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PubMed2001

Aim for a healthy weight: what is the target?

The first guideline statement of the Year 2000 edition of Nutrition and Your Health: Dietary Guidelines for Americans is "Aim for a healthy weight." The purpose of this paper is to describe the evolution of the weight guideline and discuss some issues related to it. We reviewed current and previous editions of the Dietary Guidelines and the corresponding advisory committee reports. The weight guideline has evolved over the years into one that is complex and touches on a wide range of issues. The 2000 edition emphasizes weight loss more than previous editions. Unlike the other guidelines in the Dietary Guidelines, the weight guideline has a health outcome, a "healthy" weight, rather than a behavioral outcome as its goal. Also unlike the other guidelines, the weight guideline has become more medically oriented over time. The concept of healthy weight in the guidelines includes aspects of body composition, fat distribution and weight-related health conditions. It may be difficult for the public and even for health care providers to interpret some of the concepts included in the weight guideline. Issues related to the appropriate management of weight can be complex and may require a health care provider as a resource for interpretation. Rather than try to incorporate further clinical decision-making and weight loss guidance within the weight guideline, it may be more appropriate to refer the reader to a health care provider for guidance, as was done in previous editions.

Age Factors↗

PubMed2006

Failure to achieve assent in a communicative patient: what are the caregiver's obligations?

Disclosure of facts related to an individual's health care, including level and location of care, are central to the fulfillment of informed consent. When an individual is unable to provide informed consent because they lack the decision-making capacity to process the information and/or they have been deemed legally incompetent, the health care team should obtain assent from the individual whenever possible. Questions remain as to how to proceed when assent cannot be gained and the decision involved causes a level of distress for the individual that is difficult to resolve. A focus on maintaining hope and support with a clear transition and follow-up plan are important variables to consider for an ethical, caring response.

Aged↗

PubMedDate not supplied

Best medical practice: viewpoint of a UK oncologist.

In a clinician's view, best medical practice has two distinct meanings in a tax-funded health system: optimal management as expected by the individual patient; or, the best possible within the economic limits dictated by the society. Based on this viewpoint, this article represents an oncologist's perspective on the meaning of best medical practice in the management of patients suffering from cancer, the extent to which it is achieved in the UK health system, and how far some of the present deficiencies may be overcome. There is urgent need for medical audit in the management of cancer patients in the UK because the traditional clinical freedom of doctors can lead to wide variations in management without corresponding differences in outcome as measured by benefit to the patient. We need consensus by physicians on the guidelines for optimal management of different types of cancer at various stages, both to avoid overtreatment of the individual patient and also to direct scarce resources to their most effective use. Physicians also need to agree on guidelines for giving priority to one patient over another when resources are limited, and such criteria need to be approved by society at large. The public must accept that in a non-explicit rationing system, each individual competes with every other. In the case of even more difficult ethical choices, a multidisciplinary national committee is required to advise on decision-making and its views need to be debated by the general public.

Clinical Protocols↗

PubMed1980

The patient's role in clinical decision-making.

Practicing physicians must frequently make decisions about how much they wish to encourage patient participation in clinical decision-making and how to respond to rational patient demands that do not coincide with their own decisions. These are difficult ethical dilemmas with no indisputable or universal solutions. The traditional concept of the doctor-patient relationship places the patient in a passive, compliant role. The patient's only obligation is to seek competent help and cooperate with the physician. A number of factors have contributed to the continued dominance of the traditional doctor-patient imbalance of power. Despite these factors, there seems to be a great deal of public dissatisfaction with health care delivery in the United States; demands for more patient autonomy are increasing. This paper discusses the concept of mutual participation, presents an approach to encouraging patient participation in clinical decision-making, and considers its theoretical advantages.

Decision Making↗

PubMed2005

The role of states in improving health and health care for young children.

States are uniquely positioned to make significant improvements in the quality of health and heath care for young children, due to their roles as administrators of Medicaid and the State Children's Health Insurance Program, as well as mental health, public health, and education programs. Quality improvement initiatives are often hampered, however, by lack of coordination among programs within a state, by the lack of adequate data and information technology, and the tendency of state officials to focus on short-term policy projects. Even in the face of these burdens and other difficult fiscal and administrative challenges, state officials are optimistic that improvements are possible. Potential solutions that state officials consider promising include developing specific child health quality measures, measuring and monitoring performance, making information on quality performance easily available, rewarding superior performance, and using performance measures in purchasing and program decisions.

