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PubMed1998

The ethical dilemma of population-based medical decision making.

Over the past several years, there has been a growing interest in population-based medicine. Some elements in healthcare have used population-based medicine as a technique to decrease healthcare expenditures. However, in their daily practice of medicine, physicians must grapple with the question of whether they incorporate population-based medicine when making decisions for an individual patient. They therefore may encounter an ethical dilemma. Physicians must remember that the physician-patient relationship is of paramount importance and that even well-conducted research may not be applicable to an individual patient.

Community Health Planning↗
PubMed1998

Achieving success for freestanding ambulatory care centers: investment decision-making.

This is the first installment in a series of three articles for Ambulatory Outreach on the topic of ambulatory center development. This article provides a framework for making decisions for investing in freestanding centers. The second article, to be published in the 1998 winter issue, will define the tasks and approaches required to effectively plan freestanding centers' strategies, operations and facilities. The last article, to be published in spring of 1999, will provide practical advice regarding start-up and operation of ambulatory care centers. Real-life examples of health care organizations facing these challenges will be highlighted throughout the series.

Ambulatory Care Facilities↗
PubMed2002

Using research for clinical decision-making: evaluating a research report.

Oral healthcare professionals need to ascertain the quality of journals and to read articles critically, distinguishing good from poor research. The oral health practitioner must continually review dental research articles to learn about new options for therapy and oral health products. How does the practitioner know when he/she should incorporate these new procedures into their practice? This continuing education course will present guidelines for critically evaluating the research and for making decisions about how to apply the research findings to clinical practice.

Authorship↗
PubMed2003

Health care reform and the scope of independence in decision making by environmental/family nurses. IV. Contracts realized by the payer and occupational independence of nurses.

New legal and organizational conditions enabled nurses to sign contracts directly with the disposers of allocations. It was anticipated, among others, that contracting specific health services would result in the staff obtaining greater independence in the matters of nursing. Showing one's own initiative at work may lead to an increase in satisfaction among patients and nurses, as well as the strengthening of the occupational position of nurses in the future. For this reason, the study was undertaken to confirm whether PHC nurses perceive the relationship between actual independence and performing work activities within individual or group contracts. The study was conducted in a form of a diagnostic survey, and covered 120 environmental/family nurses from non-public and public health care units. The results were analyzed from the aspect of statistical differences between the experimental and control groups. A significantly greater number of staff employed on the new basis performed independent tasks in the environment, compared to nurses employed in traditional structures. Differences were also observed concerning respondents' opinions in relation to freedom in making decisions experienced in various organizational forms. According to the respondents of the experimental group, group contracts guarantee a greater autonomy, while those of the control group evaluate individual practices in more positive terms.

Community Health Nursing↗
PubMed1988

Daily decision-making in community residences: a social comparison of adults with and without mental retardation.

In addition to physical placement in the community, the extent to which individuals experience personal autonomy may provide a crucial measure of the attainment of a more normalized lifestyle. Everyday choices and choice-making opportunities of 24 persons with mental retardation living in community group homes were compared to choices of 42 nonretarded adults. The adults with mental retardation had significantly fewer opportunities to make decisions on such matters as what to eat or wear, how to spend free time, and with whom to live. Results were discussed in terms of the need to operationalize meaningful improvements in the lives of persons with mental retardation that go beyond the appearance of the physical environment.

Activities of Daily Living↗
PubMed1999

Making decisions for children.

Making decisions for children is part of everyday orthodontic care. When conflicts arise between providers and parents, articulation of the ethical and legal principles guiding the process can be helpful. Parents are generally decision makers for their minor children, a presumption supported for practical and moral reasons and by legal precedent. The best interests of the child must guide both parents and providers. As the child matures, he or she should be brought into the decision making process as age and ability allow. A child's competency is a function of age, cognitive abilities, and personal experiences. The child should participate in the decision making process to facilitate trust, cooperation, and the development of future decisional capacities. The concepts of informed consent, parental permission, and child assent are compared and contrasted. Tables are provide that summarize these concepts and offer guidelines for providers working with children.

Child↗
PubMed1999

The performance measurement matrix: a framework to optimize decision making.

Patient care executives and performance improvement specialists continually are challenged to make decisions that have far-reaching effects on cost, productivity, and the quality of patient care. With multiple stakeholders to serve, minimal time to consider options, and an overabundance of data, new approaches to assessing and monitoring quality are needed. This article describes a framework and process to assist health care leaders in making informed and timely decisions. Six dimensions of health care--patients, caregivers, the organization, quality, efficiency, and cost--are assessed within the organization's context for overall impact on performance.

Cost-Benefit Analysis↗
PubMed1988

"Ethical workup" guides clinical decision making.

