Informed Decision-making or Decision Fatigue?
Knowledge translation literature includes evidence about supports to assist physicians in clinical decision making to improve quality and improve evidence-based care (Kawamoto et al, 2006; Grol and Grimshaw, 2003). These are called clinical decision support systems. In developed countries, patients have been found to receive only half of recommended care, the other half being either wrong, out of date, or erroneous (Grol and Grimshaw, 2003). A review of trials to identify aspects of clinical decision support making showed that decision support systems improved clinical practice in 68% of trials, and four aspects were found to be most useful. These include decision supports as part of clinician workflow, provision of recommendations instead of assessments, provision of decision support at the time and place of decision-making, and computer based decision support systems (Grol and Grimshaw, 2003).
One of the hallmarks of modern western medicine is ‘informed decision making’ or ‘informed choice’. This refers to discussing the benefits and problems of various types of care decisions and pathways of care with patients. Physicians are often time-pressed or not well enough informed about options for care, so do not provide the options in a way that is easily understood by their patients.
Goldberg (2009) in ‘Informed Decision Making in Maternity Care’ outlines the optimum in maternity care; every pregnant woman has the right to base her decisions on accurate, up to date, understandable information. This statement is backed up by all provincial, national and international organizations involved in maternity care such as College of Midwives of British Columbia, Society of Obstetricians and Gynecologists of Canada and International Confederation of Midwives. Goldberg (2009) explains that decision making can be complex and multi-layered.
I went to a perinatal conference last weekend where a talk by prenatal educator Penny Simkin spoke about “Decision Fatigue’ from the client’s point of view. The third of three studies about women’s voices on childbirth (Declerq et al 2013, study in progress, reference of prior study below), found that although pregnant women wanted knowledge, most of them were poorly informed. It also revealed that most women trusted their caregivers and usually followed their recommendations although they are presented with inaccurate incomplete information by caregivers. To remedy this, mothers are urged to consult books and websites. Penny Simkin discussed the myriad of choices offered to mothers expecting babies, concluding that there were too many options and too many choices. In Simkin’s book (2012) ‘Pregnancy, Childbirth and the Newborn’, the worksheet for preparing your birth plan shows 47 categories of birth events and 179 birth options. We were told that a ‘google’ search for induction of labour led to 8,880,000 results! What are options to this dilemma of too much information?
Midwifery care is one option. Midwives in Canada are paid to spend time (up to one hour per visit) to discuss choices and facilitate informed choice decisions. But with over 90% of women in Canada unable to access midwives for their care, childbirth classes that include evidence based discussions of informed consent patient decision making aids may be useful to fill in this gap. The Cochrane updated review of patient decision aids (Stacy et al, 2011) found that when patients use decision aids they improve their knowledge of the options, have more accurate expectations of possible benefits and harms, use their own values to make choices, and participate more in decision making regarding their care. The Ottawa Hospital Research Institute (2013) has a series of decision aids. The challenge lies in the difficulties in maintaining up-to-date evidence in the tools. These are general patient aids and few are for pregnant women. Canadian childbirth or midwifery organizations would make an important contribution if research members could develop decision aids and maintain them based on current evidence.
DeClerq E, Sakala C, Curry M, Appelbaum S, Resher P. Listening to mothers: pregnancy and birth 2 (2005). Journal of Perinatal Education.
Goldberg, H (2009). Informed decision making in maternity care. Journal of Perinatal Education. 18(1). 32-40.
Grol, R & Grimshaw, J. (2003). From best evidence to best practice: effective implementation of change in patients’ care. The Lancet. 362. 1225-1229.
Kawamoto K, Houlihan C, Balas E, Lobach D. (2005). Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. British Medical Journal. 330. 765-772.
Simkin P, Whalley J, Keppler A. (2012). Pregnancy, Childbirth and the Newborn: the complete guide. Simon & Schuster, New York, NY.
Stacy D, Bennet C, Barry M et al, (2011). Decision aids for people facing health treatment or screening decisions. The Cochrane Collaboration. John Wiley and Sons.
Ottawa Hospital Research Institute. Patient Decision Aids (2013). http://decisionaid.ohri.ca/
image from google images: doctor with pregnant woman in office.