#43 From Salty DM to Empowering Dialogue: Navigating Patient Autonomy

Justine:

So a few weeks ago, I was posting about patient autonomy and, you know, like I like to do on Instagram and I had a patient that didn’t want anything, didn’t want an IV, didn’t want fetal monitoring, nothing. And when I got report, they were like, oh, this is the perfect patient for you. Give it to Justine’s patient for Justine. And I still work with nurses that are like, I don’t get it. Like how? Why would they even come to the hospital? Why come to the hospital? Right. I get a lot of that. Like, why come? Like, why would you have your baby here if you’re not going to let us do anything? And I always explain, like, what if they didn’t want to come? Maybe they were like coerced by their family to come. Maybe they couldn’t afford a home birth. Maybe they couldn’t afford a birth center birth, whatever it is. Whatever. Like I can just get to know them, see what’s up, investigate and see what’s going on. So anyways, it inspired me to do a Tracing Tuesday about the idea. And I changed some facts, obviously, but moral of the story is like, it’s your body, you’re in charge, etc. All the things we believe in. And I got a message and I wanted to read you the message because I haven’t shared this with you yet. And I want to see, like, what you think.

Sarah:

This is the tea. Right here. I’m ready.

Justine:

Talk to us more about going against policies and procedures. And she put in parentheses, former educator here, curious to how you don’t stick to P’s and P’s and have a leg to stand on if shit goes south. So I read that one first and I responded to that one first. I hadn’t even read the rest. And I was like, oh, it’s a simple answer for me. It’s AMA forms. Like, I’m just like, sign the AMA. I’m not scared of AMA and it’s not threatening to me. And I’m not like, you’re wrong. You have to sign this paper. I’m like, listen, you can do whatever you want. There is a policy here. But like, you know, the education, you’ve been counseled by your team. And this is if we want to do this way, like no fetal monitoring at all, even without an NST, like intermittent without an NST, we would advise against that. But if that’s what you want to do, we’ll have you sign this paper and we’ll keep going. There’s also a form that you can do like declination of partial care. I just found out about that recently, so found that out. And so check with risk management even of like what forms you have in this era, era. But for me, that’s an easy answer.

Sarah:

I wouldn’t even know necessarily like where to find that form. Like I’ve literally never heard of that type of form. But we also have to remember, I was thinking about this the other day that like we function in the larger sphere of nursing in a hospital, like a lot of our stuff, like an AMA form wasn’t made for L&D, it was made for like regular nursing.

Justine:

Yeah.

Sarah:

And so there probably is a form out there. We just are so not used to using it. That like another specialty may know more about too.

Justine:

Yeah. Yeah. So for mine, it’s like you search it on our we use MediTag hashtag HCA. So if you’re in HCA, it’s probably in MediTag and you can find the form. But talk to someone, someone’s someone’s going to know where the form is. Your secretaries are great people to find these forms. They might know where it is. But then she went on to say, and follow up question, who are we to follow your standards? I’m honestly just curious. Serious face right now. If you’re telling the general public to question and even go against not set standards legally, what is the right choice I’m just a person asking all the questions, which is true.

Sarah:

Oh, I have so many so much to say.

Justine:

But in case you’re just the person, I’m just the person asking all the questions. Careful what you share online and what is right with risk management and policy and procedure, you know?

Sarah:

We are going to hyperlink the patient Bill of Rights that. Accompanies are like medical oath, by the way, there’s a nursing Bill of Rights and there’s a patient Bill of Rights. This is made by the American Nurses Association and would be endorsed by the Board of Registered Nursing. Let me start there.

Justine:

I mean, so I’ll say what I said. I’m not making this stuff up.

Sarah:

OK, hello.

Justine:

So I said, totally get it with a little smiley face. I said, we’re all about body autonomy over here. And our goal is to always remember that when we work that we work for our patients and they’re our boss. I’m honored to be a part of their birth story. And if they want certain things and understand risks and benefits, then I love to work through it with them. And I put another smiley face and then I restricted her account and moved her to my requests.

Sarah:

Oh, oh, my.

Justine:

Because I have to protect my energy.

Sarah: You know what? That is a legitimate thing that we should talk about on this episode of our energy and exactly what you just said. But I also want to address.

Justine:

Yeah. So go ahead. So you’re so right. I was talking to my sister about policies and procedures today. I told her I went on a little rant and I said, she’s in nursing school. And as a guest, they’re important policies and procedures, blah, blah, blah. But Jordan there is also a patient bill of right. And we have to remember that, too, because we sometimes forget about that when we get into nursing. And so I’m just excited to see her grow. But Sarah’s got so much to say.