Child↗

PubMed1976

Survival, hospitalization charges and follow-up results in critically ill patients.

In 226 consecutive critically ill primarily postoperative patients, we determined survival and quality of life, hospitalization charges, and consumption of blood and blood products. The patients were physiologically unstable and required intensive physician and nursing care. By one month, 123 patients had died (54 per cent), 70 were still hospitalized, and 31 were home; only one of 103 survivors had fully recovered. By 12 months, 164 patients (73 per cent) had died, 10 were still hospitalized, and 51 were home. Twenty-seven of 62 survivors had fully recovered. Hospitalization charges averaged $14,304 per patient. The total charge for blood and blood fractions was $617,710--21 per cent of the total hospitalization charge; $515,711 (83 per cent) of the blood charge went to 164 nonsurvivors, whereas $101,939 (17 per cent) went to the 62 survivors. These data document the use of increasingly limited resources in the management of critically ill patients. The medical profession must make difficult decisions to allocate these resources effectively.

Age Factors↗

PubMed2005

Depression in the older adult.

Older adults who visit the primary care physician's office often exhibit depressive symptoms. The challenge for the physician and other office staff is to determine what these symptoms mean: Loneliness? Fear? Grief? A consequence of a coexisting medical condition? A DSM depressive disorder? Or something else? Addressing ambiguous symptoms that may represent a depressive disorder may be difficult in the busy office setting. The findings of one recent study suggest that it is not lack of knowledge that impedes the recognition of depression but rather the conditions under which clinical decision making occurs. The process of ruling out medical diagnoses and opening the door to consider a mental health diagnosis can be time-consuming and circuitous, especially if the clinician is not already familiar with the patient or if the clinician who is familiar with the patient perceives insufficient time to deal with the issues raised by opening the door. The fundamental challenge for the primary care clinician as aging baby boomers inundate the health care system is to restructure office practice to recognize, assess, and manage geriatric syndromes including depression. The underlying principle for successful restructuring is acknowledging that these syndromes have multiple causes requiring multifaceted interventions. Operationally, doing simple things consistently and well may have significant impact. By consistently recognizing biologic and psychosocial risk factors for depression, by taking a careful history (including the two-question screen), and by conducting a thorough physical examination, the office-based clinician will generally have a strong clinical hunch about the presence or absence of a depressive disorder and any comorbid medical and neuropsychiatric conditions. Armed with this information, additional laboratory and brain imaging studies and subsequent management strategies are straightforward.

Aged↗

PubMed1990

Physician satisfaction under the Ontario Health Insurance Plan.

To determine the level of professional satisfaction experienced by physicians practicing in Ontario, Canada, a probability sample of 1,028 physicians was surveyed; 69% responded. The majority of Ontario doctors were at least moderately satisfied with each of 16 aspects of their work, and the percentage who were dissatisfied exceeded 15% for only four aspects. Factor analysis suggested the presence of four underlying satisfaction facets: satisfaction with quality of care, with the rewards of practice, with patients, and with the practice environment. Multivariate regression analysis supported the validity of the four-facet model and demonstrated a consistent association between lower satisfaction and younger age, lower income, and the perception that it is difficult to obtain fair reimbursement for medical services (P less than 0.05). Least satisfied physicians were most likely to have participated in the June, 1986 Ontario doctors' strike (P less than 0.001). Despite some misgivings, the majority of physicians practicing under the Ontario Health Insurance Plan in 1987 were satisfied with their professional lives. They were least satisfied with their ability to make administrative decisions and to manipulate the system for the benefit of their patients. Policymakers should be cognizant of the effects various strategies may have upon physician satisfaction as they consider new approaches to health care organization.

Adult↗

PubMed1992

Developing interorganizational relationships in the health sector: a multicase study.

Because of the wide diversity among health care organizations, interorganizational relationships (IORs) among them are difficult to manage. This article describes three case studies that, taken together, suggest that IOR performance is related to IOR development processes. Specifically, IOR performance is related to the way managers process information to manage uncertainty and ambiguity.

