Shared Decision-Making in Perinatal Care

Shared decision‐making is key to improving communication and patient satisfaction in perinatal care (Megregian et al. 2020).

Many practitioners would argue that joint decision making between patients and clinicians is a natural and integral part of everyday patient care. Yet, as Hoffmann et al. (2014) suggest, shared decision‐making is more complex than this and should be considered a framework for communicating with patients about important healthcare choices that will ultimately lead to improved standards of care.

Principles of Shared Decision-Making

Hoffmann et al. (2014) describe how shared decision-making is a continuum, with both the clinician and the patient taking varying levels of responsibility depending on the patient's preferences and the context in which the decision is occurring.

Coulter and Collins (2011) define shared decision-making as a process in which clinicians and patients work together to select the best treatments, management or support packages by combining clinical evidence with the patient’s informed preferences.

In perinatal care, it’s especially important that parents are included in all aspects of decision-making about their baby’s care. In particular:

• Healthcare providers should give consistent information to help parents understand and engage meaningfully in decision-making
• Trusting relationships should be developed with parents in order to gain valid consent
• All members of the perinatal team have a role to play in facilitating shared decision-making with parents and should be trained accordingly
• Appropriate verbal information should be provided using the PARQ format to optimise parental understanding of a proposed treatment:
  • P (Procedure)
  • A (Alternatives)
  • R (Risks)
  • Q (Questions)
• Written information should be available for common procedures to complement verbal discussions
• The level of consent sought should be appropriate to the situation
• Conversations should be clearly documented, including the key aspects of any information given to parents, their apparent understanding and their agreement to proceed.

(BAPM 2019)

The Benefits of Shared-Decision Making

In its simplest form, shared decision-making occurs when health professionals and patients work together (NICE 2023). Yet, empowering patients to make decisions about their treatment and care can involve some important and well-defined steps.

For example, care or treatment options should always be fully explored along with their risks and benefits, and the full range of choices available to the patient should be discussed. When shared decision-making goes well:

• Each party understands what's important to the other party
• Patients are supported and empowered to make informed choices and reach a shared decision about their care
• Health professionals are able to personalise care and treatment to the patient’s individual needs.

(NICE 2023)

As Hoffmann et al. (2014) point out, shared decision-making isn’t a single step to be added to a consultation. Instead, it’s a process that can be used to guide decisions about screening, investigations and treatments, and it allows patients' preferences to be incorporated into a consultation.

The benefits of shared decision-making go way beyond improving patient knowledge and patient-clinician communication - the incidence of decisional conflict or patients feeling uninformed can also be greatly reduced.

Implicit and Explicit Consent

Informed consent is essential if shared decision-making is to be successful. Yet, different procedures may require different levels of consent (e.g. implied, explicit, verbal or explicit written) (BAPM 2019). For frequently performed procedures, especially in neonatal care, blanket consent from the parents is often sought at the outset. However, the parameters of consent must still be clearly explained and not just assumed.

Levels of consent that form an integral part of shared decision-making include:

Implied Consent

This involves performing a non-urgent low-risk intervention without necessarily having a specific conversation prior to the procedure (BAPM 2019).

In neonatal care, it’s important that parents are informed about procedures whenever possible, as what is considered to be routine for healthcare professionals may be seen as invasive to a parent (BAPM 2019).

Explicit Consent

This is sometimes called ‘express’ or ‘direct’ consent. It's used for moderate to high-risk procedures and involves formally explaining the purpose and risks of an intervention. Written or verbal consent must then be gained prior to commencing the procedure (BAPM 2019).

For all significant procedures, discussions about consent or decision-making should also be recorded in the patient’s notes, stating the key aspects of the information provided (BAPM 2019).

Challenges to Shared Decision-Making

Shared decision-making isn’t always easy. Hoffmann et al. (2014) highlight the fact that within the Australian healthcare system, there are several key challenges to the widespread use of shared decision-making. In particular, there is a lack of appropriate training, as well as a lack of appropriate decision-making support tools to assist the process.

That being said, Hoffmann et al. (2014) suggest using the following five basic questions to guide the process:

1. What will happen if the patient waits and watches?
2. What are the test or treatment options?
3. What are the benefits and harms of each option?
4. How do the benefits and harms weigh up for the patient?
5. Does the patient have enough information to make a choice?

Kennedy et al. (2020) take a more optimistic view, suggesting that there are many high-quality shared decision aids that are readily adaptable for use in perinatal care. If an appropriate decision aid is given ahead of a scheduled appointment, it can also bring added value to the consultation by increasing familiarity with medical terminology and options for care, as well as providing insight into the personal values of a patient and their partner. This, in turn, can decrease decisional conflict and increase knowledge.

Despite the call to increase the use of shared decision‐making in perinatal care, there are still very few studies that have examined the effects of a shared decision‐making support strategy. Studies relating to antepartum and intrapartum care, which include common perinatal decisions such as induction of labour, are urgently needed, along with clear and practical guidelines to help both parents and healthcare providers make the most of the tools available (Megregian et al. 2020).

Conclusion

Shared decision making is central to perinatal care, yet even with strong evidence for its effectiveness, practical uptake of these ideas is often slow and there is currently a lack of high-quality research in this area.

That being said, it seems likely that paper-based decision aids such as questionnaires are just as effective as web, video or audio-based decision-making tools, and it’s clear that they can all play a part in enhancing patient care.