SEARCH · PubMed Health

Results for “Making Difficult Health Care Decisions”

Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 325 records · Page 18Linked to original sources

PubMed1993

Community empowerment: the alternative resources movement in Quebec.

In order to achieve true community participation in mental health care, a redistribution of decision-making power is needed. Currently, this power is almost exclusively in the hands of psychiatric institutions and the state. Community participation would require greater representation from community organizations. This paper describes the history of the alternative resources movement in Quebec. This movement has challenged the health care system and promoted innovative therapeutic approaches. In this process, community organizations have been faced with the difficult task of gaining more power while maintaining strong links with the communities they serve.

Adult↗

PubMed1994

Medicolegal problems associated with do not resuscitate orders.

The use and potential abuse of the do not resuscitate (DNR) order has wide-ranging ethical, legal and economic implications. A DNR order is essential for clear communication between health care professionals, but the order itself may affect the care that patients subsequently receive. In addition, the DNR order may be a crucial therapeutic decision point in the care of the critically ill. Although general guidelines exist for withholding resuscitative measures from the terminally ill and general principles have been established, Spanish legislation is ambiguous on a number of points, forcing medical professionals to make difficult choices. This has led to the systematic, indiscriminate application of resuscitative measures, motivated in many cases by the desire to avoid a possible future lawsuit. We believe clearer and more precise legislation should be developed to bring Spanish criteria into line with those of international organizations that provide a common set of guidelines on important issues relating to the right to life and the right to refuse treatment.

Beneficence↗

PubMed2004

Evidence from clinical trials: can we do better?

Randomized clinical trials provide the most internally valid evidence for medical decision-making. In many areas of neurology, results from clinical trials showing which therapies are and are not effective have had a substantial impact on patient care. Relative to observational methods, the central advantage of clinical trials is control of bias attributable to unmeasured differences between patients. However, trials also have clear limitations, including a historical failure to include a representative cross-section of patients with a given disease, and highly structured treatment regimes that are difficult to replicate in normal practice settings. These limitations tend to reduce the generalizability of results from clinical trials. This article reviews some ways in which the design and application of clinical trials could be improved so that the evidence produced would be more relevant to health-care providers and other decision makers.

Biomedical Research↗

PubMed2004

Turning an idea into reality to improve patient care: the development of the Clinical Support Systems Program.

The concept of the Clinical Support Systems Program (CSSP) was transformed from an idea into reality through the efforts of representatives of the Australian Government Department of Health and Ageing and the Royal Australasian College of Physicians. This collaboration involved developing common ground between two different perspectives: those of the funder/policy/administrative sector and those of the clinical practice world. Bridging these differences to establish an agreed approach to moving forward was a lengthy and difficult process. The process is aided by tension for change. Compromise, persistence and commitment to the end-goal by the parties involved were important features in building and maintaining the momentum of the change process. Many of the difficulties experienced could be traced to differences in decision-making processes between the clinical and the administrative paradigms. Knowledge brokers can assist in bridging the different languages and perspectives of the groups involved.

Australia↗

PubMed2004

Young adults with cancer: parents' interactions with health care professionals.

This paper examines the relationship between medical professionals and parents of young adults who are being treated by them for cancer. This study aims to discover what practices and procedures make the cancer journey easier or more difficult to manage for parents in the medical setting. Many studies of carers focus on spouses, little attention has been paid to parents of young adults in this context. Self-selected parents responded to an appeal for narratives about their adult son or daughter's cancer experience. A narrative correspondence method was used relying on contributions of a qualitative nature submitted in written form and analysed through the identification of emerging themes. Interactions with health professionals have a far-reaching effect on parents' experience. A clear understanding needs to be established at an early stage with agreement by all parties on how information and decision making should be shared. If parents feel excluded or uninformed about procedures, or believe that their son or daughter is receiving less than optimum care, this results in feelings of helplessness and frustration. While many of the issues identified in this paper might apply to relatives of cancer patients in other age groups, the effect of life stage during young adulthood exacerbates the complexities of the medical setting.

Adolescent↗

PubMed2005

Improving medical resident perceptions of health plan decision making.