Shared decision making, along with an explosion in costs and the alternatives associated with the technological revolution in medicine, has moved medical ethics from the status of a professional etiquette to that of a rigorous new discipline. A model for an "ethical workup," which medical professionals can use in healthcare setting, has four phases: expository, rational, volitional, and public. The expository phase includes medical factors, which are the most important for determining the right or wrong thing to do for a patient; ethical factors, which involve the interests, intuitions, and feelings of all those involved in a case; and socioeconomic factors, in which costs that create burdens on others become important, and in some cases decisive, considerations. The rational phase includes medical ethics categories, which determine the type of case one is facing; principles and moral guidelines, which justify decisions; and legal decisions and professional codes, which synthesize accepted wisdom about appropriate ethical behavior. The volitional phase includes ordering goods and values, which involves establishing priorities and weighing certain factors; ordering the principles, which reflect personal or institutional character and is influenced by religious and philosophical beliefs; and decision making, in which professionals consider a decision's impact on their profession, their facility, and themselves. The public phase includes making assumptions explicit, which means professionals should try to recognize underlying beliefs, admit their influence on preferred positions, and be sensitive to other perspectives and preferences; correlating initial feelings about right and wrong with the reasons supporting a decision; and organizing reasons for public communication.

Bioethical Issues↗
PubMed2000

Social processes and group decision making: anonymity in group decision support systems.

Various social processes in decision-making groups are considered detrimental to the quality of decisions. It is often assumed that removing the ability for groups to exert strong social influence on its members improves group decisions. Group Decision Support Systems (GDSSs) are increasingly used to remedy the social faults of the decision-making process in groups. In these systems, anonymity is seen as a tool to reduce the impact of the group over its members, and therefore as the key to improved group performance. This meta-analytic review examines the assumption that anonymity in GDSSs is beneficial for group decision-making on a range of performance indicators. In 6 meta-analyses of 12 independent investigations there is no support for this hypothesis. The only reliable effect of anonymity was to lead to more contributions, especially more critical ones. An alternative model is presented to account for the findings. This model argues that performance in decision-making groups depends on the social context and relevant social norms as well as on system characteristics such as anonymity. It is concluded that the integration of anonymity into phases of group decision support does not guarantee improved performance.

Confidentiality↗
PubMedDate not supplied

The use of decision analysis to examine ethical decision making by critical care nurses.

OBJECTIVE: To examine the extent to which critical care staff nurses make ethical decisions that coincide with those recommended by a decision analytic model. DESIGN: Nonexperimental, ex post facto. SETTING: Midwestern university-affiliated 500 bed tertiary care medical center. SUBJECTS: One hundred critical care staff nurses randomly selected from seven critical care units. Complete responses were obtained from 82 nurses (for a final response rate of 82%). MEASURES: The dependent variable--consistent decision making--was measured as staff nurses' abilities to make ethical decisions that coincided with those prescribed by the decision model. Subjects completed two instruments, the Ethical Decision Analytic Model, a computer-administered instrument designed to measure staff nurses' abilities to make consistent decisions about a chemically-impaired colleague; and a Background Inventory. RESULTS: The results indicate marked consensus among nurses when informal methods were used. However, there was little consistency between the nurses' informal decisions and those recommended by the decision analytic model. Although 50% (n = 41) of all nurses chose a course of action that coincided with the model's least optimal alternative, few nurses agreed with the model as to the most optimal course of action. The findings also suggest that consistency was unrelated (p > 0.05) to the nurses' educational background or years of clinical experience; that most subjects reported receiving little or no education in decision making during their basic nursing education programs; but that exposure to decision-making strategies was related to years of nursing experience (p < 0.05). CONCLUSIONS: The findings differ from related studies that have found a moderate degree of consistency between nurses and decision analytic models for strictly clinical decision tasks, especially when those tasks were less complex. However, the findings partially coincide with other findings that decision analysis may not be particularly well-suited to the critical care environment. Additional research is needed to determine whether critical care nurses use the same decision-making methods as do other nurses; and to clarify the effects of decision task (clinical versus ethical) on nurses' decision making. It should not be assumed that methods used to study nurses' clinical decision making are applicable for all nurses or all types of decisions, including ethical decisions.

Adult↗
PubMed1995

Use of certainty of opinion data to enhance clinical decision making.

Clinical decision making and diagnostic testing procedures are frequently evaluated using indices such as sensitivity and specificity. These indices require an assumption that the underlying disease state or the diagnostic test result is binary, which may be an unreasonable assumption in many clinical situations. They also fail to recognise the potential for different degrees of diagnostic confidence. In this paper, we report some data from a clinical study of postpartum mothers in which, in addition to the diagnostic result, an expression of certainty or strength of belief was ascertained. We illustrate how the certainty of opinion data can be combined with the diagnostic opinion in order to enhance the interpretation of the study, and the implications for improving the accuracy of clinical decision making in general.

Decision Making↗
PubMed2006

How important is the opinion of significant others to cancer patients' adjuvant chemotherapy decision-making?

