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Results for “Making Difficult Health Care Decisions”

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PubMed2000

[Climacteric--medicalization, minimalization or normalization?].

Women's experiences and ideas about the climacteric are not in accord with the biomedical model, in which the climacteric and the menopause are characterized as being a risk factor for various diseases and a cause of "estrogen deficiency", a hormonal disease which is assumed to persist during the rest of life. The biomedical model may lead to medicalization and pathologizing, increasing the subordination of women and making them dependent on the health care system. Women who use hormonal therapy during the climacteric have many characteristics differentiating them from women who do not use such therapy. Thus, epidemiological studies will be difficult to interpret with respect to the long term effects of hormonal therapy. It is argued that the consultation for women of middle-age should be characterized by a holistic view of the woman taking account of her gender identity, life conditions and life situation. Such a view should focus on the woman's own ideas as to diagnostic procedures, treatment and solutions. In view of the lack of knowledge about the pros and cons of hormonal therapy, women themselves should make the decision, and such decisions should be encouraged. Also, the efforts directed towards women's compliance to hormonal therapy can be questioned. Women's climacteric symptoms should neither be medicalized, pathologized or minimized.

Adult↗

PubMed2006

Evidence-based surgical practice and patient-centered care: inevitable.

Evidence-based medicine provides a well-developed framework for evaluation of clinical research. Well-designed and adequately powered randomized controlled trials provide the best information on therapeutic efficacy; however, extrapolation of the trials' conclusions to individual patients may be difficult, and for many important surgical problems, trial data are unavailable. A complementary approach of inferential decision-making helps address these limitations, and increases the clinician's confidence in the safety of an approach of unknown efficacy. Experience establishes norms and expectations, and emphasizes events that are uncommon but clinically important. Although it cannot eliminate uncertainty or controversy, the integration of analytic techniques of evidence, inference, and experience provides the surgeon with the best means of adapting treatment to the unique circumstances of the individual patient.

Delivery of Health Care↗

PubMedDate not supplied

Which patient gets the critical care bed?

Census fluctuations and the failure to develop appropriate guidelines for admitting and transferring patients have made the staffing of critical care units extremely difficult, sometimes with serious ethical and physical consequences to patients. In this report, a case is analyzed to explore some of the ramifications of the use of beds in the critical care unit.

Bed Occupancy↗

PubMed1990

A critical look at nursing observations.

Our experience has suggested that not only do nurses on hospital wards waste time making too many unnecessary clinical observations, but that it is very difficult to persuade them to modify the pattern of their practice. We therefore conducted a survey by questionnaire among trained nurses in one health district of their everyday ward practice and attitudes to clinical observations. This showed that whilst a majority of nurses questioned believe in the importance of routine observations for patient care, there is a lack of consistency in the criteria and communication procedures used that must seriously limit the value of the information obtained by the individual nurse. We believe that uncritical faith in routine observations is a barrier to rationalizing procedures to optimize efficient use of the professional skills of ward nurses in this regard. There is need for more thought to be given to the problem and in particular it is important that doctors play a more active role in decision making.

Attitude of Health Personnel↗

PubMed2001

End-of-life care in the intensive care unit: can we do better?

Everywhere we turn these days, it seems that we are confronted with a new study that reports the dissatisfaction expressed by families with the quality of care received by their loved ones who have died while in the intensive care unit. It is difficult for caregivers to accept this information, which is now commonly reported both in published studies and in the lay press. As clinicians, most of us believe that we truly care about our patients and are trying, as best we can, to act in their best interest. No caregiver wants to hear that he or she does not do a good job when caring for dying patients and their families. It is ironic that clinicians recognize and accept the need for continuing education. Yet many clinicians resent the suggestion that the skills required for end-of-life care might be viewed in the same manner, as a lifelong learning process. It is unusual for physicians to identify end-of-life-care as an area of competency that can be improved or updated. Perhaps this is why end-of-life-care has been so difficult to teach to clinicians in training. Although many medical schools offer courses on the ethics of death and dying, formal training in end-of-life care skills is not routinely given in most postgraduate training programs. Learning these skills is a matter of on-the-job training for most caregivers. Not only have we been unable to measure any beneficial impact from education initiatives for end-of-life care, we have yet to identify clear indicators for end-of-life care. For caregivers, enhancing end-of-life skills may be a matter of improved listening skills, attention to the proper environment for end-of-life discussions, and a willingness to facilitate end-of-life decision-making. Encouraging caregivers to view end-of-life skills as a lifelong educational process, identifying core competencies in end-of-life care, and training clinicians in these skills are the challenges for the future. The quality of care our patients receive at the end of life will depend on our ability to answer these difficult questions.