OBJECTIVE: To determine the effect on medical residents' perceptions resulting from attending a medical policy meeting. STUDY DESIGN: Pre- and postsurveys administered to residents attending BlueCross BlueShield of Tennessee's (BCBST) Medical Policy Subcommittee meeting. This group is a subcommittee of the Medical Policy Review Committee (MPRC), which is responsible for the final approval of medical policies at BCBST. METHODS: Residents were invited to attend BCBST's Medical Policy Subcommittee meeting to determine what impact observing this process would have on their attitudes toward health insurers' use of scientific evidence. This subcommittee, which consists of both BCBST medical directors and network physicians, plays a key role in determining whether new medical technologies or new uses of established technologies are medically necessary, cosmetic, not medically necessary, or investigational. Residents were given a pre- and postsurvey to assess their attitudes regarding the methods insurance companies use to make coverage decisions. RESULTS: Medical residents rated BCBST's use of scientific evidence higher after attending the subcommittee meeting. Only 4 of the 10 residents surveyed prior to the subcommittee meeting agreed with the statement, "Insurance companies base their coverage decisions for medical treatment on scientific evidence." In the postsurvey, all 10 residents indicated that they agreed with the statement. Other questions showed similar positive changes in residents' opinions of the health plans' decision making. CONCLUSIONS: Many medical residents likely have negative perceptions of health insurers and may be prone to believe that medical policy decisions are based predominantly on financial impact. Such attitudes can easily persist as they move into private practice. Although drawing firm conclusions from this small study is difficult, exposing residents to actual decision-making processes within insurance companies may be one means of improving their opinions of how such decisions are made.

Attitude of Health Personnel↗

PubMed2002

Are primary care groups and trusts consulting local communities?

Primary care groups and trusts (PCG/Ts) in the English NHS were established in 1999 and have responsibility for providing and commissioning health-care for around 100 000 people. PCG/Ts are dominated by health professionals, but are responsible for representing the interests of the local community. This paper assesses how they have informed and consulted local communities and the perceived impact of this consultation on decision-making. The paper uses evidence from the National Tracker Survey of PCG/Ts, a longitudinal survey of 72 (15%) of the PCG/Ts in England, using data from telephone interviews with chairs and chief officers, and postal questionnaires to lay board members and representatives of Community Health Councils (CHCs). Eighty-one per cent of PCG/Ts had public involvement working groups. Methods of consulting the community included consulting CHCs (87%), holding public meetings (75%) and consulting local patient groups (67%). Only 31% of chairs felt they were effective at consulting. Ninety-two per cent of CHC representatives attended all board meetings. Most CHC representatives reported that there had been little or no consultation with the CHC in areas such as commissioning, service development or clinical governance. Only 14% of CHC representatives rated PCG/T consultation with the public as effective. Eighty-seven per cent said that local communities were largely unaware of the existence of PCG/Ts, and 70% commented on the weaknesses in PCG/T efforts at public consultation. Public participation is being taken seriously by PCG/Ts, but most are struggling to develop effective ways of involving local communities. Efforts to involve the public may become little more than token gestures. The proposed abolition of CHCs may make it more difficult for PCG/Ts to obtain a lay perspective. Effective consultation requires the development of new methods and adequate resources, but a stronger lay voice in the governance structures of PCG/Ts is needed.

Community Health Planning↗

PubMed2005

Purchasing or providing nursing home care: can quality of care data provide guidance.

OBJECTIVES: To examine whether quality of care differed for veterans in Department of Veterans Affairs (VA) nursing homes and those on contract in community nursing homes, and whether the VA was contracting with nursing homes providing better quality of care than other nursing homes. DESIGN: Observational study using administrative databases from 1997 to 1999. SETTING: Ten VA and 650 community nursing homes in New York state. PARTICIPANTS: Four thousand seven hundred sixty-three veteran and 195,438 nonveteran residents of these nursing homes. MEASUREMENTS: Risk-adjusted rates of pressure ulcer development, functional decline, behavioral decline, and mortality. RESULTS: Veterans in VA nursing homes were significantly (P< .05) less likely to develop a pressure ulcer (odds ratio (OR)=0.63) but more likely to experience functional decline (OR=1.6) than veterans in community nursing homes. Residents of community nursing homes with VA contracts were significantly (P< .05) less likely to develop a pressure ulcer (OR=0.91) but more likely to die than residents in noncontract homes. Few nursing homes were consistently among the best or worst performers on all measures; only seven of 650 nursing homes were in the top or bottom decile and 34 in the top or bottom quartile for each measure. CONCLUSION: Large purchasers and providers of nursing home care such as the VA are unlikely to find information on quality of care useful in making decisions on whether they should "make" or "buy" care. Nursing homes performing well on one quality measure may perform poorly on another, and it is difficult to identify nursing homes that are consistently among the best or worst. Other consumers may encounter similar difficulties when using data on nursing home quality.

Aged↗

PubMed2001

Doctors' and nurses' perceptions of ethical problems in end-of-life decisions.