Sarah:

I’m like I was stuffing my face as she was talking about that, as I’m listening and like making lots of facial expressions. So I am ready to go. OK, so first of all, it would be wildly irresponsible for us to make up ish to put on the Internet. All right. So let’s be clear. We hold ourselves to the highest standard. And everything we get we put out there is for educational purposes only. There is so much nuance in our specialty. There is so much like specifically looking at the patient and taking the patient circumstance into account. There is no blanket statements across medicine, but particularly across labor and delivery because it’s so flexy and flowy. All right. So that’s number one. Number two is that not only don’t we make up things that we’re we’re using, like we’re going back to the basics, right? I’m like, I don’t know where to go. I’m like shaking my arms because I’m like kind of excited about this. And also like, oh, yeah, there is a patient bill of rights that is like the patient’s expectations, their rights as a human being. They are not incarcerated. They have and even those that are incarcerated still have rights, by the way. And so the moment you walk into the hospital, we treat them like everything is stripped away. Yes, doctor. Yes, nurse. When really like we are a collaborative care team. And this is part of the problem with medicine today in a way that the culture is like, I’m going to tell you what to do. We’re going to this. We’re going to this. Like instead of asking permission. Well, we can still be on the same page. And most of the time, it’s so funny, like I’ll have birth coaching clients where they’ll come in and suggest pitocin, which, by the way, I’ve already probably given them a warning of that the conversation was coming. They’ll ask for time and everybody will roll their eyes in the room and they’ll expect that they’ll they’ll walk back in and we’ll have refused pitocin. And sure enough, the patient’s like, yeah, let’s start some pit because it makes sense clinically. That’s all we’re talking about here. And so really the culture shift that is the push, whether that be on Instagram or any of our programs, mentorship, what we did in Cancun, physiologic birth is remembering back to the basics of understanding. And here’s how I would parse out the policies and procedures piece versus the Patient Bill of Rights. They are completely separate. We have our own little nursing and medical bubble that we do have to be held to. We have a standard of care. We have our licensure. We have our scope of practice. We have chain of command that we are required to follow. And no one here is saying that you should not follow those things, including your policies and procedures. Policies and procedures are in place to help set up and standardize the standard of care for how we practice as practitioners. So when there is a doubt or there is a dispute and somebody has a strong opinion about something, you have something to fall back on versus it just being all these subjective opinions about what the clinical scenario is. And I feel like this, I feel like that. No, they’re a protection for us, but not like in theory. You put like a lot of times we put policies and procedures ahead of the patient’s needs, ahead of their wants, ahead of their preferences and not taking any of that into account. There is a way where we collaborate on care. And yet we’ve missed it. Like that comment to me is I don’t think is wrong. I think probably comes from a place of a good heart, of really trying to understand and being trained within a system where they are so afraid and so ingrained that this is the way we practice, that all of this talk is so uncomfortable and threatening because it would be such a big change. And so we want to hold space for that. We want to have grace for that. But at the same time, understand there is a separation between policies and procedures are how we practice rather than us making up things at the bedside. But the patient’s experience is a completely different sphere, a completely different side of the scenario where they have all these rights where they’re not incarcerated, they have a right to participate in their care. They have a right to understand what’s going on. They have a right to a second opinion. All of that is the standard to protect the patient from the hierarchy, from the patriarchy, from the money focused system that is the hospital world, knowing that it’s a business and they may not be for profit, but they’re for profit. We all know this. And so, you know, understanding that that exists, to me, there’s two separate things going on here and to go back on policies and force policies on a patient is not really even really in their scope or their sphere of what they have control autonomy or even like the right to. Now in policies and procedures, is it our expectation to know our policies and procedures, know the standard of care, know what’s safe or unsafe? Absolutely. And then we carry that to the patient in an educational sense. So you say the patient has the right to the information to say, Hey, you’re refusing an IV, here’s our concerns here. Here’s what this means for you. Here’s a few scenarios where that may impact your care negatively. And we are concerned. We are held to these policies and procedures, but then it’s released into the patient’s hands and then they decide what they do with it to turn it back around for their decision. And honestly, if you’ve built rapport, if you have like a certain trusting, safe relationship and they’re not coming at it from an on guard place and you’re telling the truth and you’re presenting information in a non coercive way, most of the time, guess what, most patients, exactly. They’re going to look at you and go like, Oh, that makes sense. Oh, I trust you that you’re actually telling me the truth. And so maybe I should start an IV. And actually now that I’ve have all that information, I feel safer. I feel more comfortable having the saline lock in place and knowing that my care team is flexible to my preferences. But for us to throw policies back in their face only creates opposition. It only creates division and that disconnect where then actually that’s what causes unsafe environments and unsafe outcomes.

