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Results for “Making Difficult Health Care Decisions”

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PubMed1987

Management of bulbar symptoms in amyotrophic lateral sclerosis.

The bulbar symptoms of ALS include difficulty with the management of swallowing, saliva, aspiration, and communication. These symptoms originate from the disability of the oropharyngeal muscles and actually represent varying degrees of severity of a single problem. The management of these symptoms requires the concerted effort of a rehabilitation team, which should include a surgeon, speech pathologist, neurologist, psychosocial worker, and dietitian. Early education of the patient and patient's family greatly facilitates successful management of bulbar symptoms. Early recognition of the signs of dysphagia, aspiration, and communicative disability are important in order to provide solutions before severe and possibly life-threatening debilitation occurs. The treatments and techniques presented in this chapter must be applied to each patient on an individual basis. The moral and social decisions regarding the providing or withholding of treatment to ALS patients are difficult ones. It is important, however, to realize that management decisions of ALS patients must deal not only with the quantity of life but also the quality of life. This distinction often falls into a 'gray zone' with management of bulbar symptoms since swallowing difficulties are life-threatening as well as uncomfortable. One of the difficulties that we present ourselves as health care providers in ALS is that, more often than not, our patient is in a noncommunicative position and cannot contribute to treatment decisions. If careful and aggressive care is taken to preserve the communicative abilities of our patients, the difficult situation of making decisions based on the family's inclinations and our own inclinations can be avoided. When we are confronted with a decision to maintain or cease support for a patient, the moral and emotional issues that present can be overwhelming. However, the patient's input, if it were direct and included the ability to express complex thoughts, could often provide the information necessary to make the decisions more clear.

Airway Obstruction↗

PubMedDate not supplied

Selected reflections on quality of medical care evaluation in the 1980s.

Quality assessment of medical care in the 1980s will face several challenges. Most important is the current move toward cost containment. Issues such as making cost-benefit tradeoffs and defining the focus of medical care will be difficult to resolve. With the help of patients and nonhealth professionals, decisions and tradeoffs can be made and a viable equilibrium between cost containment and quality of health care may be achieved.

Cost-Benefit Analysis↗

PubMed2002

Nursing informatics. Applications for long-term care.

Long-term care (LTC) settings, specifically nursing homes, have found it difficult to manage the regulatory process and provide quality resident care without computerization. Clinical information systems in the current health care environment, including LTC, need to provide five functions. These five functions are providing the legal record of care; supporting clinical decision-making; capturing costs for financial purposes; accumulating a database for administrative queries, quality assurance, and research; and supporting data exchange between systems. While computerization may have occurred in LTC, the application of the informatics concepts with nursing standardized languages and financial and database usage may not have occurred. To succeed in the current health care environment, nursing informatics concepts need to be implemented in LTC. As a result, the quality of care for older adults in nursing homes will be improved. The purpose of this article is to identify application for nursing informatics use in the LTC setting.

Databases, Factual↗

PubMed2003

The significance of quality of life in health care.

This paper compares a traditional biomedical model with an outcomes model for evaluating health care. The traditional model emphasizes diagnosis and disease-specific outcomes. In contrast, the outcomes model emphasizes life expectancy and health-related quality of life. Although the models are similar, they lead to different conclusions with regard to some interventions. For some conditions, diagnosis and treatment may reduce the impact of a particular disease without extending life expectancy or improving quality of life. Older individuals with multiple co-morbidities may not benefit from treatments for a particular disease if competing health problems threaten life or reduce quality of life. In preventive medicine, diagnosis of disease is made more difficult because of ambiguity, uncertainty, lead-time bias, and length bias. In some circumstances, successful diagnosis and treatment may actually reduce life expectancy or overall life quality. Example applications of the outcomes model from clinical policy analysis, individual decision making and shared decision-making are offered. The outcomes model has received little attention in dental health care but may have parallels to applications in other areas of medicine.

Decision Making↗

PubMed1999

A systematic review of interventions to improve health professionals' management of obesity.

