Method: We conducted an exploratory single-center simulation study. Fifteen obstetricians and 15 neonatologists counseled simulated patients (SPs) portraying a pregnant woman presenting with ruptured membranes at 23 weeks gestation. The SPs were instructed to ask, “What would you do?” if the physician presented more than one treatment option (e.g. comfort measures versus attempted neonatal resuscitation). We audio and video-recorded the simulations. Two investigators (BTE, FM) independently reviewed the video segments and iteratively developed codes to classify physician response categories.
Result: All but one encounter (29/30) included the SP’s prompt. All 15 of the neonatologists and 6/14 (43%) obstetricians deflected the question, saying, “I don’t know,” either because: “I’ve never faced this decision before;” “I don’t know what your values are;” or “It doesn’t matter what I would do.” One obstetrician ignored the question and 2 explicitly declined to answer it. After deflecting the question, physicians often restated the morbidity and mortality statistics; repeated the management options; or offered to provide the patient with additional information to help them make their own decision. Five of 14 (38%) obstetricians provided a personal preference, opinion, or recommendation; no neonatologists did. Several physicians discussed values indirectly by describing the decisions of other parents; emphasizing that “good parents” who make “loving decisions” have chosen either option. Only one of the physicians directly explored the patient’s values. However, the majority of physicians (17/29, 58%) stated that it was a “personal decision” for which there were “no right answers.” Many redirected patients to seek guidance from family, friends, and religious leaders, rather than the physician, to aid them in decision-making.
Conclusion: Obstetricians and neonatologists responsible for counseling women about “preference sensitive” treatment options in the face of periviable delivery typically avoided disclosing personal opinions or recommendations regarding resuscitation. Their efforts to respect autonomy and avoid biasing parental decision-making may have the unintended consequence of implicitly or explicitly communicating messages that could leave patients feeling abandoned or disregarded. “What would you do?” inquiries represented a missed opportunity for providers to facilitate values elicitation which could guide decision-making, with or without disclosing personal opinions.