In my last post, I talked about 4 steps of teaching informed decision-making: Values Clarification, Communicating Values with Birth Plan, Key Questions to Ask, and Informed Decision Making. This post is all about that last step.
Note: we prefer the term Informed Decision Making to Informed Choice for a few reasons: 1) Choice sounds like there was a clear black and white list of options, and we check a box… decision-making is often murkier than that. 2) Choice sounds a little entitled (my four-year-old likes to shout “It’s my choice so I get to do this!” I tell him that’s not really the case…) Decision-making sounds more like a discussion between the parents and the caregiver and a careful evaluation of the options.
So, how do we teach informed decision-making?
Teaching Method 1: The Five Finger Method
I say “Before your caregiver made the recommendation to you, they already did a risk-benefit analysis. They already thought of what the options were, and thought about the balance between which would be most effective and which would be lowest risk. Let’s say they considered 5 options. [Hold up one hand, five fingers spread.] This option [touch pinkie] would definitely work – it’s very effective, but it’s too high risk – your health situation is not dire enough to need that level of intervention. This option [touch thumb] is really low risk, but it’s not clear if would be effective… it’s benefits are not good enough to offer. This option [touch middle finger] is the best compromise – that’s why your caregiver offered it. But remember, it’s the best compromise for any non-specific person in your situation. That doesn’t mean that it’s the best compromise for you! When you look at those options, you might find that this one [touch index finger] feels like the best answer to you. You understand it might not be effective, and that you might then have to escalate to one of these, but you’d like to try it first. Or, you might be exhausted and done with labor, and ask to do this one [touch ring finger] because you just want to do something you KNOW will work to solve the problem.”
I then give an example: I start with a non-birth-related example. I want to take them out of the realm of birth (where some may feel like this is all complicated and only experts understand it) into some different field where they feel like they have all the info they need.
Two examples I have used: the air conditioner and the loose shelf. I kind of like the air conditioner example better because it brings up the idea that maybe before we ask an expert for an intervention, we should think about whether something is really a problem. But if I’m working with mostly low income clients, it could come from a place of privilege to be able to consider all five options there…
The air conditioner example. “So, the air conditioner broke in my friend’s car last August. Now she knows even before she asks someone what her options are likely to be – she could do nothing and just live with it [touch thumb]- after all, this is Seattle – how many days do you need A/C? she could repair it [touch middle finger], or she could replace it [touch pinkie]. Now, if she goes to the mechanic and says ‘what should I do’, is the mechanic going to offer ‘do nothing’ [thumb]?? No! He figures that if you came to him asking for help, you want him to do something! He might say ‘well, I could repair it. That’s cheaper than replacing (lower cost = lower “risk”) but it might break again. Or I could replace it. Higher cost, but we know it’s effective.
“So, she’s asked her key questions. She’s gathered all the data from the mechanic’s point of view. Now she needs to look at her values and also at her budget, which the mechanic knows nothing about. If she’s trying to save money for something that’s much more important to her, she may decide either never to fix the A/C [thumb] or to tough it out through August, and save money between now and next summer to repair it then [index finger]. If she’s tight for money but can afford it she may start with a low level repair [middle finger]. If she can afford it and she REALLY hates being hot she might try a more comprehensive repair [ring finger.] If she’s got plenty of money, she might go straight to replacement so she doesn’t have to deal with it again.”
The loose shelf example: I won’t detail it here, because i include it as the example in the quadrants tool I describe below.
Now that I’ve taught the five finger theory and given a quick example, now I want to apply this to birth. AND I want them to practice decision-making. I present a scenario, and tell them they have to ask me questions about benefits, risks, and what other options I considered. Then they have to think about their own values and priorities and what choice they would make
Slow Labor Progress example (you’re past 6 cm, but have gone 4 hours with no progress). Recommendation: Try Pitocin and position changes for an hour or two to see if we can speed it up. [Point to your middle finger to show that is the middle-of-the road recommendation that caregiver made. Note: it’s important that you hold up all five fingers and point to the middle one. Don’t just hold up your middle finger. 🙂 ] Parents can ask: what are the other options: pinkie – we could do a cesarean now – that would get the baby out, but there’s risks to a cesarean, and your situation is not that big of a problem. Ring finger – could also break your bag of water. Index – could start with really low dose Pit. Thumb – Could just try position changes and maybe some nipple stimulation, but I’m not convinced that’s going to do anything. So, now parents have all the info. They need to reflect on their goals and values. Let’s imagine one family who had originally planned a home birth and wanted as low of interventions as possible. They might say to the caregiver: “Thank you for all that information. We understand that your recommendation is the most likely to be effective with the least risks. But, our original hope was to be as low intervention as possible, so let’s start with a low dose Pit [index finger] and see if that’s enough.” Another family, who has always been open to whatever interventions were needed to help labor progress well, and who are now very tired and just wanting to hold their baby might say “Let’s move this along – let’s do the Pitocin and break my bag of waters… I’m ready to rock.”
Teaching Method 2: The Quadrants
In this PDF: Decision Making Quadrants, I describe the full process of this method. But basically, you’re asking people first to consider their
- intervention style: are they quick to intervene or are they willing to let something be a problem for a while before they intervene?
- Self-Help or Expert Help: Do they like to solve things with their own skills, or do they prefer to turn it over to an expert?
- Benefits vs. Risk: Do they choose the most effective thing even if it comes with more possible risks? Or are they very cautious about risks and more likely to try lots of less effective options first?
- In a particular decision-making moment, how do they balance their normal decision-making style with the urgency/severity of the current situation while taking their values into account.
- Examples include: the loose shelf, pain medication preferences
Teaching Method 3: The Values Clarification / Decision-Making worksheet
Teaching Method 4: Help Students Learn More about their Decision Making Style