4J-6
EVALUATING SHARED DECISION-MAKING IN PERIVIABLE DELIVERY COUNSELING USING OBJECTIVE STRUCTURED CLINICAL EXAMINATIONS
Method: Data were collected over 3 years (2013-2015) of annual OSCEs. Trained standardized patients (SP) portrayed a pregnant woman presenting to clinic at 23 weeks gestation with preterm premature rupture of membranes (PPROM). Residents were instructed to counsel the patient as they would in their typical practice and develop a plan for her care. OSCE sessions were directly observed, video- and audio-recorded. Braddock’s 9-item measure of shared decision-making was adapted to a 10-item scoring rubric, adding one item to rate empathic behaviors. Each item was rated as 0 (absent), 1 (partial), or 2 (complete). Two coders independently rated the encounters. Discrepancies were resolved by consensus.
Result:
Twenty-six fourth-year residents participated. All residents provided ‘complete’ discussions of the clinical issue/nature of the decision, and all received ‘complete’ or ‘partial’ ratings for informing the patient of her prognosis (62% and 38%, respectively) and assessing the patient’s understanding (4% and 96%). The vast majority of residents received ‘complete’ or ‘partial’ ratings for discussions of the patient’s role in decision-making (42% and 50%, respectively); discussions of management alternatives (69% and 23%); and discussions of risks and benefits of those alternatives to the infants (31% and 58%) and to mom (46% and 46%). Discussions of the patient’s goals of care and larger context of the decisions (i.e., related to resuscitation preferences, disability, or quality-of life concerns) were absent in 69% of residents’ discussions. Likewise, the majority of residents (62%) had no discussion of the patient’s preference, typically suggesting that no decision be made until after talking to neonatology. Only 42% of residents discussed uncertainties related to the decision.
Conclusion: We developed an OSCE to evaluate the degree to which OB/GYN residents utilize SDM when counseling patients about periviable birth and delivery management. Residents consistently convey information related to diagnosis, prognosis, decision-making roles, risk, benefits and alternatives; but often fail to address uncertainties and patients’ goals or preferences. This suggests that, while ample medical information is conveyed, critical elements of SDM related to patient’s values, goals and preferences are not explored. Interventions and training are needed to facilitate SDM in periviable care.