Justine:

No, and all of that. Yes. And you’re right in this scenario. So I was precepting a nurse that’s about to go on her own. Are my new like little role, as we’ve talked about before, is I’m precepting like at the end of their time, just to see like, Oh, are you like, do you need more time? Are you okay? And I got, I was so excited that she got to see this and she was obviously a little nervous cause she’s new. And I was like, what an honor to be able to like witness like a hot, like a home birth birth center kind of birth in the hospital. And what ended up happening was the patient got an IV at the patient got monitored and patient got an epidural all by her choice, but because we’ve been in there excited to be a part of her experience and like whatever she wanted. And you’re absolutely right. We just talked her through all the things and she got everything like that the other nurses were scared about and so.

Sarah:

What a beautiful opportunity for this preceptee to be able to witness the patient care process in a way that empowers and supports and respects another human being’s decisions. And also see it shift like in exactly that same scenario. It’s like they, they will, if they trust you. And they can see that you are looking out for them, likely they’re going to consider it and they may still refuse. But then what you do is you chart patient explained all these different things. Doctor came in, explained all these different things. Patient verbalizes understanding that it causes this if blah, blah, blah. And they understand the risks and they wish to proceed without an IV will continue to monitor. And this isn’t just a wash my hands, throw it out into the world. Like, well, screw you. Like I’m annoyed that you don’t listen. That instead it’s let me continue to monitor you and un-flex my care within the realm of how do I keep you safe within the boundaries that you’ve set for your care, understanding the risks. You’re not responsible for those risks. If you’ve documented the conversation, right. And, and there’s a certain level of, if the conversation has gone in a way that is truly follows shared decision-making, they know those aren’t the cases that are being like sent to court or whatever, or the, and honestly, honestly, probably not the worst outcomes. I don’t have numbers on that, but I would guess that most of the time, when all this happens, nothing actually goes wrong. And if there’s a shift in status where an IV becomes much more risky, it is our responsibility to begin the conversation again and say, Hey, up until this point, this is where we’ve been. Your circumstance has changed. And so now the risk has increased. Our concern has increased and the potential for outcomes, name what they are, has increased. And so we want to make sure you understand that, that if you continue to proceed without the IV or without the monitoring or blah, blah, blah, fill in the blank, whatever it is, that this risk is no longer what it used to be. And so we’re going to recommend that now there would be a shift in the way that we care for you. Refuse, on them. So going back to, I feel like we’ve, we’ve parsed that out enough to give people a little window. It’s you. Yeah, I hope so. And also to understand like where we’re coming from, because I know that this isn’t the first comment that you get. And to be honest, you all like the, the, the education that’s offered on Instagram and social media and all of that, and all of the free ish that you get, but those comments coming in have an impact and that I’ve heard Justine over the years and not to out you, but I’m gonna is that like, that makes you not want to participate. It makes you not want to post. It makes you want to give up and run away because we’re, we’re, we’re humans on the other side of this and we technically don’t have to do any of this stuff. I could just be working in the hospital and so could Justine and, you know, and so we take it on, we know it’s a part of the like big picture and that comes with the territory, but at the same time, I would love to know from you, Justine, what was the impact? I know you sort of mentioned it, but let’s talk about the impact of some of these types of comments from like a back office insider scoop perspective.

Justine:

Well, you know, it’s not surprise, surprise to know they don’t make me feel good and then they immediately make me doubt. Like, is it wrong? Like, is what we’re doing wrong? And then I’m like, no, what we’re doing is right. Like we’re all about changing it up, man. We’re changing birth on earth here and I just, it doesn’t feel good. And I’m an Enneagram nine. And if you know anything about Enneagrams, you know what that means. And if you don’t, we’ll have an episode here soon, but I like to avoid conflict. And so sometimes I don’t even, I’ll just, especially if they’re in my requests, I will not engage, I will delete and I don’t need to engage. This person was not in my request. So I opened it up and she can see that I read it, which is much more challenging. But I just try to respond back with as much love as possible and no hate. Cause I do think she probably comes from a good place. And cause I went back and read our thread too, cause I have history with a lot of people on Instagram and so I’m like, what have we talked about before? And I’m like, I think she just truly doesn’t know and is concerned about our license. And I like to reframe it now after our episode with Jen. And if you haven’t listened to that episode with Jen Atkisson, you should go back and listen because it’s like, she’s, she’s afraid of someone getting hurt. Right. And so she wants to, first, I think like legally we think like, oh, she doesn’t want to be sued. We don’t want to lose our license, but the ultimate goal is we don’t want anyone to be hurt and I totally get that. But we want people to also understand that. Yes, people could get hurt, but there’s a lot of hurt birthing people that have perfect babies and perfect labors and perfect deliveries, but they are still hurt. And it’s because of the care they received so.

