Peer answers- patient preferences and decision making

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 Respond to 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.






Peer 1

Susannah Beier 

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While I am fully supportive of incorporating patient preferences and values in their treatment plan, I also know from a medical standpoint that it is not always in the best interest of the patient. Throughout my years in medicine, I have witnessed many occasions where the patient arrived in labor and delivery with a very detailed birthing plan.

For example, I had a patient bring in a 4-page birthing plan with every little detail, including the essential oils she wanted to use during each phase of labor, music she wanted to play, noise level, refusal of a cesarean section, etc. Of course, this patient failed to progress and wound up with an emergency cesarean section causing the patient to have negative feelings about the birthing process and the labor and delivery staff. “Findings showed that women relied on many resources when planning a birth and that changes made to a woman’s initial birth plan affected her recollection of the birth experience” (Cook & Loomis, 2012, p.158). 

I think that it is fine for a patient to verbalize their preferences and values; however, it is important for them to be realistic about the fluidity of medicine, especially during labor. The patient’s preferences and values impacted the trajectory of the situation because she wasn’t willing to accept the doctor’s recommendation to perform a cesarean section. The doctor had informed the patient that she was not progressing as expected, but she refused to accept a c/s and was focused on fulfilling her birthing plan. “During both the development and implementation of the birth plan, women must negotiate their expectations and make health decisions with their care providers” (Cook & Loomis, 2012, p. 160). Had the patient accepted a c/s earlier on and realized that it was medically necessary, some of her preferences might have been fulfilled; however, since she refused a c/s until it became an absolute emergency, her preferences were no longer able to be incorporated.

“Patient decision aids (PDAs) have been developed as a way to support patient participation in the decision-making process and to increase the likelihood of reaching a treatment decision that is both clinically sound and in line with patients’ values” (Ankolekar et al., 2018, p. 3). The patient decision aids on childbirth can help the patient make an informed and realistic decision about birth choices, pain management during labor, and spontaneous or induced labor (The Ottawa Hospital Research Institute, 2019). Using the decision aid inventory in my professional practice or personal life could be very helpful as it provides balanced information on a wide variety of topics and can aid in making an informed decision about treatment benefits and risks as well as help in identifying personal preferences and how they might impact healthcare choices.


Ankolekar, A., Dekker, A., Fijten, R., & Berlanga, A. (2018). The benefits and challenges of using patient decision aids to support shared decision making in health care. 
JCO Clinical Cancer Informatics, (2), 1- 10.

 Cook, K., & Loomis, C. (2012). The Impact of Choice and Control on Women’s Childbirth Experiences. 
The Journal of perinatal education
21(3), 158–168.

 The Ottawa Hospital Research Institute. (2019, June 26). 
A to Z search results. Patient Decision Aids – Ottawa Hospital Research Institute.

Peer 2

Alyssa Butterbaugh 

Patient Preferences and Decision Making

Working in the emergency room allows me to see so many different people every day and work with individuals with many different preferences and views on health. I believe incorporating patient preferences is so important and makes a difference in their overall outcomes. When reading the prompt for this week’s discussion, one scenario came to mind very vividly. While the end of life is unfortunately something we see in the emergency room often, this patient’s case hit me differently than others. A 67-year-old woman called 911 for shortness of breath around dinner, when on the scene she was told it was anxiety by EMS and decided with EMS that it wasn’t bad enough to come into the emergency room. Early morning the next day the woman calls 911 again and is brought into the ER where I work in respiratory distress. On arrival, the woman was very pale, tachypneic, tachycardic, and hypotensive. We knew very quickly we needed to know what the woman’s wishes were regarding resuscitation because of her rapidly deteriorating condition. The woman said she did not want us “to put a tube down her throat because I know I won’t survive it”. We educated the patient on how taking this portion of the resuscitation process away, limits our ability to bring her back if she were to stop breathing. The woman continued to decline. We medicated the woman with many different things and placed her on BiPAP to attempt to regain stable vitals, continuing to educate her along the way. Her brother was at the bedside when we got to the point of knowing she wasn’t going to make it much longer without further respiratory support. The doctor at the time explained that he felt she was not able to think clearly due to the low oxygen circulation and needed the brother to tell us if we would be intubating her within seconds. The brother said he wanted us to do everything in our power to save her, and we did. We intubated and coded this patient for over an hour with the return of ROSC 3 times. This woman passed away that night and, in my opinion, was denied the ability to pass based on her preferences. Was the woman capable of making her own decisions at this moment, or was her hypoxia changing her decisions? I don’t know,  but I know reflecting on the situation, every nurse and tech in the room was thinking the same thing, why did we intubate her when she did not want it? I cannot say that the woman would still be alive if we had not intubated her, the end was inevitable with or without intubation, but I still wish we could have respected her preferences in the moment and simply made her comfortable. 

            In this scenario, the patient’s preferences were followed for a short time, but to provide full support on the brother’s request, we did not follow the patient’s preferences and it ended in her death. We ultimately educated the patient along the way and allowed her to take it as far as her dying breaths before following family requests, so the plan of care was altered to provide minimally invasive support via BiPAP and medications rather than immediate intubation and medications. Documentation of dying wishes and resuscitation preferences in place allows emergency workers to provide the most patient-centered care possible (Waldrop et al., 2019). Having documentation of wishes before having prolonged hypoxia may have made it clear to the provider as to her true wishes rather than assuming the hypoxia was keeping her from thinking appropriately. 

The decision-making aid that I felt fit this scenario the best was “Plan Well Guide: A novel decision aid to support serious illness decision-making” which walks individuals step by step through the process of deciding what their preferences would be in a medical emergency, how to make a will and how to share it with family (The Ottawa Hospital Research Institute, 2019). In this situation, a written document of the patient’s wishes when she was well would have clarified if the decisions being made by the patient were truly being altered by her hypoxia. In general, having a living will is great for everyone. You never know when you’ll need one and it is a way to know your wishes will be known. These decision guides are helpful tools for a professional and I think should be shared with not only medical professionals but can be shared with patients as well to help them understand their options and processes more clearly. The use of decision aids should become a best practice as it optimizes informed decisions without pressure (Bonner et al., 2021). I could use this if I were to run into a medical problem, I am not well-educated on or to assist a family with medical decisions. Overall, these are great resources. 


Bonner, C., Trevena, L. J., Gaissmaier, W., Han, P. K., Okan, Y., Ozanne, E., … & Zikmund-Fisher, B. J. (2021). Current best practice for presenting probabilities in patient decision aids: fundamental principles. 
Medical Decision Making
41(7), 821-833.

The Ottawa Hospital Research Institute. (2019). Patient decision aids. Retrieved from 

Waldrop, D. P., McGinley, J. M., Dailey, M. W., & Clemency, B. (2019). Decision-making in the moments before death: challenges in prehospital care. 
Prehospital Emergency Care
23(3), 356-363.

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