OBJECTIVE: To determine the existence and effectiveness of interventions to improve health professionals' management of obesity or the organisation of care for overweight and obese people. DESIGN: A systematic review of intervention studies, undertaken according to standard methods developed by the Cochrane Effective Practice and Organisation of Care (EPOC) Group. PARTICIPANTS: Trained health care professionals and overweight and obese patients. MEASUREMENTS: Objective measures of health professionals' practice and behaviours, and patient outcomes including satisfaction, behaviour, psychological factors, disease status, risk factors, and measures of body weight, fat, or BMI. RESULTS: Twelve studies that met all the review inclusion criteria were identified. Three were randomised controlled trials of health professional-oriented interventions (such as the use of reminders and training) and one was a controlled before and after study to improve collaboration between a hospital clinic and GPs. A further eight randomised controlled trials were identified of interventions comparing either the deliverer of weight loss interventions or the setting of the delivery of the intervention. The heterogeneity and generally limited quality of identified studies make it difficult to provide recommendations for improving health professionals' obesity management. CONCLUSIONS: At present, decisions about improving the provision of services for overweight and obese people must be based on the evidence from patient interventions and good clinical judgement. Future research is required to identify cost-effective strategies for improving health professionals' management and the organisation of care for overweight and obese people.

Body Weight↗

PubMed2002

Quality-of-life assessment in palliative care.

Success in oncology has traditionally been measured in terms of cure, survival, and tumour response. However, more recently, health-related quality of life has emerged as an important outcome, particularly in the palliation setting. We review published randomised studies from two areas in palliation: those assessing the effectiveness of palliative care programmes and those looking at the effects of palliative chemotherapy compared with best supportive care. In the latter studies, there was an improvement in research methods between the late 1980s and 2000, owing to the use of standardised instruments, specification of endpoints, and improvements in data presentation and interpretation. A range of health-related quality-of-life instruments were used in the studies, which makes comparisons difficult. This was particularly true of the palliative-care programmes. Attrition due to the death of patients in the study groups was also a problem and needs to be taken into account in study planning and design, as well as in data collection. A common standard for scoring health-related quality of life measurements both within and between instruments would improve the interpretation of findings and their clinical application, thereby giving them greater effect on clinical decision-making.

Female↗

PubMed2006

National Institutes of Health state-of-the-science conference statement: Cesarean delivery on maternal request March 27-29, 2006.

OBJECTIVE: To provide health care providers, patients, and the general public with a responsible assessment of currently available data on cesarean delivery on maternal request. PARTICIPANTS: A non-U.S. Department of Health and Human Services, nonadvocate 18-member panel representing the fields of obstetrics and gynecology, preventive medicine, biometrics, family planning and reproductive physiology, nurse midwifery, anesthesiology, patient safety, epidemiology, pediatrics, perinatal medicine, urology, urogynecology, general nursing, inner-city public health sciences, law, psychiatry, and health services research. In addition, 18 experts from pertinent fields presented data to the panel and conference audience. EVIDENCE: Presentations by experts and a systematic review of the literature prepared by the RTI International-University of North Carolina Evidence-based Practice Center, through the Agency for Healthcare Research and Quality. Scientific evidence was given precedence over anecdotal experience. CONFERENCE PROCESS: The panel drafted its statement based on scientific evidence presented in open forum and on published scientific literature. The draft statement was presented on the final day of the conference and circulated to the audience for comment. The panel released a revised statement later that day at http://consensus.nih.gov. This statement is an independent report of the panel and is not a policy statement of the National Institutes of Health or the federal government. CONCLUSIONS: The magnitude of cesarean delivery on maternal request is difficult to quantify. There is insufficient evidence to evaluate fully the benefits and risks of cesarean delivery on maternal request compared with planned vaginal delivery. Any decision to perform a cesarean delivery on maternal request should be carefully individualized and consistent with ethical principles.

Cesarean Section↗

PubMed2005

Colombia: in vivo test of health sector privatization in the developing world.

The reform of the Colombian health sector in 1993 was founded on the internationally advocated paradigm of privatization of health care delivery. Taking into account the lack of empirical evidence for the applicability of this concept to developing countries and the documented experience of failures in other countries, Colombia tried to overcome these problems by a theoretically sound, although complicated, model. Some ten years after the implementation of "Law 100," a review of the literature shows that the proposed goals of universal coverage and equitable access to high-quality care have not been reached. Despite an explosion in costs and a considerable increase in public and private health expenditure, more than 40 percent of the population is still not covered by health insurance, and access to health care proves uncreasingly difficult. Furthermore, key health indicators and disease control programs have deteriorated. These findings confirm the results in other middle- and low-income countries. The authors suggest the explanation lies in the inefficiency of contracting-out, the weak economic, technical, and political capacity of the Colombian government for regulation and control, and the absence of real participation of the poor in decision-making on (health) policies.

