Sunday, October 05, 2008

Patient preferences and mode of delivery

Susanne suggested that I review the article in this month's journal Obstetrics and Gynecology, Mode of Delivery: Toward Responsible Inclusion of Patient Preferences. The article is written by seven women, two obstetricians and five professors of philosophy, including Rebecca Kukla. I have quoted Kukla's philosophical work on mothering in previous posts.

The paper is interesting, but I found it curiously out of touch with the current realities of obstetric care. I was also confused by the emphasis on "cost effectiveness," and societal consideration which really has no place in a discussion between patient and provider, and can only be addressed on a system wide basis.

It seems to me that the authors started with their conclusions and then worked backward to justify them. Their conclusions were that women should have more choice in determining mode of delivery for VBAC, breech and twins, and essentially no choice in maternal request C-section. Their desired conclusions rest on unexamined assumptions, that vaginal delivery is inherently "better" than C-section delivery, and that the current C-section rate is "too high." The authors offer no discussion or justification of these assumptions, which guide all subsequent reasoning.

Let's first look at what the authors said:
We believe that responsible guidelines around mode of delivery are a function of four considerations, which interact in complex ways. First and foremost are clinical considerations of safety and efficacy, which include the extent to which the provider is comfortable with managing the specific approach. Second are considerations of cost effectiveness, which are especially important for options whose use would be prevalent. Third are the broader clinical and social consequences of expanding choice. Considerations here include the potential for diversion of resources, unintended shifts in institutional practices and provider expertise, as well as potentially subtle shifts in the pressures or untoward cultural presumptions subsequent patients will face. These three factors circumscribe boundary conditions on what providers can responsibly provide to individual patients. They also provide comparative information key to informing choices within the range of broadly safe
and cost-effective options.

Fourth are considerations of patient values and preferences, including the extent to which patients would trade one set of possible outcomes for another, how important differences in potential outcomes are to them, and how robustly variable preferences are across the population. In general, the stronger the preferences, and the greater the divergence among them, the stronger the case for patient-flexible guidelines. For one thing, the standard for acceptable medical risk and cost is in part a function of what patients value — as elsewhere in medicine, an option that brings a slightly higher risk or cost can be acceptable if it has a benefit that some patients value highly. Further, where outcomes are broadly equivalent in aggregate risk of adverse outcomes or cost, patient preferences are of obvious importance.

These four considerations are critical to defining what constitutes responsible care. The higher the probability of significant harm, the more restricted the range of reasonable options, even in the context of divergent patient preferences; the stronger and more variable the patient preferences, the more they should be given directive weight; the higher the externalities, and the less cost-effective an option, the more justification for prescriptive guidelines.
Simply put, the authors believe that the four considerations for decision making should be:

1. safety
2. cost effectiveness
3. social consequences of expanding choice
4. patient preferences

In my judgment, the authors are pretty far off the mark in their conclusions. They include two considerations that have no place in patient-provider discussions, and they ignore two considerations that have tremendous impact on the current situation in obstetrics today.

Neither cost effectiveness, nor social consequences have any place in patient-provider discussions of treatment choices. I'm surprised that the authors included them. Change the specialty from obstetrics to oncology, and the problem becomes glaringly obvious. When cancer patients face the failure of first line treatment for their disease, and are considering the next step to prevent inevitable death, neither cost effectiveness, nor social consequences have any place is a discussion of options.

Should an oncologist suggest to a patient that it would be cheaper or better for society if the patient would just go home and die? Of course not. Undoubtedly, once a patient has failed first line treatment, it WOULD be cheaper and generate far few problems for "society" if the patient just gave up. That's not how we make medical decisions. A core principle of medical ethics is "beneficence," determining what is good for the patient. The interests of society (or the insurance company) have no place in the patient-provider relationship.

As far as I can tell, cost and societal considerations mask the handwaving necessary to reach the authors' predetermined conclusions. Allowing greater choice in mode of delivery, but prohibiting maternal request C-sections can only be intellectually justified by including the interests of society (or so the authors believe). Otherwise, it would make no sense to assert that women who value vaginal birth as an interest in and of itself should be allowed to incorporate that value, but women who value C-section birth should not be allowed to act on their personal values.

Secondly, and inexplicably, the authors fail to consider two interrelated factors that are driving the currently high C-section rate, malpractice claims and the inability of patients to understand risks. The authors acknowledge that C-section IS the safer mode of delivery in the situations under consideration:

VBAC: "After a number of well-publicized reports of complications of trials of labor after previous cesarean, and motivated by the small but real risk of uterine rupture"

twins: "the small but statistically significant risk of complications in delivery of the second twin."

breech: "In 2000, a large, randomized trial of cesarean compared with vaginal delivery for breech, the Term Breech Trial, found that combined perinatal and neonatal mortality and serious neonatal morbidity were significantly lower in the planned cesarean delivery group compared with the planned vaginal delivery group (1.6% compared with 5%)."

Therefore, since C-section is known to be the safer mode of delivery, there is essentially no defense in a malpractice case when complications occur during vaginal delivery in the three settings under discussion: VBAC, twins and breech. I find it inexplicable that the authors fail to address this critical point: C-section IS safer, and doctors have no defense for failing to perform a C-section in these settings.

So when it comes to the authors' first consideration in these situations, safety, C-section is almost always the safer option.

The authors, appropriately, devote a great deal of attention to the issue of patient preferences:
For example, as with women who have not had a prior cesarean, many women facing birth after cesarean strongly value the opportunity to deliver vaginally... For these women, decreased access to VBAC can be experienced as a significant loss...
... Women who place high value on vaginal birth may also wish to avoid the significant discomfort and small risk of emergent cesarean associated with external cephalic version and articulate a reasoned preference for vaginal breech delivery.
Those preferences are real, but the authors fail to address the basic issue that the standard for determining treatment is informed consent, not preferences. Simply preferring a vaginal delivery does not constitute informed consent for refusing a medically indicated C-section. This is not a trivial distinction, and the authors' failure to address it calls into question their conclusions about the role of preferences.

I find the paper very disappointing. It does not offer any practical advice for a systematic way of incorporating patient preferences into decisions about mode of delivery. In its failure to acknowledge the central role of malpractice litigation when C-section is known to be the safer option, and its failure to address the critical issue of informed consent, it mischaracterizes the problem and offers merely a weak justification for predetermined conclusions.


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