Chief Executive Officers, Hospital↗

PubMed2005

Conceptual framework of knowledge management for ethical decision-making support in neonatal intensive care.

This research is built on the belief that artificial intelligence estimations need to be integrated into clinical social context to create value for health-care decisions. In sophisticated neonatal intensive care units (NICUs), decisions to continue or discontinue aggressive treatment are an integral part of clinical practice. High-quality evidence supports clinical decision-making, and a decision-aid tool based on specific outcome information for individual NICU patients will provide significant support for parents and caregivers in making difficult "ethical" treatment decisions. In our approach, information on a newborn patient's likely outcomes is integrated with the physician's interpretation and parents' perspectives into codified knowledge. Context-sensitive content adaptation delivers personalized and customized information to a variety of users, from physicians to parents. The system provides structuralized knowledge translation and exchange between all participants in the decision, facilitating collaborative decision-making that involves parents at every stage on whether to initiate, continue, limit, or terminate intensive care for their infant.

Artificial Intelligence↗

PubMed1998

Reducing emotional conflict during the organ donor process.

It is widely recognized that nurses support and play a paramount role in the organ donor process. Nurses are faced with conflict as they deal with a grieving family while at the same time providing aggressive medical treatment to a clinically dead patient. Nurses' attitudes regarding the organ donor process will affect the process and families either positively or negatively. The organ donor coordinator in our hospital and the transplant community support the nurse, who in turn supports the family before, during and after the process. The family needs, emotional conflict and difficult decisions will be identified as perceived by a critical care nurse who was a member of an organ donor family.

Adult↗

PubMed2005

An evaluation of taster days to recruit untrained health care staff to pre-registration mental health nurse education within one UK university.

With a decrease in the amount of college leavers available to recruit to nurse training and a simultaneous increase in demand for nurses, achieving recruitment targets is becoming more difficult. The widening participation agenda has encouraged us to look wider and one very rich area for recruitment is untrained health and social care staff. Some of this group do eventually opt for professional education, but many could take up places sooner, but lack the confidence or the information they need to make informed decisions. The mental health directorate of an NHS Trust (Shropshire County PCT) agreed to fund 2 'Taster Days' for up to 40 untrained healthcare staff. The Trust was keen that this opportunity was offered to value the contribution, continued learning and skills development of their untrained staff. The Taster Days were to be delivered within the Faculty of Health & Sciences of Staffordshire University. The Trust gave permission for their name to be used on advertising materials and in subsequent publication. A literature review highlighted a dearth of material, consequently allowing freedom to develop and trial our own ideas. Current students and student nurse ambassadors (funded by Advantage West Midlands and Stoke Local Strategic Partnership through Full Circle) were involved in developing materials and the delivery of the day. An evaluation of the day and recommendations are included.

Career Choice↗

PubMed1998

Advance directives and advocacy in end-of-life decisions.

This article examines the issue of advocacy for all adults in end-of-life decisions to help enhance the role of health care providers as partners in decision making. The ethical issues of death and dying are of particular concern for the elderly. Conflicts may prevent providers and nurses from creating a good dying experience for patients and family. Among the many issues associated with end-of-life decision making are futility, autonomy, and quality of life, a "good death," advance directives, family distress, and the culture of medicine. To overcome related barriers, involved health care providers can promote advocacy by offering choices in end-of-life care and providing an environment of listening and communication. Initiating and maintaining dialogue on this difficult subject will provide better care to patients and families.

Adult↗

PubMed1999

Genetic abortion: considerations for patient care.

Women who receive abnormal prenatal diagnosis results potentially face two emotionally difficult decisions. In this article, the first decision--whether or not to terminate the pregnancy--is presented with a discussion of the factors that may influence a women's choice. Women who choose to terminate the pregnancy face a second decision when more than one type of abortion procedure is available. Two second trimester abortion procedures--dilation and evacuation and labor induction--are compared and contrasted to delineate potential advantages and disadvantages of each. The decision-making process is examined, emphasizing the individual ways in which women may weigh this information to make a fully informed decision. In addition, a number of recommendations are offered to health care providers in the role of discussing options and supporting women in their choices.