Colombia↗

PubMed1995

Patient advocacy at the end of life.

Caring for the competent, fragile, elderly patient at the end of life is becoming increasingly challenging. This case explores several ethical areas of concern that arise when caring for patients who have written durable powers of attorney for health care decisions and face life or death choices. Areas covered are informed consent with the elderly patient, the family's right to be involved in decision-making, futility of treatment, and the nurse's role as patient advocate during times of difficult decision-making. Recommendations for increased nursing intervention during these times are incorporated.

Advance Directives↗

PubMedDate not supplied

[Current trends in biomedical ethics in the United States of America].

In the United States, contemporary biomedical ethics began to develop in the 1960s, together with the advent of major advances in basic research and clinical application and the establishment of health care entitlement programs. Problems of a moral nature promptly arose in the fields of biology and medicine that have generated ongoing debate. Today, the five topics of greatest importance are the rights and autonomy of the patient, the meaning of the "sanctity of life" as opposed to the "quality of life," interventions in nature, the allocation of resources, and the function of the public in decision-making about health. Ethics committees have been set up in 60% of hospitals to examine the most difficult problems and provide pertinent advice. Another trend that may be very significant in the future is a politicization of bioethical questions and a division into factions that will introduce political rhetoric into the field of medicine.

Bioethics↗

PubMed2003

Planning for positive clinical & financial returns with telemonitoring.

Telemonitoring is a burgeoning market in the home care industry. Making the decision to invest in telemonitoring technology can be difficult in the best situations. The financial investment is significant, the risks can be high, and the need to achieve a positive return is critical to future success. In spite of the risks, this relatively new technology in home care holds the promise for the redefinition of the industry.

Community Health Nursing↗

PubMed1999

Go the extra mile--use the Delphi Technique.

AIM: The Delphi Technique is reviewed and its potential contribution to the management of change assessed. BACKGROUND: Change management is an essential skill required, not just by managers, but by all staff working in health care. Modern theories advocate participation and free communication to engender commitment and ensure successful change. Data collection methods associated with surveys--interviews and questionnaires--are regularly used to obtain information for service development. Indications of likely resistance are more difficult to obtain. KEY ISSUES: The Delphi Technique is critiqued and found to incorporate many attributes that can produce information which would be otherwise difficult or impossible to obtain. A recently published study performed by the author illustrates this potentiality. An indication of the impact of the findings on the subsequent implementation of change by service managers is provided. CONCLUSION: The Delphi Technique is a useful management tool that can provide data that are difficult to obtain by other means.

Attitude of Health Personnel↗

PubMed2007

Traumatic memories of relatives regarding brain death, request for organ donation and interactions with professionals in the ICU.

Little is known about the memories of relatives after they have been confronted with the brain death of a loved one and the request for organ donation. We conducted this study, guided by Grounded Theory, to explore relatives' experiences, their interactions with health care providers and what influenced their memories. We interviewed 40 relatives (31 consenting to and 9 refusing organ donation) of 33 brain-dead individuals. Relatives described their experiences as a difficult process composed of several stages spanning from the initial encounter to the final decision about donation. Long-term memories of bereaved relatives were influenced by the characteristics of their decision-making style (clear vs. ambivalent) and the perceived quality of the interaction with professionals on the intensive care unit. Organ-focused behavior of professionals and an ambivalent decision-making style of relatives appear to be risk factors for traumatic memories.

Adolescent↗

PubMed2003

Characteristics associated with reported CAM use in patients attending six GP practices in the Tayside and Grampian regions of Scotland: a survey.

OBJECTIVES: To study the nature of CAM use in primary care attenders, the involvement of their NHS healthcare professionals in their CAM care and differences in characteristics between CAM users and non-users. DESIGN: Postal questionnaire for primary care attenders and analysis of practice leaflets. SETTING: Six Scottish GP practices with a range of practice size, CAM provision within practice, deprivation and rurality. RESULTS: Five hundred and fourteen primary care attenders described 1194 incidences of CAM use and gave details about their main therapy. 37% had contact with a practitioner, the rest mainly self-prescribed. The perceived effectiveness of CAM was high. Patients used CAM for a variety of health problems, mainly as an adjuvant to orthodox medicine rather than an alternative. The involvement of the NHS in CAM delivery was small but there is a significant role to ensure patient safety, especially regarding herb-drug interactions. Disclosure rate of CAM use was low. CAM offered options in areas where the provision in the NHS is difficult, including musculo-skeletal and mental health problems. Provision of CAM by the GP is associated with higher CAM use in primary care attenders. CONCLUSIONS: It is recommended that healthcare professionals include patients' use of CAM in history taking and clinical decision making.

