How to Write an ICD

One thing I wish I had going into NC was a solid tutorial on how to write an Informed Choice Discussion… ICDs are one of the pillars of midwifery and is really where art and science come together beautifully… This is where you can really start to develop your own style as a midwife as well. For me, I think I’m pretty casual, I use very plain language and lots of metaphors. When you’re a student, the hard thing about ICDs is that you need to translate complicated medical tests into something that a client can understand while still keeping in mind all the medicine and lab values in the back of your head. Another thing is trying not to overwhelm the client with too much info and stats… (you’ll know you’ve lost them when their eyes glaze over…) yet still, give them enough information to make an informed choice. The last thing, and I think this might be difficult at different stages of your career is avoiding bias. Bias about common things like circumcision you’d expect but be careful in developing bias about GBS testing or genetic screening too. If all your clients decline or alternatively always agree to certain tests, you may want to re-evaluate your ICD.

So let’s get right to it: the key is to use your BRAIN!

BRAIN is a pretty common acronym floating around in regards to ICDs and it’s actually pretty helpful. I use BRAIN and tack a couple more things on to cover all my bases.

Before we get into BRAIN, the first thing you should do is discuss Background Information relevant to the test/procedure/topic.

  • What are we testing for?
  • What gestational age/timeline?
  • Background anatomy and physiology relevant to the test
  • Why we get concerned about this issue/how does this relate to pregnancy?

BRAIN
B – Benefits

  • Can include benefits to the test or procedure or benefits to mom and baby with what current research says

R – Risks

  • Can include risks of taking the test to mom and baby and/or risk criteria to opt someone in or opt someone out of the test/procedure

A – Alternatives

  • Are there any alternatives to the test/procedure?

I – Intuition

  • What does your gut tell you to do?
  • This is the parent’s decision to make – it’s your job to lay out all the information in an unbiased way, offer your professional opinion, and make their decision become a reality as best you can

N – Nothing

  • What happens if we don’t do the test/procedure?
  • Are there consequences? Can we wait to make a decision?

Additional things to add as per the CMO…

Community Standards

  • What are other parents doing? What do most people do around here?
  • What do other health care providers typically recommend?
  • What is even available in this community?
  • Are there any laws regarding this procedure/test/medication?
  • Don’t forget about current research

Relevant Information to the Midwifery Scope of Practice

  • Can midwives order this test?
  • What happens with the results? Will care have to be transferred to a physician or just a consultation be needed?

Professional Recommendation

  • Given the client’s risk factors and history, what do you think?
  • Give your professional opinion, not what you would do if this was your pregnancy

Questions

  • Now that you’ve bombarded the client with all this info – ideally it should be a conversation – ask them if they have any questions…
  • One of those questions should be: what do you think about the test? Do you want to do it or not?

ICD Cheat Sheet

Background Information
Benefits
Risks
Alternatives
Intuition
Nothing
Community Standards
Scope of Practice
Recommendation
Questions


So how does this work in practice? I write my ICDs as a mix of clinical notes and colloquial phrasing – how I would actually say things… like a script.

Try writing your own. Say them out loud as you write, see if they make sense, do you ramble? Do you go off on tangents? Do you say too many percentages and figures? Simplify.

Ask to practice with your family – people that don’t know anything about the topic – see if they can explain the topic back to you, which is generally a good indication of comprehension.

Listen to midwives and other students do their ICDs – do you like their style? Anything they mention that you’d change? Your ICDs will evolve over time as you get more comfortable talking to clients. My goal was to write 1-2 ICDs per week in Normal Childbearing. I have over 40 now with many more that I need to write – but I certainly have a good base!

If you have any questions or want to practice, please contact me. Good luck in clinic!


 

ICD Resources:

Informed Choice

Click Here to Download the ICD Cheat Sheet PDF

 

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