AIMS: To identify and compare doctors' and nurses' perceptions of ethical problems. Rationale. Ethical problems are a source of tension for health professionals. Misunderstandings or conflicts may result from differing perceptions of ethical problems. If true collaboration is to be achieved, it is important to understand the perspectives of others, particularly when difficult end-of-life decisions must be made. METHODS: In this qualitative study a total of seven doctors and 14 nurses working in acute care adult medical-surgical areas, including intensive care, were asked to describe ethical problems that they frequently encounter in practice. Interviews were taped and transcribed. Thematic analysis followed. RESULTS: All participants experienced ethical problems around decision making at the end of life. The core problem for both doctors and nurses was witnessing suffering, which engendered a moral obligation to reduce that suffering. Uncertainty about the best course of action for the patient and family was a source of moral distress. Competing values, hierarchical processes, scarce resources, and communication emerged as common themes. The key difference between the groups was that doctors are responsible for making decisions and nurses must live with these decisions. Each group, therefore, asked different questions when encountering and interpreting sources of moral distress. CONCLUSIONS: It was concluded that observed differences between doctors and nurses were a function of the professional role played by each rather than differences in ethical reasoning or moral motivation. Although this was a small qualitative study on one institution, and may not be generalizable, results suggest that doctors and nurses need to engage in moral discourse to understand and support the ethical burden carried by the other. Administrators should provide opportunities for discourse to help staff reduce moral distress and generate creative strategies for dealing with this.

Adult↗

PubMedDate not supplied

Strategies for a successful organizational transition. Identifying staff roles and fulfilling their needs during changing times.

For a successful reorganization of the laboratory, there is a role for each staff member to play during the transition. The role of those in laboratory administration is that of leading change agent. Corporate support staff, such as those in a human resources department, can advise the laboratory director in their areas of expertise. The role of the medical and technical supervisory staff is that of chief implementers of the plan. General laboratory staff has a confusing dual role--not only must they continue to provide laboratory services during the transition, but they also may have to change what they are doing and how they are doing it. Success also depends on meeting the individual personal needs of staff. Laboratory directors and administrators want to make a meaningful contribution to health care. Corporate support staff need to feel that they are a part of the change process. Supervisors' needs vary--coping with the loss of identity, position, or territory will be difficult for some; others will want to be involved in all stages of planning and implementation. The major need of the general laboratory staff is stability. Strategies are listed for each staff grouping to help the laboratory director coordinate staff roles and satisfy staff needs during the transition period.

Attitude of Health Personnel↗

PubMed2000

Treatment of psoriasis: an algorithm-based approach for primary care physicians.

Psoriasis is characterized by red, thickened plaques with a silvery scale. The lesions vary in size and degree of inflammation. Psoriasis is categorized as localized or generalized, based on the severity of the disease and its overall impact on the patient's quality of life and well-being. Patient education about the disease and the treatment options is important. Medical treatment for localized psoriasis begins with a combination of topical corticosteroids and coal tar or calcipotriene. For lesions that are difficult to control with initial therapy, anthralin or tazarotene may be tried. The primary goal of therapy is to maintain control of the lesions. Cure is seldom achieved. If control becomes difficult or if psoriasis is generalized, the patient may benefit from phototherapy, systemic therapy and referral to a physician who specializes in the treatment of psoriasis.

Adrenal Cortex Hormones↗

PubMed2005

Sicily statement on evidence-based practice.

BACKGROUND: A variety of definitions of evidence-based practice (EBP) exist. However, definitions are in themselves insufficient to explain the underlying processes of EBP and to differentiate between an evidence-based process and evidence-based outcome. There is a need for a clear statement of what Evidence-Based Practice (EBP) means, a description of the skills required to practise in an evidence-based manner and a curriculum that outlines the minimum requirements for training health professionals in EBP. This consensus statement is based on current literature and incorporating the experience of delegates attending the 2003 Conference of Evidence-Based Health Care Teachers and Developers ("Signposting the future of EBHC"). DISCUSSION: Evidence-Based Practice has evolved in both scope and definition. Evidence-Based Practice (EBP) requires that decisions about health care are based on the best available, current, valid and relevant evidence. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources. Health care professionals must be able to gain, assess, apply and integrate new knowledge and have the ability to adapt to changing circumstances throughout their professional life. Curricula to deliver these aptitudes need to be grounded in the five-step model of EBP, and informed by ongoing research. Core assessment tools for each of the steps should continue to be developed, validated, and made freely available. SUMMARY: All health care professionals need to understand the principles of EBP, recognise EBP in action, implement evidence-based policies, and have a critical attitude to their own practice and to evidence. Without these skills, professionals and organisations will find it difficult to provide 'best practice'.

Adult↗

PubMed1994

Reproductive decision-making in the age of AIDS.

