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At least 253 records · Page 14Linked to original sources
PubMed2006

Decisions to limit life-sustaining treatment for critically ill patients who lack both decision-making capacity and surrogate decision-makers.

OBJECTIVE: Many intensive care unit (ICU) physicians have withdrawn life-support from a patient who lacked decision-making capacity and a surrogate decision-maker, yet little is known about the decision-making practices for these patients. We sought to determine how often such patients are admitted to the ICU of a metropolitan hospital and how end-of-life decisions are made for them. DESIGN: Prospective, observational cohort study. PATIENTS AND SETTING: Consecutive adult patients admitted to the medical ICU of a metropolitan West Coast hospital during a 7-month period in 2003 to 2004. MEASUREMENTS: Attending physicians completed a questionnaire about the decision-making process for each patient for whom they considered limiting life-support who lacked decisional capacity and a legally recognized surrogate decision-maker. MAIN RESULTS: Of the 303 patients admitted during the study period, 49 (16%; 95% confidence interval [CI], 12-21%) lacked decision-making capacity and a surrogate during the entire ICU stay. Compared with all other ICU patients, these patients were more likely to be male (88% vs. 69%; p = .002), white (42% vs. 23%; p = .028), and > or =65 yrs old (29% vs. 13%; p = .007). Physicians considered withholding or withdrawing treatment from 37% (18) of the 49 patients who lacked both decision-making capacity and a surrogate decision-maker. For 56% (10) of these 18 patients, the opinion of another attending physician was obtained; for 33% (6 of 18), the ICU team made the decision independently, and for 11% (2 of 18), the input of the courts or the hospital ethics committee was obtained. Overall, 27% of deaths (13 of 49) during the study period were in incapacitated patients who lacked a surrogate (95% CI, 15-41%). CONCLUSIONS: Sixteen percent of patients admitted to the medical ICU of this hospital lacked both decision-making capacity and a surrogate decision-maker. Decisions to limit life support were generally made by physicians without judicial or institutional review. Further research and debate are needed to develop optimal decision-making strategies for these difficult cases.

Adult↗
PubMedDate not supplied

Concept analysis of decision making.

TOPIC: Client decision making in relation to health care. PURPOSE: To develop a conceptual analysis of client decision making regarding health care that represents the current state of the science in order to better understand how clients make decisions. SOURCES: Published literature. CONCLUSIONS: A model of client decision making is presented with implications for nursing. Defining attributes, antecedents, consequences, and empirical referents of decision making are developed and illustrated by case presentations.

Adolescent↗
PubMed2005

Parental treatment decision making in pediatric oncology.

OBJECTIVE: To review progress and future plans for a research program about parents' making treatment decisions for their children with cancer. DATA SOURCES: Theoretical papers, review articles, and research reports. CONCLUSION: Three important questions need to be addressed to achieve the goal of supporting parents in treatment decision making: 1) Whatfactors predict a parent's preferred role iln decision making? 2) What are the critical outcomes from parental decision making that nurses could help to improve? 3) Is it role choice, actual role assumed, or congruence between preferred and actual role in decision making that predicts decision outcomes for the parents? IMPLICATIONS FOR NURSING PRACTICE: Research-based responses to the remaining questions about parent treatment decision making will help nurses develop and test interventions designed to support parents in their decision making experiences.

Attitude to Health↗
PubMed2005

Not all patients want to participate in decision making. A national study of public preferences.

BACKGROUND: The Institute of Medicine calls for physicians to engage patients in making clinical decisions, but not every patient may want the same level of participation. OBJECTIVES: 1) To assess public preferences for participation in decision making in a representative sample of the U.S. population. 2) To understand how demographic variables and health status influence people's preferences for participation in decision making. DESIGN AND PARTICIPANTS: A population-based survey of a fully representative sample of English-speaking adults was conducted in concert with the 2002 General Social Survey (N= 2,765). Respondents expressed preferences ranging from patient-directed to physician-directed styles on each of 3 aspects of decision making (seeking information, discussing options, making the final decision). Logistic regression was used to assess the relationships of demographic variables and health status to preferences. MAIN RESULTS: Nearly all respondents (96%) preferred to be offered choices and to be asked their opinions. In contrast, half of the respondents (52%) preferred to leave final decisions to their physicians and 44% preferred to rely on physicians for medical knowledge rather than seeking out information themselves. Women, more educated, and healthier people were more likely to prefer an active role in decision making. African-American and Hispanic respondents were more likely to prefer that physicians make the decisions. Preferences for an active role increased with age up to 45 years, but then declined. CONCLUSION: This population-based study demonstrates that people vary substantially in their preferences for participation in decision making. Physicians and health care organizations should not assume that patients wish to participate in clinical decision making, but must assess individual patient preferences and tailor care accordingly.

