have any questions?” but the truth is that if a patient says “no” doesn’t mean that they understand it, it may mean that they have no idea what you’ve said and don’t even know where to begin with questions. So a more effective strategy is to do teach-back techniques of asking, “I’ve told you a lot of information and I’m not always as good at explaining things to people as I hope to be, can you tell me back what you understand about what we’ve talked about so far?” Another teach-back strategy that I utilize that I think often times fits in the periviable situation where you’ve counseled a woman who might be alone at first or needs to go talk to other family members as she considers her options, is, “you know, we’ve talk about you wanting to share this with your partner or ask your mom her thoughts, when you talk to that person, what are you going to tell them? What are you going to tell them in terms of what I’ve explained to you?” So those are options for you to approach how to begin the conversation about what the patient knows, telling them the information but then assessing their understanding on the end to make sure that they are actually walking away with information and that you’re on the same page.
The second area that I tend to find is really challenging for folks is this notion that somehow we can’t give patients a realistic sense of what’s going and at the same time help them to maintain hope. And so, I have a couple strategies that I think can be utilized to really assist doctors in trying to find the balance for both. One phrase that I actually learned from a fellow when I was training is this notion that “we’re not always optimistic but we’re always hopeful.” And I actually say that to patients a fair amount because the truth is I am always hopeful but then I tell them also that it is my job, unfortunately, to prepare for the worst while I’m always hoping for the best. In giving them this frame of understanding that I absolutely want the very best for you, that said, there is what’s possible and there is what’s probable. I think that we do patients a disservice if they don’t go away understanding what is the best case situation that could happen, the worst case situation that could happen, both of which help to understand the possible, but also the probable – what’s most likely to end up happening. I think often times we want to paint sort of a rosy picture, or just focus on the positive to help them maintain hope. But if we’re also invested in shared decision that is also informed decision making that we should help patients understand the possible and the probable. I try do so by helping them to understand best case scenario, worst case scenario, and most likely outcome.

The final thing that I think people really struggle with and sometimes I watch the eyes glaze over when I’m talking about shared decision making in particular is this notion of values elicitation. What does it mean? How do you do it? The reason it’s important to not just assume people’s values and to actually elicit them and talk about them, bring them to the fore, is to ensure that we’re actually making management plans that are aligned with what their goals of care are as opposed to our own values and our own goals. I think that one strategy that I have found to be really effective in that setting of trying to elicit values from patients is to evoke a hypothetical patient or talk about other patients that you’ve cared for. It gives you kind of an indirect ability to help them understand what they might want to consider or to at least determine if these are any of the things that they are concerned about. And so an example would be, saying to a patient, “you know, I’ve cared for women who would always wonder and would always really struggle with the notion that had I had the c-section would that have been the thing that would have made the different? Would that have given my baby a better chance? And for those women who are going to wrestle with that and lose sleep over that, I would usually, probably recommend that they consider having the c-section. But that said, I’ve also talked to women and explained the risk, and also helped them to understand that we can’t really say for sure that a c-section is going to improve their baby’s outcome. And a number of women hear that and say ‘you know it’s really a risk that is too great to take on for this pregnancy and all my future pregnancies if you can’t tell me that it’s definitely going to help to make a difference.’ And for those women, a vaginal delivery might really be the optimal choice.” So that is sort of an example of this idea of bringing in values that people have considered, considerations, from the outside, of the hypothetical patient that you’ve cared for, and then also bridging that, you know using those bridging statements (“for a patient like that, I’d probably recommend this; for a patient like this, I think this might be a better choice”) and of course that leaves us to consider, especially for patients that we’re just meeting for the first time, it gives us the room to say “you know, I’ve cared for different kinds of patients and we’re just getting a chance to meet one another so you know, which of those patients sounds more like you.”

When I consider the places that people tend to really get stuck and the advice I’d give them to navigate those sticky points, the first would be is to avoid the spiel, to start with where people are with an ask-tell-ask strategy, to make sure that whatever we’re telling them actually conveys both possibility and probability, and then to circle back and ask them to teach you what you just taught them to assess their understanding. And also to make sure that we’re eliciting values along the way and one of the strategies that I have found most useful in that regard is to evoke the hypothetical patient and to bridge their concerns, their values, their goals to a management plant that might work for this patient. And that’s how I practice.

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