Abortion, Therapeutic↗

PubMed1994

Can our health services be saved by technology evaluation? The Quebec experience.

The finances to support our health services at their present level are lacking, and much of the shortage is due to new health technologies. Through the utilisation of technology assessment (TA), it is hoped that we may be able to eliminate useless technologies and that the money so saved will allow us to maintain our health care services intact. Such hopes are exaggerated. The uses and limitations of TA are reviewed in the light of recent experience gained with the Conseil d'évaluation des technologies du Québec. Technology assessment has only limited value in exposing ineffective technologies. More often, it can illuminate inappropriate use of technologies. However, its real value lies elsewhere, namely in making difficult choices between different technologies. An example is the choice between expensive, low osmolar contrast media in radiology and the cheaper, high osmolar material which causes more frequent reactions. Credible estimates of how much benefit will result from the commitment of how many extra dollars can facilitate such decisions. However, the user must clearly understand the limitations of cost-effectiveness estimates, which should never be used for policy purposes without full knowledge of all the qualifiers on which the estimates depend.

Canada↗

PubMed2006

The dangers of rationing dialysis treatment: the dilemma facing a developing country.

The increasing burden of chronic kidney disease places enormous strains on resources of all countries, but especially of those with emerging economies. Few developing countries are able to afford dialysis programs and those that do ration this scarce resource. In South Africa, rationing has been practiced since the introduction of dialysis. Our renal unit carefully screened patients with end-stage kidney disease (ESKD) based on certain medical and socioeconomic criteria. The outcome of these decisions taken by the Assessment Committee is reviewed in this study. Details of the 2442 patients with ESKD assessed between 1988 and 2003 for the renal replacement program were captured. Using univariate and multivariate analysis, the odds of being accepted for treatment based on several variables were determined. The majority (52.7%) of patients with ESKD were not offered renal replacement therapy in the period of study. The number of kidney transplants progressively decreased, as did the number of patients accepted. The patients mostly likely to be accepted for renal replacement therapy were aged 20-40 years, white, employed, married, non-diabetic, and lived in proximity to a dialysis center. Almost 60% of patients were denied renal replacement treatment because of social factors related to poverty. In a developing country, where rationing of treatment is unavoidable, it is difficult to ensure equity of treatment and certain groups are advantaged over others. In our experience, socioeconomic factors influenced decision to accept patients more profoundly than medical ones.

Adult↗

PubMed2006

Palliative sedation: nurses' perceptions.

Patients with advanced illnesses suffer from a myriad of distressing symptoms. Palliative care aims to alleviate the distress caused by such symptoms. In extreme circumstances palliative sedation may be implemented to manage symptom distress that is not responsive to standard treatment modalities. Nurses are involved in the care of patients receiving palliative sedation as well as their families. To date, however, little research has been conducted examining the nurses' experiences with, and perceptions about the use of palliative sedation in end-of-life care. In order to redress this gap in the literature a descriptive-exploratory study guided by the theory of symbolic interactionism was conducted. Face-to-face interviews were conducted with 10 nurses working on an adult in-patient palliative care unit within a long-term care facility in Canada. The major theme emerging from content analysis of interview transcripts was that of 'Working your way through the quagmire'. The metaphor of the quagmire captured the difficult and complex issues nurses grappled with in instances where palliative sedation was used, and integrates the major categories into the key analytic model emerging from this study.

Adult↗

PubMedDate not supplied

The ethics of organ donation.

1. The primary bioethics principles, which are evidenced in the analysis and discussion of organ donation are: autonomy, beneficence, justice, and utility. 2. Organ donation encompasses a variety of ethics-laden issues ranging from invalidation of individual rights to the accepted criteria for donation. However, any of these issues can be categorized as relating to procurement, consent, and allocation. 3. The application of bioethical principles is integral to the decision-making process involved in organ-donation issues. It is the responsibility of nurses, physicians, ethics committees, and organ-procurement organizations, as well as the donors, recipients and their respective relations, to understand and determine which principles support a proposed decision on organ donation or allocation. 4. Human beings must discover and utilize valid principles in order to make effective ethical decisions in difficult or complex situations. By defining and applying the principles of bioethics, individuals can make sense of such painful experiences as those that address organ donation.

Ethics, Nursing↗