“Doctor, what would you do?”: Physicians’ responses to patient inquiries about periviable delivery

Abstract

Objective To qualitatively assess obstetricians’ and neonatologists’ responses to standardized patients (SPs) asking “What would you do?” during periviable counseling encounters. Methods An exploratory single-center simulation study. SPs, portraying a pregnant woman presenting with ruptured membranes at 23 weeks, were instructed to ask, “What would you do?” if presented options regarding delivery management or resuscitation. Responses were independently reviewed and classified. Results We identified 5 response patterns: ‘Disclose’ (9/28), ‘Don't Know’ (11/28), ‘Deflect’ (23/28), ‘Decline’ (2/28), and ‘Ignore’ (2/28). Most physicians utilized more than one response pattern (22/28). Physicians ‘deflected’ the question by: restating or offering additional medical information; answering with a question; evoking a hypothetical patient; or redirecting the SP to other sources of support. When compared with neonatologists, obstetricians (40% vs. 15%) made personal or professional disclosures more often. Though both specialties readily acknowledged the importance of values in making a decision, only one physician attempted to elicit the patient's values. Conclusion “What would you do?” represented a missed opportunity for values elicitation. Interventions are needed to facilitate values elicitation and shared decision-making in periviable care. Practice Implications If physicians fail to address patients’ values and goals, they lack the information needed to develop patient-centered plans of care.

Women’s Preferences for Maternal and Neonatal Morbidity and Mortality in Childbirth

“…27 Parental concerns about quality of life and the notion that “there are worse things than death” may be drivers of perinatal decision making, yet physicians infrequently have the skills, tools, or comfort level to elicit values and preferences related to death and disability. 28 Our study has important limitations that must be accounted for when interpreting our findings. Because we recruited a convenience sample of participants from community-based clinics and events, the study population may not be representative of the local, regional, or national population.…”

‘Whatever decision you make it will be the right one’: A parent's reflection on difficult decision‐making in premature birth

“…A study that simulated a situation similar to ours explored physician's responses when asked by an expectant mother facing peri‐viable delivery ‘what would you do?’, and found most physicians deflected this question . The authors suggest that this is a missed opportunity to elicit family values, one of the key tenets of shared decision‐making.…”

“…The authors suggest that this is a missed opportunity to elicit family values, one of the key tenets of shared decision‐making. In addition, failure to acknowledge the significance of this question, where an attempt is made by a parent to connect with the health professional on a personal level, can feel like abandonment in a time of great need for a personal response . Many years earlier Quill and Cassel (1995) also used this terminology and argued that there is an ethical obligation for ‘nonabandonment’ by health professionals, when faced with challenging medical situations …”

Values clarification: Eliciting the values that inform and influence parents' treatment decisions for periviable birth

“…A process is needed to assist parents in preference construction and values clarification (VC). Unfortunately, physicians lack skill in VC and oftentimes fail to elicit values, placing parents at risk of misinformed decision making, decisional conflict, and regret, which may have long‐term implications for parental mental health, and QOL following delivery …”