Attitude of Health Personnel↗

PubMed2005

Guidelines on the ethics of clinical research in anaesthesia.

PURPOSE OF REVIEW: This review will identify ethical issues arising from conflicts of interest in sponsored clinical trials, and the need for compliance with recent privacy legislation. It will guide investigators facing ethical dilemmas that compromise the integrity of their research because of conflicts of interest or a flawed consent process. Authors will learn about changes in journal editorial policies that will require registration of clinical trials and consent for publication of case reports. RECENT FINDINGS: Recently, ethics review committees and clinical investigators have violated research ethical guidelines and authors have ignored journal policies on disclosure of data in multicentre clinical trials. Published reports show selective reporting of data from clinical trials that biases the body of evidence available for clinical decision-making. Privacy laws legislate that patient consent for the use of their health information, other than for their clinical care, must be obtained explicitly. SUMMARY: Clinical trial registration and the need for consent for publication of case reports aim to restore and improve the integrity of biomedical publication. Journal policies that incorporate these changes may be persuasive in interpreting privacy laws, in a practical way, to protect patients from harm. It is difficult to eliminate all ethical problems with sponsored trials and government regulatory drug-approval processes may require review.

Journal Article↗

PubMed2001

The health care information directive.

BACKGROUND: Developments in information technology promise to revolutionise the delivery of health care by providing access to data in a timely and efficient way. Information technology also raises several important concerns about the confidentiality and privacy of health data. New and existing legislation in Europe and North America may make access to patient level data difficult with consequent impact on research and health surveillance. Although research is being conducted on technical solutions to protect the privacy of personal health information, there is very little research on ways to improve individuals power over their health information. This paper proposes a health care information directive, analogous to an advance directive, to facilitate choices regarding health information disclosure. RESULTS AND DISCUSSION: A health care information directive is described which creates a decision matrix that combines the ethical appropriateness of the use of personal health information with the sensitivity of the data. It creates a range of possibilities with in which individuals can choose to contribute health information with or without consent, or not to contribute information at all. CONCLUSION: The health care information directive may increase individuals understanding of the uses of health information and increase their willingness to contribute certain kinds of health information. Further refinement and evaluation of the directive is required.

Advance Directives↗

PubMedDate not supplied

Barriers to the physician decision to offer hospice as an option for terminal care.

Hospice is one care alternative available to the terminally ill, but if physicians do not offer this option, it is not likely to be considered by a patient who is making end-of-life decisions. A 15-item questionnaire to determine which barriers hinder or delay a physician's decision to discuss hospice with patients was sent to 147 physicians in one area of western Wisconsin. The study population included primary care physicians (family practitioners, internists and pediatricians) and specialists (cardiologists, gastroenterologists, nephrologists, neurologists, oncologists, pulmonologists, radiation oncologists, and urologists). The barriers receiving the most citations were: "patient or family hasn't accepted the terminal diagnosis," "patient or family desires to continue life-prolonging treatment," "patient has no family or friends to help hospice provide care," and "difficult to prognosticate amount of time patient has to live." Personal interviews with 13 of the participating physicians revealed additional barriers: "concern over loss of involvement with patient," "admitting patient to hospice causes some inconvenience," "deficit in physician knowledge of local hospice program," "introduction of hospice late in course of illness," and "use of home health services instead of hospice." Knowledge of these barriers may lead to an interdisciplinary approach to ensure that patients receive information of all alternatives available for terminal care.

