Practice Advice: When a client declines aspects of care
January 17, 2023
Note: This article was originally published in the Winter 2023 edition of our On Call newsletter and has not been updated.
A midwife is caring for a client planning a home birth. At 35 weeks gestation the client tells their midwife they want to labour and birth on their own, without any interventions, and they will not call a midwife to attend. The midwife explains to the client the research on the safety of home birth with a trained care provider and recommends the client plan their home birth with a midwife in attendance. The client reaffirms her desire to birth without midwives in attendance and to have midwifery care during the postpartum.
What does the midwife need to know in order to consider this?
A midwife needs to know what their obligation is to support their client’s decision. The Professional Standards requires that the midwife recognizes the client as the primary decision-maker. This means a client can make decisions about their care even when the midwife disagrees with the decision and the decision does not align with the best available evidence. The Professional Standards also requires that the midwife must support the client’s right to accept or refuse treatment in keeping with the Health Care Consent Act, S.O. 1996. In this scenario, the client is exercising their right to labour and birth without their midwife.
When a client makes a decision about their care that a midwife does not agree with, it is important for the midwife to understand what is motivating the client’s choice so further discussions can be had about ways to ensure the safest care possible while respecting the client’s choice. Informed choice discussions require the midwife offer alternative courses of action and likely consequences of not having a particular treatment or element of care in an objective way. Recognizing the client as the primary decision-maker means the client’s informed choice should not be influenced by the midwife’s personal biases or preference for a particular approach to clinical care.
It should be noted that clients choosing care that their midwife disagrees with does not demonstrate that there is no longer a relationship of trust and discharging a client for that reason may not be defensible.
While there is nothing in this particular scenario that is outside the midwifery scope of practice, sometimes midwifery clients may ask their midwife to do something that is out of their scope. In all cases, the midwife must ensure that the care the client is requesting is in the midwifery scope of practice and in their individual scope.
#14 Listen to clients and provide information in ways they can understand.
#15 Support clients to be active participants in managing their own health and the health of their newborns.
#16 Recognize clients as the primary decision-makers and provide informed choice in all aspects of care by:
16.1 providing information so that clients are informed when making decisions about their care.
16.2 advising clients about the nature of any proposed treatment, including the expected benefits, material risks and side effects, alternative courses of action, and likely consequences of not having the treatment.
16.3 making efforts to understand and appreciate what is motivating clients choices.
16.4 allowing clients adequate time for decision-making.
16.5 ensuring treatment is only provided with the client’s informed and voluntary consent unless otherwise permitted by law.
16.6 supporting clients’ rights to accept or refuse treatment.
#17 Ensure clients have 24-hour access to midwifery care throughout pregnancy, birth, and postpartum.
#21 Ensure that your personal biases do not affect client care.
What does the midwife need to have in place in order to do this work?
The midwife must have informed choice discussions with the client to ensure the benefits and risks in having a home birth without a midwife in attendance are understood. In this scenario, there are options that may be offered to the client including attending the birth in an observer role (e.g., be in the house providing little, or no monitoring, in or outside the birthing room but be available to act if requested or needed). Documentation should include the options provided, the decisions made and the midwife’s role in the immediate postpartum and up to discharge at six weeks. All discussions should be recorded accurately and objectively including any updates to the care plan.
The plan should be discussed with other midwives in the midwifery practice group for feedback. Midwives in the practice must also be aware of the client’s decision to ensure continuity of care should they be the one on call if the client calls in labour of after the birth.
#5 Maintain contemporaneous, accurate, objective, and legible records of the care that was provided during client care.
#25.5 providing complete and accurate client information to other midwives or care providers at the time care is transferred over to them.