Adolescent↗

PubMed2004

From human ability to ethical principle: an intercultural perspective on autonomy.

Based on an empirical study regarding ethical challenges within intercultural health care, the focus of this article is upon autonomy and disclosure, discussed in light of philosophy and anthropology. What are the consequences for patients if the patients' right to be autonomous and to participate in treatment and care decisions by health care workers is interpreted as an obligation to participate? To force a person to make independent choices who is socio-culturally unprepared to do so, may violate his/her integrity. This may in turn jeopardise the respect, integrity and human worth the principle of autonomy was meant to ensure, and if so, may damage any relationship of trust that may exist between patient and health care worker. There is necessarily a link between autonomy and disclosure. Western disclosure practices may make the relationship between patients and health care workers difficult--even distrustful. To confront a patient with a very serious diagnosis may be seen not only as a tactless action, but also an unforgivable one. Hence, among many ethnic groups it is a family member's duty to shield patients from bad or disquieting news, e.g., a cancer diagnosis. If a family member is used to interpret in such situations, will the information given equal the information communicated by that interpreter? Even though respect for a person's autonomy is part of the respect for a person, one's respect for the person in question should not depend on his/her ability or aptitude to act autonomously.

Choice Behavior↗

PubMed1976

Utilization review, attempted suicide, and involuntary hospitalization.

A patient's refusal to participate in recommended treatment is a problem faced in all branches of medicine. However, psychiatry faces special problems because of its authority to impose hospitialization of suicide attempters, cases were identified where there was indepdent agreement between both the experts' standards and the treating resident psychiatrists that hospitalization was required. Despite this agreement, the patients were not hospitalized because the patients refused. By most criteria, these patients were a high risk group. They had made repeated suicide attempts, used lethal means which eventuated in serious medical consequences, and were still suicidal when referred for treatment. The emergency room psychiatrists reported feeling confused, anxious, and annoyed in dealing with these patients, and the patients signed out against medical advice. A review of these cases indicated that discussions of social control vs. medical responsibility and clear criteria for hospitalization should be incorporated into residency training programs since the emergency room resident faces these tension-producing issues frequently with several different types of patients. Moreover, utilization review criteria may help to set standards which will assist the psychiatrist in making these difficult decisions.

Adult↗

PubMedDate not supplied

The Ottawa patient decision aids.

CONTEXT: Shared decision-making programs, or patient decision aids, have been developed for difficult decisions in which patients need to consider benefits versus risks. PRACTICE PATTERN EXAMINED: Decision aids currently used in practice in Ottawa, Ontario, Canada. DATA SOURCES: Published studies of patients faced with decisions about hormone therapy, prenatal testing, lung cancer treatments, and anticoagulation for atrial fibrillation; administrative data on distribution of decision aids; and a survey mailed to pulmonologists and surgeons. RESULTS: Although most patients considering health care options arrive for counseling with strong predispositions toward a particular option, some are uncertain about their choice and express the need for information, clarification of values, and advice about their options. Decision aids prepare patients for decision making by increasing their knowledge about expected outcomes and personal values. The aids are used in our local centers, and more than 6000 kits have been distributed in Canada, the United States, Europe, and Australia. They primarily affect the decisions of patients who are undecided at baseline and sometimes reduce the proportion of patients who choose more intensive options. CONCLUSION: The Ottawa patient decision aids assist patient decision making, particularly among those who are undecided.

Adult↗

PubMed1998

Parental touch of the neonate: encourage or condemn?

The available literature regarding parental touch and its use on premature infants indicates differing views on whether touch should be encouraged or condemned. Findings of this literature review indicate that touch can have a detrimental physical effect on the infant, however positive long-term benefits for parent and child. The absence of direct guidelines for nursing staff working in a neonatal intensive care unit make decisions about parental touch difficult. The result from this literature review suggests that guidelines for nursing staff need to be established, so that optimum care is provided for both infant and parent.

Adult↗