Respond to two colleagues.

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Marco and Pearl

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to at least two of your colleagues  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.

Marco RE: Discussion – Week 8 main post

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Patient Preferences and Decision Making

             As medical professionals, we strive to give the best care possible to our patients. It is through this EBP class that we have become more proficient at evaluating the validity, reliability, and, ultimately, the credibility for research material that will help drive our evidence-based practice (Melnyk & Fineout-Overholt, 2019). However, we risk falling into the trap of becoming so focused on the best treatment modalities that we fail to consider if that treatment decision is what the patient wants or even agrees to have. During my career in the Emergency Room, I have witnessed, many times, how some physicians inform the patient of the procedure they need but fail to be given them any alternative treatments to the procedure. As up and coming clinicians, we must focus on providing quality patient outcomes by utilizing practical, evidence-based decision-making skills. In order to facilitate this process, we need to first; research evidence-base theories, utilize clinical expertise, and lastly, elicit patient treatment preferences (Fowler, Levin, & Sepucha, 2011). I believe if we can follow this model, we can genuinely achieve quality patient outcomes as well as excellent patient satisfaction.

I can recall a situation while working in the emergency room years ago. My patient, Mr. Jones, came in with a complaint to feeling butterflies in his chest. He was a middle-aged male in relatively good health with not many, if any, risk factors. He stated that the feeling in his chest started approximately six hours before arriving in the ED. We, of course, quickly obtained an EKG. The EKG showed Mr. Jones was in Atrial Fibrillation (A-Fib) with a ventricular rate of around 100. B/P was, from what I remember, adequate. Mr. Jones appeared asymptomatic other than the unfamiliar feeling in his chest. The attending ED physician spoke with the patient and his wife and told them what they needed, which was, in his opinion, cardioversion. I am not questioning whether or not that was the best treatment given the patient’s condition. I am merely stating that all the treatment options were not explained to the patient; hence the patient was not given alternative treatment choices. We proceeded with the procedure, and ultimately the cardioversion was unsuccessful, and the patient remained in A-Fib. The patient and his family were very disappointed that he had to go through this procedure, only to have it fail to convert his rhythm.

        Mr. Jones was eventually discharged with an anticoagulant and a referral to an Electrophysiologist. I believe if the patients would have been given all the alternatives, they may have opted to see a specialist before being unsuccessfully cardioverted in the ED. If we consistently consider the patients preference when planning treatments, we will ensure that we involve the patient in their treatment decisions. Patients involvement in treatment decisions will not only improve outcomes but patient’s satisfaction as well. The decision aid is an extremely useful tool that should be utilized to help educate the patient in regard to the different treatment options. Pt can also evaluate the risk and benefits to each treatment, which will aid them on their decision. Pts can easily get on the website, search for their condition, and take a questionnaire. After receiving some information on alternative treatment, the tool helps them evaluate the best decision for them based on how they respond to the questionnaire.  (The Ottawa Hospital, 2019). In the future, I will take advantage of this patient decision aid to help inform and educate my patients and involve them in their care plan and treatment decisions.

References

Fowler, F., Levin, C., & Sepucha, K. (2011, April). Informing And Involving Patients To Improve The Quality Of Medical Decisions. Health Affairs. http://dx.doi.org/https://doi.org/10.1377/hlthaff.2011.0003

Melnyk, B., & Fineout-Overholt, E. (2019). Evidence-Based Practice (Fourth ed.). Philadelphia, PA: Wolters Kluwer.

Patient Decision Aids. (2019). Retrieved from https://decisionaid.ohri.ca/AZsumm.php?ID=1177

PEARL

RE: Discussion – Week 8

COLLAPSE

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              Evidence based practice enhances healthcare quality, improves patient outcomes, reduces costs, and empowers clinicians. This is known as quadruple aim in healthcare. And the most important reason for consistently implementing evidence-based practice is that it leads to the highest quality of care and the best patient outcome (Melnyk & Fineout-Overholt,2019). Patients being a major part of their care decision is very important especially if they have the capacity to do so. But if they are unable to decide, the assigned medical power of attorney or legal guardian should be allowed to do so. The hardest step in evidence-based medicine is to incorporate patient values, preferences, and circumstances into the patients care (Hoffmann, Montori, & Del Mar, 2014). Sometimes decision aids can step in and assist the patient in educating them to make an informed decision about their care (Schroy, Mylvaganam, & Davidson, 2014).

As a critical care nurse, most of the patients I care for are very sick, and for many of them, their time in my care is the end of their life. While nurses try their hardest to save every patient, they also have learned how to be realistic and know when to expect that the patient has reached the end. Sometimes patients’ prior condition is taken into consideration in decision making. Clinicians must act in patients’ best interests and use evidence-based decision making which includes using their judgement to help patients make decisions (Melnyk & Fineout-Overholt, 2018). I had an 80-year-old patient that developed gall bladder issues and needed surgery. She went in for a cholecystectomy and while in hospital, developed ileus. She was sent home with a sludge drain and was living on enteral nutrition. Further problems developed with her drain causing intra-abdominal abscess. More surgeries needed to be done which led to sepsis and acute respiratory distress. The care team had to be transparent with the family, all measures to save her life was incorporated. Maxed out on vent setting, use of CRRT machine, ROTO prone machine used, maxed out on all pressor. Palliative care was consulted and multiple discussions between the medical care team and family was made to determine course of action. But family wanted to continue care despite knowing the severity of patients’ case. Patients suffered for months on this life support machine before families decided to let go and opt out for withdrawal of care.  Had a shared decision-making patient (surrogate) decision aid was used earlier in the process, the outcome may have been different. Decision on continuation of life is ultimately the decision of the patient and appointed surrogate. No one is comfortable making these decisions, and clinicians should be trained in communication to facilitate treatment decision (Kon, Davidson, Morrison, Danis, & White, 2016). Our job as healthcare professionals is to offer the best scientific evidence available while considering the patient’s values, goals, and preferences. To avoid cases like this, I would ensure that patients have advanced directives made during admission to help reduce prolonged and unnecessary treatment. This is a useful too to add to the patient’s education list because it makes the patient’s wishes known, that way we are not suffering patients when there are no other options.

                                                                References

Hoffmann, T.C., Montori, V. M., & Del Mar, C. (2014). The connection between evidence based

            Medicine and shared decision making. JAMA, 312, 1295-1296. doi:10.1001.2014.10186.

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:10.1098/CCM.00000000001396.

Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence Based Practice in Nursing and

            Healthcare: A Guide to Best Practice (4th ed.). Philadelphia, PA: Wolters Kluwer Health.

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.

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