Adult↗

PubMedDate not supplied

Protecting patients as costs are cut.

In today's managed healthcare era, cost-control measures that encourage underutilization of resources create fears that patients will receive less care than their conditions, injuries, or illnesses warrant. Patients need protection now that the rules have changed. Traditionally, patients have relied on direct caregivers to put their patients first. As individuals, caregivers want to be patient advocates; however, changes in the healthcare environment make it difficult for them to maintain their advocacy role. Clinical decision support criteria that are contained in a resource management program can help providers and payers maintain a balance between cost containment and healthcare quality.

Cost Control↗

PubMed1995

Evaluating a comprehensive outpatient clinical information system: a case study and model for system evaluation.

Decisions about information system implementation are often justified through a cost-benefit analysis. The ability to improve efficiency and outcomes while decreasing costs through information systems--by allowing for multiple and instant simultaneous access to information, through data monitoring and altering, through automation of protocols, and by collecting information for population-based health care as opposed to individual illness-care--are all potential benefits of a comprehensive clinical information system. Measuring the quantitative impact of these system improvements, however, is difficult. Doing a complete cost-benefit analysis of a comprehensive clinical information system is unrealistic due to the many assumptions necessary and the multiple confounding factors that are involved. In our Clinical Information Systems deployment in Kaiser Permanente, Northwest Region, we have elected not to do a detailed cost-benefit analysis. Instead, we have done an evaluation, based on success criteria, of a pilot implementation of a vendor-supplied system. This evaluation is based on clinician acceptance, system usage, technical factors, and quantitative effects on physician productivity. We also considered qualitative factors such as relationship with and responsiveness of the system vendor. We are moving ahead to regionalize this clinical information system based on such an evaluation of our pilot project. This paper outlines the approach that we have taken in evaluating our implementation of this system. It may provide some guidance for organizations on how to make a decision about whether or not to regionalize a clinical information system based on the evaluation of a pilot-site implementation.

Ambulatory Care Information Systems↗

PubMedDate not supplied

[Expert assessment of unconventional treatment methods within the scope of legal health insurance--problems based on current court decisions].

Court decisions of the Federal Court for Problems of Social Welfare (Bundessozialgericht) make health insurance pay for unconventional methods under certain circumstances. Physicians of the Health Insurance Medical Service (MDK) have to examine whether these conditions are fulfilled in a special case. The specific problems they encounter there are being described in this paper. Hermeneutic differences can be noticed. To guarantee the quality of medical care, which is the duty of the statutory health insurances, seems to be difficult in the case of "unconventional" medical methods.

Complementary Therapies↗

PubMedDate not supplied

Using metaphor to clarify emerging roles in patient care management teams.

Difficult economic times, competition for scarce resources and changing organizational paradigms are driving health care institutions to re-examine the ways in which they provide care. They must continually strive to provide excellent patient care and ensure positive patient outcomes while responding to increasing fiscal constraint. At Toronto's Hospital for Sick Children, consistent with current trends, nurse managers are asked to take on broad spans of responsibility. The need to decentralize much of the decision making, problem identification and problem solving functions to the multidisciplinary team is a reality of those changes. This paper describes a process the dialysis staff undertook to better understand new organizational imperatives using an orchestra metaphor as a suggestive tool to help people clarify new roles and relationships in organizations that are evolving from a hierarchical model to a knowledge-based team approach to work. The intervention was successful for some people and not others. An analysis of the outcomes is provided from the nurse manager's perspective.

Hospital Restructuring↗

PubMed2001

Confidentiality.

Issues of confidentiality are complicated by the relationships we have to patients and others who have valid interests in the confidential information. There are no straightforward answers to problems which involve complex relationships and sensitive information. The best we can do is to think thoroughly and carefully about the issues in each case, and use our knowledge of the people involved to reach a decision. Doctors faced with difficult decisions of this kind should be assured that everyone finds them difficult. Sharing the burden with experienced colleagues can be helpful.