Sarah:

A-freaking-men, that’s a whole nother episode. I mean, we talk a lot about that. This is like episodes we’ve had and like potential for more conversation. But I think too, that is such a good point because it’s what’s more valuable, the potential for hurt or the fact that the patient did feel disempowered and out of control and like a number on a factory roll belt or factory line of the. Whatever it’s called. But that, that Justine, I think is such a good point to point out that like we have to be treating the brain as an organ. And while they may end up with a C-section is their brain okay and if it’s not, that has potentially more lasting impact than even a fill in the blank of something else that could happen. Obviously a death is not the ideal scenario, but that’s why we’re there to keep them safe and we’re not there to write their story. We’re there to support them in their preferences and adjust our care to be as safe as possible and make sure that every decision is theirs to make, but it comes from a place of fully understanding what that means for them. I think that also brings up a point of just like a boundary for all of us that I think is like a good life lesson to remember. I know we talk a lot about this. We’ve talked a lot about this across the years, but like it’s not worth my mental health and there may be times. And if you’re trying to have engage in conversation with anyone, whether it be on Instagram with our accounts or whether it be in life that like there is an approach likely that may be more effective in facilitating a conversation and probably the intent of this person or whatever. But the impact was that she got restricted in her account. And if that were to happen to you, maybe it’s just like a, hey, noted in my brain. And also just like there is an approach and I’ve had criticism that way. I had an email come in recently that was like criticizing a YouTube video that I did and talking about losing weight or something and how like I was fat phobic. And it was this whole thing, which I don’t think I am. And I was just literally stating up to date research, but regardless, it triggered a nerve. And what like as we evolve as humans, we can be faced with circumstances like that and go, screw them. They suck. Or, you know, depending on the approach, I think there is a certain level of protection that we all need to be aware of, of the energy we surround ourselves with. And if the response was this is going to steal my joy. I know I’ve had many a time where I’m like, I’m starting to read something and I cannot finish it for the sake of my ability to function the rest of the day. And that we all have autonomy over our brains and our bodies for. I told my mom recently when we were, we were having a hard conversation and they were, it was related to a trauma of mine. And I was saying that like, I am okay talking about this because I know this has impact on those around me, but I need a heads up. And so for me to set a boundary like that is sort of the same as you restricting an account. It’s not necessarily something, something purposeful, but I think there needs to be grace on those sides that just because we, you know, have a social media following doesn’t mean that you just get to say whatever you want and get away with it without protecting us. We have a lot of work to do around here. We all do. And it is paramount that we protect the energy we surround ourselves with. And I want to be clear that like we’re open to having those conversations given that it’s in like an appropriate space sort of on our terms a little bit. I mean, ours and yours, you know what I mean?Like.

Justine:

And I think because I was like, why did it like hit me a different way? And I think it was the who are we to follow your standards? It’s not my, ours, my standards. Right. It’s standards like it’s human standards, patient bill of rights standards. So I think that too, I’m not someone that I want it. I don’t want us to be seen as like we’re making standards, which we are trying to level up the standard of care in birth for sure. But we’re not just making it up.

Sarah:

But so much of it. Right. So much of what we do is like we’re going back to basics of all the things that we’ve forgotten and how that that movement is so countercultural. But we’re reminding us of what our actual job is and what like humanity looks like in birth again. I hope that’s the vibe you’ve gotten. And that is our goal. We’re not here to fight the system. We’re here to work with the system and work with each and every one of you to better this system. And to be honest, this is a systems issue. Don’t get me started on that one, too. There’s an episode again. But it’s sort of this like it starts one patient at a time when we’re dealing with such a big issue. And when you have the patient that comes in without with all these strong requests, get curious about what that might mean and where that comes from. And we cannot force, it is a assault to force anything on anyone else. Touch what you start an IV without consent. And they’re telling you, no, that is assault or battery. I’m not really sure because I’m not a legal person. It’s one of the two. But like you can be charged and we’re not. But this is where we really do have to start taking this stuff seriously, you know, and until there’s a few cases in the news of people actually getting tried. Unfortunately, people are going to continue to get hurt in their brain and that’s what we’re trying to avoid around here.

Justine:

Thanks for spending your time with us during this episode of Happy Hour with Bundle Birth Nurses. If you like what you heard, it helps us both if you subscribe, rate, leave a raving review and share this episode with a friend. If you want more from us, head to [bundlebirthnurses.com](https://bundlebirthnurses.com) or follow us on Instagram or TikTok.

Sarah:

Now it’s your turn to go and give patient centered care. Have the hard conversations, but maybe do your own process and consider the words that come out of your mouth or your fingers have impact on others so we can continue to have productive, evidence-based and game changing care for our patients. We’ll see you next time.