Adult↗
PubMed2005

The role of the neonatal intensive care nurse in decision-making: advocacy, involvement in ethical decisions and communication.

Neonatal intensive care unit (NICU) nurses are often faced with complex clinical and ethical problems. Little is known about the role of the NICU nurse in ethical decision-making, or processes that inform decision-making in this setting. The purpose of this study was to explore and describe nurses' perceptions of their role as patient advocate, clinical situations that cause them concern and the extent of their involvement in ethical decision-making. A combined quantitative and qualitative research design was used. A questionnaire was administered to nurses working in the NICU of the sole perinatal tertiary referral centre of Western Australia, Australia. Findings showed that NICU nurses saw their role in ethical decision-making primarily as advocating for the best interests of the infant and family, that they used clinical knowledge and experience to guide ethical decision-making, they were able to clearly articulate ethical problems and respond to them according to the clinical scenario and, while being primarily assertive in presenting their views, some nurses took a more passive approach. These findings support the need for development of a multidisciplinary model for ethical decision-making, where the view of all team members are considered.

Australia↗
PubMed1988

Principles of clinical decision making--an introduction to decision analysis. A special communication.

Physical therapists are becoming increasingly aware of the growing complexity of clinical decision making. The level of understanding and the sophistication necessary to diagnose, treat, and manage medical problems has increased concomitantly with the increase in new diagnostic and therapeutic procedures. The purposes of this special communication are to discuss the principles of clinical decision making and to present a hypothetical situation to illustrate a decision analysis process for choosing among alternative treatment protocols.

Cryotherapy↗
PubMed2002

Dementia and dignity: towards a new method of surrogate decision making.

Autonomous decisions are decisions that reflect the self who makes them. Since patients in need of surrogate decision making can no longer enjoy the dignity of being free to express who they are through choice and action, surrogates should strive to, at least, make sure that decisions on behalf of the patient reflects that patient's self. Concepts of the self, then, underlie views about the role autonomy should play in surrogate decision making. Alzheimer's disease (AD) complicates the situation because it is a disease which effects the self and theorists disagree about which aspect of the AD self the decision should reflect. This disagreement has led to a seemingly irresolvable split between those who favor the then self and those who favor the now self. The debate has stalled because while both of these views are attractive, neither seems adequate. That is, neither view is complete because each focuses only on one aspect of a whole self. In this paper, I argue that a good mode of surrogate decision making is one that focuses on the whole self and I offer practical advice concerning how we can begin to think about how such a decision might be made.

Aged↗
PubMed2004

Precautionary principles: a jurisdiction-free framework for decision-making under risk.

Fundamental principles of precaution are legal maxims that ask for preventive actions, perhaps as contingent interim measures while relevant information about causality and harm remains unavailable, to minimize the societal impact of potentially severe or irreversible outcomes. Such principles do not explain how to make choices or how to identify what is protective when incomplete and inconsistent scientific evidence of causation characterizes the potential hazards. Rather, they entrust lower jurisdictions, such as agencies or authorities, to make current decisions while recognizing that future information can contradict the scientific basis that supported the initial decision. After reviewing and synthesizing national and international legal aspects of precautionary principles, this paper addresses the key question: How can society manage potentially severe, irreversible or serious environmental outcomes when variability, uncertainty, and limited causal knowledge characterize their decision-making? A decision-analytic solution is outlined that focuses on risky decisions and accounts for prior states of information and scientific beliefs that can be updated as subsequent information becomes available. As a practical and established approach to causal reasoning and decision-making under risk, inherent to precautionary decision-making, these (Bayesian) methods help decision-makers and stakeholders because they formally account for probabilistic outcomes, new information, and are consistent and replicable. Rational choice of an action from among various alternatives--defined as a choice that makes preferred consequences more likely--requires accounting for costs, benefits and the change in risks associated with each candidate action. Decisions under any form of the precautionary principle reviewed must account for the contingent nature of scientific information, creating a link to the decision-analytic principle of expected value of information (VOI), to show the relevance of new information, relative to the initial (and smaller) set of data on which the decision was based. We exemplify this seemingly simple situation using risk management of BSE. As an integral aspect of causal analysis under risk, the methods developed in this paper permit the addition of non-linear, hormetic dose-response models to the current set of regulatory defaults such as the linear, non-threshold models. This increase in the number of defaults is an important improvement because most of the variants of the precautionary principle require cost-benefit balancing. Specifically, increasing the set of causal defaults accounts for beneficial effects at very low doses. We also show and conclude that quantitative risk assessment dominates qualitative risk assessment, supporting the extension of the set of default causal models.