GOALS: Decisions regarding adjuvant chemotherapy are difficult, since value tradeoffs are involved. Little is known about the importance of the significant others in patients' decision-making regarding adjuvant treatment. We surveyed patients with breast and colorectal cancer about the importance they assigned to the opinions of their significant others and assessed correlates of these importance scores. MATERIALS AND METHODS: One hundred and twenty-three patients rated on a five-point scale how much they cared about the opinion of six significant others. MAIN RESULTS: Most important was the opinion of their treating specialist, followed by that of their partner, children, other family, friends, and colleagues. Women assigned higher scores to the opinion of their children, younger patients to that of their specialist, and patients who were about to undergo chemotherapy to that of their family. Patients with breast cancer and patients without paid employment assigned slightly more importance to the opinion of their partner. CONCLUSIONS: Information on the influence of significant others may help clinicians when involving patients in treatment decision-making and discussing patients' treatment preferences.

Adult↗
PubMed2003

Decision making under conflict: decision time as a measure of conflict strength.

Conflict and choice are closely related in that choice produces conflict and conflict is resolved by making a choice. Although conflict was invoked in psychological approaches to decision making early on (Lewin, 1931/1964), no generally accepted measure of conflict strength has been established (Tversky & Shafir, 1992). The present study introduces a model (multiattribute decision field theory) that predicts a decision time pattern depending on the conflict situation. In a risky decision-making experiment with multiattribute choice alternatives, decision time is investigated as a possible measure of conflict strength. It is shown that the model can be fitted to a complex choice pattern.

Adult↗
PubMed1993

Whither the rationale for thrombolytic agent administration? A retrospective review of traditional intuitive decision-making using a decision analysis model.

Of 50 consecutive patients admitted to Nenagh Hospital coronary care unit 50 per cent did not develop a myocardial infarction. Only 10 patients had definite evidence of infarction on admission. Of the 40 remaining patients, only 15 subsequently developed electrocardiographic and enzymatic confirmation of infarction. Streptokinase was administered to 5 patients who did not infarct, and was not given to 10 patients who did. These decisions to use or withhold thrombolytic therapy were retrospectively reviewed using a computer programme incorporating a decision analysis of the benefits and risks of thrombolysis. The programme examined four scenarios that used different estimates of the chance of death from infarction (pdiMI), and different safety profiles of thrombolytics. The scenario that assumed the worst safety profile and estimated pdiMI from patient age would have recommended thrombolytic treatment to the most with, and to the least without, acute infarction (i.e. 60 per cent of patients with an infarct and 8 per cent without an infarct would have been treated). Depending on the scenario assumed, the traditional intuitive method of decision-making gained from 0.08 and 0.25 quality adjusted life years (QALY's) for the average patient. Had decision analysis been used to guide these decisions these gains would have been enhanced by from 0.21 to 0.28 QALY's per patient, regardless of scenario used.

Decision Support Techniques↗
PubMed2003

Naturalistic decision making: a model to overcome methodological challenges in the study of critical care nurses' decision making about patients' hemodynamic status.

The quality of critical care nurses' decision making about patients' hemodynamic status in the immediate period after cardiac surgery is important for the patients' well-being and, at times, survival. The way nurses respond to hemodynamic cues varies according to the nurses' skills, experiences, and knowledge. Variability in decisions is also associated with the inherent complexity of hemodynamic monitoring. Previous methodological approaches to the study of hemodynamic assessment and treatment decisions have ignored the important interplay between nurses, the task, and the environment in which these decisions are made. The advantages of naturalistic decision making as a framework for studying the manner in which nurses make decisions are presented.

Critical Care↗
PubMed2004

Modifying unwarranted variations in health care: shared decision making using patient decision aids.

Shared decision making is the process of interacting with patients in arriving at informed values-based choices when options have features that patients value differently. Patient decision aids (PtDAs) are evidence-based tools designed to facilitate that process. Numerous randomized trials indicate that PtDAs improve decision quality and prevent overuse of options that informed patients do not value. Therefore, they have a potential role in reducing unwarranted variations in the use of preference-sensitive health care options. However, barriers to their widespread use need to be addressed with coherent plans for ensuring good standards, improving access to PtDAs, training practitioners, testing practice models, and launching demonstration projects.

Cost-Benefit Analysis↗
PubMed2003

[Shared decision making in breast cancer patients--qualitative study on mutual decision making in breast cancer in a university hospital].

This qualitative study examines doctor-patient interactions and interviews with breast cancer patients referring to shared decision making. The interviews have been evaluated according to the method of grounded theory. Videos of doctor-patient interactions show information and discussions on therapy planning. Breast cancer is a serious, in many cases life-threatening disease. The primary therapy is characterised by confrontation with the diagnosis, fear and hope of the patients and the subsequent treatment. Central themes of the article are the context and implicit assumptions of doctors influencing the shared decision making approach.

Adaptation, Psychological↗