Client Request for Care Outside of Standards

INTRODUCTION & PURPOSE 

From time to time, circumstances arise where a client chooses care outside of standards of practice, after an Informed Choice Discussion has occurred. This policy is intended to assist midwives in addressing situations where the issues are unresolvable and a safe, acceptable solution to a client request cannot be found within midwifery standards. 

Ethical principles underlying health care emphasize the rights of individuals to choose among alternative approaches, weighing risks and benefits according to their needs and values. Midwives are responsible for being clear about their scope and standards of practice, and limitations, giving recommendations for care if appropriate and for informing clients about risks, benefits and alternative approaches. 

POLICY 

In circumstances where a midwife, or team of midwives, recommends a certain course of action in compliance with standards of practice or with the midwife’s judgment of safe care, and the client refuses to follow that advice: 

PRENATAL CLIENT 

In non-emergency situations and when it is reasonable to expect there is time to find a solution: 

• Respect and seek to understand why the client is making the choice
• Discuss why care is outside of standards of practice, including rationale and supporting evidence
• Endeavor to address client’s needs within standards of practice
• Consult with another midwife, physician, specialist, peer review group or ethicist
• Discuss with the client, recommendations obtained through consultation
• Consider the safest and most ethical course of action from the following choices:

Continue Providing Care 

• • Continue making recommendations for safe care 
  • Inform colleagues who may become involved in care 
  • Document all discussions and decisions 

Discontinue Care 

• • Clearly communicate to the client that care is discontinued 
  • Send letter via registered mail confirming termination of care 
  • Maintain a copy of the letter and proof of client receipt in the client record 
  • Facilitate transfer of client care to an alternate caregiver 

 

• Document consultations and discussions in the client record 

Saskatchewan College of Midwives Administrative Policy & Professional Practice Guidelines Manual 

Section: Professional Practice Section Number: I Page 2 of 2 

Subject: Client Request for Care Outside Standards 

CLIENT IN HOSPITAL 

In a hospital setting, when a client declines consultation, and/or transfer of care: 

• Remain in attendance.
• Provide care within scope and standards of practice.
• Access appropriate resources and consult with appropriate care provider(s) (i.e. OBS, NICU).
• Provide clinical care to the best of your ability.
• Contemporaneously document all discussions and decisions, when possible.

CLIENT IN LABOUR 

In circumstances where the previously agreed upon place of birth is in hospital and client is requesting out of hospital birth: 

• Review that out of hospital birth is outside of the standards of practice or against the midwife’s professional judgement.
• Review the midwife and client agreed upon plan of care.
• Advise client, the midwife is not obliged to attend the client out of hospital.
• If the client refuses to attend hospital, the midwife should recommend calling 911 for transport to the hospital from client’s current location.
• Document all discussions and decisions.

EMERGENCY SITUATIONS 

In an Out of Hospital Birth situation where client refuses consult, transfer of care, transfer to hospital and/or declines emergency transport: 

• Call EMS and other appropriate resources such as the hospital, OB, specialist, supervisor or manager, back up registered midwife.
• Remain in attendance and be prepared to manage an urgent situation, until the situation is resolved.
• Continue to provide the best care possible to the client as required under the Code of Ethics and within the scope and standards of midwifery practice.
• Continue discussion about consultation or transfer of care as per SCM policy on Case Review, Consultation and Transfer of Care and inform the client of risks associated with client decision.
• Midwife shall self-assess for signs of mental and/or physical fatigue to ensure client safety.
• In the case of an emergency transport, transfer care of client to appropriate MRP.
• Contemporaneously document all discussions and decisions, when possible.
• It is safer for a client to give birth with a midwife in attendance than to give birth alone. SCM will support any midwife who attends a client at home, even when care is outside of standards, provided the midwife has acted in accordance with this policy and remains within their scope of practice.