Respond to the four 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 situa

Qwinnetta: For this discussion, I chose the topic of tonsillitis/tonsillectomy as it is a very common thing we see on my surgical floor. The most significant experience I remember was not a patient of my own, but I ended up speaking with the mother. The patient (and his primarily Spanish-speaking family) came in for a normal tonsillectomy and adenectomy(T&A). They usually make younger patients stay overnight for monitoring and his stay was uneventful and we went home the next morning. That night his mom called and said he had some pink colored spit. She said the patient felt fine and was able to eat and was not swallowing a lot. The doctor on call told her that it is normal and if he is not bleeding a lot, he should be fine. The next night, when I was at work, his mother called our unit hysterically because his doctor’s office was closed and said he was throwing up blood and would not stop. I quickly found his chart in EPIC since it was my first night on and I had never heard of him and then encouraged her to come back to the ED immediately. Turns out he ended up having to go the PICU and get multiple blood transfusions. Turns out discharge instructions were given to her in English and that was not their primary language. She did not know what to watch out for and let the patient return to his normal activity as soon as they got home, and he ate something he should not have that caused him to bleed. This experience caused the hospital to only use video interpreters when explain discharge instructions and getting consents for surgery. Many T&As are uneventful but this one stuck out to me because the language barrier affected the health literacy of this family. This life-threatening situation could have been avoided if proper steps had been taken to ensure that the procedure was understood, and the family had access to resources if something went awry. This could have been an opportunity to use shared decision making using a method of patient centered communication (Hoffmann et al., 2014). 

The decision-making tool by HealthWise (Healthwise Staff, 2023) did not factor in most social determinants of health, especially economic stability, and access to healthcare (Office of Disease Prevention and Health Promotion, n.d.). It did a decent job weighing medical pros and cons but did not talk about the underlying costs of those options. It discussed how it may be better to not have the surgery if the child does not have at least 3 infections a year. That makes sense but what if the family has no transportation? How can they get to the doctor for treatment three or more times a year? Plus, factoring in missed times from work and school, other siblings, and the costs of all those doctor's visits may be something to consider.  

Jamie: For this topic, I chose to discuss end-of-life care with Covid-19 patients. I worked in the hospital during the Covid-19 pandemic on a step-down floor that at times functioned as an ICU because our ICU was too full of COVID-19 patients. We often had to adapt and overcome the new challenges. It started with changing the different oxygen devices that were allowed on our floor, starting with a nasal pendant and going all the way to high-flow oxygen machines. Zhong and colleagues (2022) found that adding high flow oxygen to general care floors allowed for faster and more effective rapid responses for patients. End-of-life care was a conversation that needed to be had on our floor quite frequently because the next step was intubation in the ICU with not always the best odds of getting extubated eventually. While there are many different cases that I could talk about, one patient that still sticks with me was a Cambodian-speaking elderly gentleman. He had been known for taking his high flow oxygen off intermittently and desaturating so someone would have to go into his room and remind him to put it back on. On top of his Covid-19 infection, he also had measles. One night, I was working an evening shift (1500-2300). It was 2315 and I was waiting for my relief to come and get report so that I could go home and while I was waiting, he started to desaturate and was not popping back up. So, I donned my N-95, shield, gown, and gloves, and I entered his room to find him sleeping peacefully with his oxygen in his nose where it belonged. My heart dropped because I knew that he was going to have to leave our floor and go to the ICU due to being on the maximum amount of oxygen our floor could accommodate. We called a rapid response to get him moved to the ICU and I attempted to get a Cambodian interpreter on our Ipad translator to let him know what was going on. Unfortunately, he was on our floor for over an hour trying to get an ICU bed that could accommodate not just his Covid infection but also his Measles infection. Through the entire conversation, we were unable to get a Cambodian interpreter on the line. 

The decision-making tool from Health Wise (2020) did factor in most patients because it just discusses the different treatment options (ICU care with CPR, ICU care with no CPR, medical care, comfort care). All of these treatment options are presented to patients when they are in the hospital and are explained to them. However, education is a social determinant that the Health Wise did not factor in. The patient may get these options explained to them, however, if they do not understand what is being presented to them, they might not be aware of what they are agreeing to (Office of Disease Prevention and Health Promotion, n.d.). It is important as a provider to make sure that the patient is able to explain back the end of life care that they choose to accept. 