Decision Making↗
PubMed1984

Do patients want to participate in medical decision making?

Although shared decision making by patients and clinicians has been advocated, little is known about the degree of participation in decision making that patients actually prefer or about clinicians' appreciation of these preferences. We administered questionnaires about three aspects of decision making to 210 hypertensive outpatients and to their 50 clinicians, who represented three types of medical practices. We found that 41% of patients preferred more information about hypertension; clinicians underestimated patient preferences for discussion about therapy in 29% of cases and overestimated 11% (k = .22); and 53% of patients preferred to participate in making decisions, while clinicians believed that their patients desired to participate in 78% of cases. Many patients who preferred not to make initial therapeutic decisions did want to participate in ongoing evaluation of therapy. Thus, clinicians underestimate patients' desire for information and discussion but overestimate patients' desire to make decisions. Awareness of this discrepancy may facilitate communication and decision making.

Adult↗
PubMed1986

Cognitive development and the dynamics of decision-making among adolescents.

Cognitive development was examined in relation to the amount of time students would deliberate before making a decision, the effect of perceived emotional stress on decision making, and identification of all possible decisions that would have to be made. Subjects were 94 eighth-11th grade students in New Mexico and Montana. Results indicated abstract thinkers had a better decision-making process than concrete thinkers and made more health promoting decisions. Health educators are challenged to create educational strategies that enhance abstract development and teach classic steps of decision-making, thus improving the decision-making ability of youth.

Adolescent↗
PubMed2005

A communication model of shared decision making: accounting for cancer treatment decisions.

The authors present a communication model of shared decision making (CMSDM) that explicitly identifies the communication process as the vehicle for decision making in cancer treatment. In this view, decision making is necessarily a sociocommunicative process whereby people enter into a relationship, exchange information, establish preferences, and choose a course of action. The model derives from contemporary notions of behavioral decision making and ethical conceptions of the doctor-patient relationship. This article briefly reviews the theoretical approaches to decision making, notes deficiencies, and embeds a more socially based process into the dynamics of the physician-patient relationship, focusing on cancer treatment decisions. In the CMSDM, decisions depend on (a) antecedent factors that have potential to influence communication, (b) jointly constructed communication climate, and (c) treatment preferences established by the physician and the patient.

Communication↗
PubMed2006

Beyond substituted judgment: How surrogates navigate end-of-life decision-making.

OBJECTIVES: To characterize how surrogates plan to make medical decisions for others. DESIGN: Descriptive study using semistructured qualitative interviews. SETTING: Surrogates were interviewed by telephone from their homes. PARTICIPANTS: Fifty experienced surrogate decision-makers identified to make decisions for older, chronically ill veterans. MEASUREMENTS: Surrogates were asked to describe advance care planning conversations with loved ones and how they planned to make future medical decisions. Thematic content analysis was used to identify bases for decision-making. RESULTS: Surrogates described the motivators and the content of advance care planning conversations with loved ones. Surrogates described five bases for decision-making: (1) conversations (making decisions based on their knowledge of their loved ones' preferences), (2) relying on documents (referring to their loved ones' advance care directives), (3) shared experience (believing an "inner sense" would guide decisions because of shared lived experience with loved ones), (4) surrogates' own values and preferences about life, and (5) surrogates' network (enlisting the help of others). CONCLUSION: Although ethicists and clinicians expect surrogates to use substituted judgment or patients' best interests when making decisions, these data indicate that many surrogates rely on other factors such as their own best interests or mutual interests of themselves and the patient or intend to base substituted judgments on documents with which they have little familiarity.

