4. Acknowledging Environmental Norms: A PCDM Key Element

A key element in the person-centered decision making (PCDM) process is to acknowledge environmental norms, in addition to personalizing the care plan. You can facilitate an understanding of the options available, the benefits and risks of these options, and how to apply these to the patient’s context and values.

You learned that PCDM is a collaborative process that enables people to make healthcare decisions. One part of this process is to explore how environmental factors could impact the available options for care. Environmental factors include: 1) regional resources, 2) social norms, 3) community standards, and 4) institutional routines. Assessing the available regional resources includes: the number and location of family doctors, specialists, or midwives; and the type and level of facilities (health centers, community hospitals, tertiary care hospitals, emergency services) that the family can access if necessary. Even when facilities exist, staffing patterns might vary by time of year or day. There may also be local practice guidelines and/or institutional protocols that are linked to the availability of expertise or clinical comfort level of the providers.

In the PCDM process you should discuss the environment and explore how these factors impact decision making and feasibility of preferred options. It is the responsibility of each team member to remain up-to-date about which environmental factors may impact decision making. This can be challenging when members of a team are unfamiliar with certain aspects of the environment that play a role in the decision-making process, or, more likely, have different or conflicting needs for resources. An example is knowing when the on-call specialist is onsite, when the operating room is booked, or, in Florence's case, knowing what factors affect her ability to birth with her family at her side.

As we are about to see in Florence’s case, her desire to preserve her birthing wishes at the time of her birth, and to birth vaginally, may be affected by what we call 'human resource planning', which means that the provider that is available to attend her birth may impact her options. Such environmental factors that affect people's choices can be anticipated and discussed ahead of time so that the team can explore the feasibility of people's preferred options and make arrangements as necessary.