Hannah: I work in an inpatient mental health facility. We have patients admitted often due to medication non-adherence. Through the years, there have been multiple cases where medication non-adherence was linked to the inability to pay for their medications. The decision aid chosen is antipsychotic medication.

Social Determinants of Health  

Social determinants of health are the conditions where the patient lives, works, plays, and worships that may influence health status (Academic Guides: Social Determinants of Health: Social Determinants of Health, n.d.). The social determinant of health that is most concerning here is economic stability. It is a revolving door. To afford medications, they need to work but to work, they need their medications, so they are mentally stable. Public programs exist to help with this, but a lot of mental health patients do not have the required mental capacity to fill out all the necessary paperwork. It is as though they are just lost in the system.

Patient Preference

Shared decision-making is an excellent way to incorporate patient preference into mental health. Shared decision-making is where the provider explains the risks and benefits of treatment, and then the provider and patient decide together (Fiorillo et al., 2020). This allows the patient to feel involved in the decision, and they will be more likely to comply with treatment.

Impact of Values

If these patients were helped to obtain federal and local government assistance to get their medications, most of them could work and contribute to society economically. This would offset the financial burden of mental health. The shared decision-making model could be used to determine which medication will be the cheapest but adequate for a specific patient.

Decision Aid

The decision aid chosen was antipsychotic medication. The treatment plan focused on changing or stopping medications. It provided no information concerning determinants of health. However, it did conclude that using the decision aid to make personalized choices for medication regimens would lead to greater compliance (Zisman-llani et al., 2018). If this treatment plan were to be changed to include the influence of social determinants of health, further advances could be made in antipsychotic compliance. After all, how are patients supposed to be compliant with medication if they cannot afford it? This decision aid would be helpful in personal practice as a guide toward personalized patient care.

Erica: As a critical care nurse, I have experienced numerous instances where the treatment plan outcome was impacted by not incorporating patient preferences and social determinants of health. A particular incident that will remain etched in my mind is when I worked with a Chinese cancer patient who was experiencing extreme pain because they had dismissed their treatment program in favor of traditional medicine. When the patient initially came to the hospital, she had been taking the Chinese traditional medications that were recommended by her grandmother. She was brought to the hospital in a critical state and we had to perform urgent medical action to ensure her state was stabilized. A week later, she was ready to go home and she was given her medication and chemotherapy schedule. What we did not consider is that the patient could go back to taking the traditional medicine because according to her grandmother, consistent use of the traditional herbs would eventually cure her cancer and she would not need any chemotherapy sessions. 

Based on the social and community context when referring to the social determinants of health, interaction with family, friends, and the community can impact an individual’s health and wellbeing (Walden University, 2023). Furthermore, the patient’s values can impact their view on treatment and consequently affect their attitude and adherence to the recommended treatment options (Kennedy et al., 2017). In this case, the patient’s interaction with family and traditional values and beliefs affected her treatment significantly. Upon routine follow-up we learnt that she had stopped the hospital medication and instead continued to use the traditional herbs. She also missed her first chemotherapy session because she believed she did not need it. We had to really convince her to come to the hospital and even though she was adamant, she now appreciates our efforts because she is free of cancer after the treatment. 

Including patient preferences, social determinants of health, and values can have considerable impact on the treatment plan, hence the need to include them. It is important to consider the factors within the individual’s environment and incorporate them during treatment to improve outcomes. Using a patient decision aid (PDA) can help to improve chances of success in any treatment process. As noted by McAlpine et al. (2018), many patients with cancer may experience delayed decision-making due to unavailability of information and anxiety on the best options available for them. In my case, the PDA applied was for cancer related decisions and care, which helped the patient in facing their fears and concerns and hence make an effective decision. The patient decision aid was effective in helping the patient to make a decision to undergo chemotherapy and eventually become cancer free. The decision aid inventory can be used in my professional life as I meet more individuals experiencing cancer. I would use it to help them accept the situation and select a treatment option that works for them.

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