Adult↗
PubMed1999

Triage decision making: educational strategies.

Patient triage in Accident and Emergency departments requires emergency nurses to make rapid decisions based on their knowledge and experiences. The development of triage decision-making skills can be addressed through the use of simulations, 'thinking aloud' technique, reflection and the decision rules of experienced emergency nurses. Clinical educators and experienced emergency nurse mentors are encouraged to recognize that skill acquisition in triage decision making requires practice before registered nurses can engage fully in the process of triaging patients in the emergency department. It is essential to experience the process of triage decision making in order to develop an understanding of the clinical information attended to, the sequence in which the information is processed and the rules used to combine information leading to a decision on the triage category for each patient. By using triage simulations developed from 'real triage cases' the process of decision making can be experienced by nurses. Further, if these simulations are accompanied by the collection of verbal protocols, nurses have opportunities retrospectively to explore their decision making with reflection. In addition, the presentation and use of decision rules used by experienced triage nurses can enhance the development of skills in novice triage nurses.

Clinical Competence↗
PubMed2000

A handful of questions. Supporting parental decision making.

Advances in healthcare have improved the survival rates of children with serious health problems. Parents, relieved that their child is alive, often face the challenge of caring for a child with a chronic illness and must make healthcare decisions that have life-long consequences. Supporting parents through the decision-making process is a complex challenge for the advanced practice nurse. This article offers an original and dynamic decision-making assessment tool to help the advanced practice nurse provide effective evaluation and appropriate support for the parents. This "Handful of Questions" was created using a patient-oriented decision-making model by Pierce and the work of other decision-making researchers. The literature reviewed includes the topics of surrogate parental decision making and an examination of the relationship between the decision-maker and healthcare providers.

Adult↗
PubMed1985

Individual differences in the use of simplification strategies in a complex decision-making task.

Decision time results were used to assess the strategies that 90 college undergraduates used in a complex decision-making task. Trend analyses revealed that the functions relating choice time to the number of choice alternatives in a set and the number of attributes comprising those alternatives contained linear (increasing) components. In addition, for a portion of the subjects, there was a quadratic effect of the number of attributes available to the decision maker on choice time, suggesting that these subjects adopted simplification strategies at high levels of task complexity. Reliable individual differences in these trend components were observed, consistent with individual differences in motivation and/or processing capacities. These individual differences were included in an information-processing model of decision behavior that captured the choice time data observed in this study. Subjects' ratings of apartments were used as a basis to assess the extent to which the use of simplification strategies resulted in preference reversals. Contrary to expectation, subjects whose choice times contained quadratic components demonstrated fewer preference reversals at high levels of information load.

Cognition↗
PubMed2005

Neural activity in macaque parietal cortex reflects temporal integration of visual motion signals during perceptual decision making.

Decision-making often requires the accumulation and maintenance of evidence over time. Although the neural signals underlying sensory processing have been studied extensively, little is known about how the brain accrues and holds these sensory signals to guide later actions. Previous work has suggested that neural activity in the lateral intraparietal area (LIP) of the monkey brain reflects the formation of perceptual decisions in a random dot direction-discrimination task in which monkeys communicate their decisions with eye-movement responses. We tested the hypothesis that decision-related neural activity in LIP represents the time integral of the momentary motion "evidence." By briefly perturbing the strength of the visual motion stimulus during the formation of perceptual decisions, we tested whether this LIP activity reflected a persistent, integrated "memory" of these brief sensory events. We found that the responses of LIP neurons reflected substantial temporal integration. Brief pulses had persistent effects on both the monkeys' choices and the responses of neurons in LIP, lasting up to 800 ms after appearance. These results demonstrate that LIP is involved in neural time integration underlying the accumulation of evidence in this task. Additional analyses suggest that decision-related LIP responses, as well as behavioral choices and reaction times, can be explained by near-perfect time integration that stops when a criterion amount of evidence has been accumulated. Temporal integration may be a fundamental computation underlying higher cognitive functions that are dissociated from immediate sensory inputs or motor outputs.

Action Potentials↗