Informed Decision-Making used to be called Informed Consent. For obvious reasons, we need to change this phrase. When there is no option for anything but consent, that is coercion.

In midwifery care, the process of informing clients of their choices and helping them gather enough information to make a decision and then documenting that sovereign (non-coerced) decision is a key part of defensive charting. It is based on the philosophy that the client is the sovereign decision-maker - and in fact, no one but the parent should be making decisions about their and their babies health. This pre-supposition is tricky in our modern medical culture. It is absolutely the right thing to do, however, it leaves the midwives open to intense scrutiny about lack of skill, or even lack of standard of care.

Therefore, this is a critical part of the course and your learning curve. To be defensive, any and all of the information, both written and oral that you share with your clients, both directly and indirectly (like your website or promotional materials) needs to be free from bias. This means that you need to do enough personal inner work to first understand your bias and then truly embrace the belief that just as you wouldn’t want anyone to mis-lead, bias, or coerce you in the course of pregnancy and birth and parenting, neither should you do that to anyone else - EVEN and especially on controversial topics. If you do feel so strongly about certain choice-points that you would judge someone for choosing differently than that, it is up to you to loudly announce this bias before clients enroll in care and own your bias in all informed decisions-making conversations and documents.

Once you clear or loudly announce your biases, then you need to document the informed decision- making process with your clients.

The way that you do this defensively is basically a spectrum. On one side we have a quick (but clear) informal verbal conversation, where the client voices their choice and you record their choice in the encounter notes. And on the other side of this spectrum, during a hostile, volatile situation where the choice the parents want to (or are) making endanger YOU, is to get witnesses on the scene to coo-borate your ‘side of the story’. Where you land on this gage depends on the amount of risk you take on.

Remember the ‘climbing the birth tree’ image - informed decision-making does NOT mean you must follow them out on a limb. Signing a document under your clients, MEANS you AGREE with their choice - do not sign unless you really do.

Here are the increasing methods of defensive documentation for the informed decision-making process in community-based birth.

You identify a choice point, so you have a non-biased conversation about options with your clients:

1. Parents voice their choice
2. Parents voice their choice and you record it in their chart 
3. Parents voice their choice and they sign a pre-written informed decision-making document outlining their choice and that is added to their chart
4. Parents voice their choice, sign a pre-written informed decision-making document, and add in their own hand-writing why they choose that
5. Parents voice their choice, sign a informed decision-making document written in that moment for their case, and add in their own hand-writing why they choose that
6. Parents voice their choice, write and sign a document that not only outlines the choice, but adamantly refuses the alternatives
7. Parents voice their choice, write and sign a document that not only outlines the choice, but adamantly refuses the alternatives, and after 911 is called, refuse to be transported by paramedics 

All of this presupposes a few philosophical beliefs.

1. You believe that a parent is the sovereign decision-maker for their body and their baby.
2. You believe that you are obligated to understand and voice your own risk in taking care of clients.
3. You believe that you do not need to keep clients in care that you do not feel safe with.
4. You also believe or are legally bound not ‘abandon care’ with a client without giving them time and or assistance in finding the next level of care.

Check out the graphic below and share a story in the comments about how you decide where to land on this informed decision making process in order to protect yourself.