The forecast for the HIV epidemic in the United States includes increasing numbers of infected women and children, the latter of whom will be born to infected mothers. As the epidemic progresses, nurses will be more frequently called on to assist women in making difficult reproductive decisions. Using four levels of analysis, this discussion explores current knowledge about reproduction in HIV-infected women and suggests interventions and nursing actions.

Adolescent↗

PubMed1994

A kidney donor's dilemma: the sibling who can donate--but doesn't.

The decision making process undertaken by a sibling who chooses not to donate a kidney to a brother or sister who needs a transplant is the subject of this article. Presented from the perspective of the potential donor client, the paper focuses on the moral and ethical concerns indicated when there are two equal but competing rights involved in the decision. It also addresses pertinent attitudinal dimensions and social and health issues that affect all parties--the client, the marital partner, the family of origin, and the patient's immediate family. The article concludes by addressing "what" and "how" social workers assist clients after the difficult decision not to donate has been made.

Adult↗

PubMed2002

"But isn't it depressing?" The vitality of palliative care.

A common question about palliative care from those unfamiliar with the work is, "But isn't it depressing?" This view distances palliative care workers from the general public and reflects a deeply held belief that matters associated with death and dying are negative. Published definitions fall short of capturing a full understanding of the work, making it difficult to communicate the meaning of palliative care. This qualitative study examined the experiences of six long-term palliative care workers. Palliative care was described as "a way of living" and, throughout the descriptions, the concept of "vitality" emerged as the core meaning of palliative care. In the current economic environment, where there is competition for health care funding, more widespread agreement about the meaning of palliative care is important if informed decisions are to be made about allocation of resources.

Attitude of Health Personnel↗

PubMed1996

Outcomes research: a primer for plastic surgeons.

The growing emphasis on cost-effectiveness in the United States health care industry has highlighted the need for comprehensive outcomes research in a variety of medical specialties. Currently, there is a relative paucity of reliable data characterizing the long-term results of many medical and surgical treatments. This shortage of outcomes research is particularly acute within plastic surgery where the benefits of treatment are often intangible and notoriously difficult to measure. In evaluating the effectiveness of medical treatment, conventional clinical research has focused primarily on morbidity and mortality as the outcomes of interest. In contrast, current outcome studies assess the results of interventions from the patient's perspective, measuring the impact of medical care on physical functioning, well-being, and quality of life. The resulting data can assist consumers, providers, and payers in making more appropriate health care decisions. As the outcomes movement has matured, it has evolved into two major areas of study: effectiveness research that evaluates the relationships between specific medical interventions and outcomes of care, and quality assessment that seeks to provide the best outcomes at the most reasonable costs. This review details the origins and trends of current outcomes research, examining the implications of this movement for plastic surgery. The growing impact of outcomes data on treatment guideline formulation in both the public and private sectors is also described. Finally, a brief review of outcomes study design, including definition of variables and selection of instruments, is presented.

Cost-Benefit Analysis↗

PubMed1987

After "Eve": whither proxy decision-making?

One of the most difficult problems facing physicians is how to approach proxy decisions made on behalf of congenitally incompetent patients. The author considers two recent court cases that attempt to provide guidelines: Re Stephen Dawson, which opts for a substituted-judgement approach, and Eve v. Mrs E.) which injoins best-interests considerations. The author explores the impact of Eve v. Mrs. E. as superseding Re Stephen Dawson, considers its ethical implications and attempts to clarify the best-interests criterion by sketching some guidelines for its interpretation. In so doing, he tries to reconcile the two decisions by laying bare their common underlying ethical rationale. The author concludes by pointing out some ethically questionable implications of Eve v. Mrs. E. in the area of allocation of health care resources.

Adult↗

PubMed2003

Economic evaluation of osteoarthritis treatment in Europe.

Osteoarthritis is one of the leading causes of disability. Among the available treatments, NSAIDs are the most common. The present paper reviews economic studies conducted in the last five years on the treatment of osteoarthritis in Europe. The majority focus on NSAID therapy, mainly comparing COX2-specific inhibitors against COX non-specific inhibitors. The reviewed studies estimate healthcare costs only. The final results indicate that, owing to the lower incidence of adverse events, COX2-specific inhibitors should now dominate over traditional NSAIDs. However, the differences found in the methods used to measure costs suggest that results should be interpreted with caution. To estimate costs, authors used diverse values that were not always consistent with the studies' perspective. Furthermore, many did not report resource consumption patterns, making comparisons among the studies difficult, as economic results are influenced by the price/charging policies of different countries. Economic evaluations have the potential to affect health policy by assisting the ranking and prioritisation obligations of decision makers. In this context, it is important to meet strict methodological guidelines.

Europe↗