Community Standards in Informed Choice
Describing community standards in an informed choice discussion involves explaining the rationale for the standard, including protocols, clinical practice guidelines (CPGs) and policies commonly used in the community to guide the provision of care. The purpose of each guiding document is different.
- CPGs are tools intended to inform practice, but are not directive.
- Practice group protocols generally provide step-by-step instructions and list relevant considerations.
- Hospital policies may fall into either category. Some only apply to hospital employees, but others may apply to all health-care providers, including midwives.
- College of Midwives of Ontario (CMO) Standards of Practice set a minimum standard of care that is mandatory for providers, but is subject to informed choice by clients.
These documents supplement, rather than replace, professional judgment. The midwife’s critical appraisal of the value and applicability of the guiding document in the care of a particular client is also part of the informed choice discussion. Midwives explain to the client the guiding document’s rationale and the risks and benefits of disregarding or of using the document’s guidance in the client’s circumstances.
Protocols, hospital policies or CPGs that no longer reflect current evidence or do not interpret evidence through a midwifery lens can be challenging to incorporate into discussions with clients. Health-care providers may choose not to incorporate them or be unable to apply these guiding documents to their practice. Court cases have concluded that health practitioners need to make clients aware of recommendations in the documents from their own profession (e.g., AOM CPGs, CMO standards) and those used in their community (e.g., SOGC, hospital). Clients are free to make decisions outside of these standards, but must be informed about them for their decision to be informed. The CMO standard When a Client Chooses Care Outside Midwifery Standards of Practice addresses the responsibility of the midwife in this situation.
The following considerations may be helpful when navigating these situations:
- At times, midwives deliberately and correctly choose not to follow guiding documents, whether out of respect for client choice, because they are outdated, or because of the specific clinical circumstances. Carefully documenting the considerations reviewed with the client shows that the decision to not follow the guiding document was an appropriate and deliberate plan of care, rather than omission or error on the part of the midwife.
- Midwives are normally expected to follow the protocols adopted by their practice groups. There is a risk that midwives will not incorporate these protocols into practice and informed choice discussions if they are not aware of them, disagree with them or the protocols are outdated. To mitigate this risk, practice groups can implement good practices to engage midwives in the writing and approval process for practice protocols and for keeping them current.
- Some hospital policies may apply to all health-care providers (e.g., privacy, induction booking, infection control) whereas others may only apply to employees.
- If a hospital policy is written to apply to everyone or if it is vague, midwives would be expected to comply because hospital by-laws usually have a provision requiring privileged staff to act in accordance with hospital policies. Compliance may simply involve having and charting an informed choice discussion that includes the hospital policies. The client remains free to choose.
- If a clinical hospital policy (e.g., a policy that says that non-stress tests will be performed for every admission) clearly states that it applies to nurses and excludes midwives, the midwife should consider incorporating the policy into the informed choice discussion, as it may be deemed a community standard. This is true whether clients intend to deliver at home, birth centre or hospital. However, since midwives are expected to use clinical judgement and support their clients’ choices, there is no legal obligation for midwives to recommend hospital policies.
- Hospital colleagues may have a different perspective on compliance with hospital policies. Midwives may benefit from engaging in proactive discussions with these colleagues about differences in interpretation and care rather than waiting until there is a potential conflict over a clinical situation. Volunteering or seeking appointment to committees that draft policies for maternal and newborn care may allow midwives to have meaningful input.
- In theory, physicians are required by law to offer the same sort of informed choice that midwives offer, but may be more familiar with the terms “informed consent” or “patient- centered care” as it is described in an Ontario Medical Association policy document.
- In the longer term, concerns about midwives not following hospital policies may be most effectively mitigated by efforts to change the institution's policies and practices through strategic alliances. Hospital risk managers may support updating policies to better reflect current evidence. Senior hospital staff and hospital lawyers may be allies in ensuring exceptions are made to hospital policies that should not apply to midwives, thereby protecting midwives’ status as independent health-care provides. Hospital ethicists may advocate for change that better respects the importance of informed client consent or refusal of intervention.
Most importantly, information provided to clients to make informed choices should be comprehensive and thoroughly documented. Risk for the midwife and potential harm to the client is most likely to occur if the midwife:
- is not aware of all of the guiding documents;
- does not include them all in the information shared with the client;
- disregards rigorous evidence; or
- does not comply with college requirements.
These omissions can result in decreased safety and quality of care, legal liability, college complaints and harm to the reputation of the midwife and the whole practice. Following standards for providing informed choice for clients and using good clinical judgement mitigate the risks of providing care which is different than community standard.