Adolescent↗

PubMed2002

Northern nursing practice in a primary health care setting.

BACKGROUND: This paper explicates the nature of outpost nursing work, and/or the day-to-day realities of northern nursing practice in a primary health care setting in Canada. The study was carried out to systematically explore the work of nurses in an indigenous setting. Institutional ethnography, pioneered by Dorothy Smith was the methodology used to guide this research. The theoretical perspective of this methodology does not seek causes or links but intends to explicate visible practices. AIM: It is intended to explicate the social organization of specific discourses that inform work processes of nurses working in remote indigenous communities. METHODOLOGY: The data originated from various sources including spending 2 weeks in a northern remote community shadowing experienced nurses, taking field notes and audio taping interviews with these nurses. One of the two researchers was a northern practice nurse for many years and has had taught in an outpost nursing programme. As part of the process, texts were obtained from the site as data to be incorporated in the analysis. The lived experiences have added to the analytical understanding of the work of nurses in remote areas. Data uncovered documentary practices inherent to the work setting which were then analysed along with the transcribed interviews and field notes derived from the on-site visit. Identifying disjuncture in the discourse of northern nursing and the lived experience of the nurses in this study was central to the research process. RESULTS: The results indicated that the social organization of northern community nursing work required a broad generalist knowledge base for decision making to work effectively within this primary health care setting. The nurse as 'other' and the invisibility of nurses' work of building a trusting relationship with the community is not reflected in the discourse of northern nursing. Trust cannot be quantified or measured yet it is fundamental to working effectively with the community. CONCLUSION: The nurses in this study saw building trust to promote health and well-being in communities as very important, yet very difficult to achieve. The difficulty in part stems from the constraining, structural, administrative, historical, cultural and political contextual realities that have shaped northern community nursing.

Attitude of Health Personnel↗

PubMed1990

Informed consent and the elderly. An ethical challenge for critical care nursing.

Nursing ethics was long reticent about ethical challenges that elderly patients pose for critical care nursing. One of these, the legal doctrine of informed consent, has important implications for critical care nursing ethics. Deriving from the principle of respect for persons and intended to preserve their autonomy, informed consent represents both a duty and an ideal for care givers to implement in the process of ethical decision making. All too often the ideal is lost, however, and the doctrine reduced to a sterile and bureaucratic procedure. When elderly patients are unable to give an adequately informed consent, advance directives can enable them to express their wishes by prior choosing. If they become cognitively impaired, however, it is much more difficult to determine what, if any, preferences such a patient might express if able to do so. Medical empowerment of the elderly, a laudable social goal, can be as contradictory as informed consent itself and many elderly patients may opt out of their own decision making. The resultant moral distress of such a complex process is still another ethical challenge that faces the critical care nurse. Because nursing holds a position of moral centrality among the health care professions, critical care nurses cannot avoid the prospect that issues like those identified in this article will continue to challenge and confront them in the coming decade. By turning to colleagues in nursing as well as other professions, nurses can best strengthen and consolidate their vital role as mediators of meaning and morality in life-and-death situations.

Aged↗

PubMed1993

Conflict of interest in the procurement of organs from cadavers following withdrawal of life support.

The University of Pittsburgh policy for procuring organs from non-heart-beating cadaver donors recognizes the potential for conflicts of interest between caring for a "hopelessly ill" patient who has forgone life-sustaining treatment and caring for a potential organ donor. The policy calls for a separation between those medical personnel who care for the gravely ill patient and those involved with the care of transplant recipients. While such a separation is possible in theory, it is difficult or impossible to attain in practice. However, such a separation of duties would be unnecessary if an arbitrator were appointed to monitor the proceedings as they take place on a case-by-case basis. In this way, the biases--real or potential--of the individuals involved could be identified, and the harmful effects of the unavoidable conflicts of interest could be minimized.

Attitude of Health Personnel↗

PubMedDate not supplied

The administrator's quest for quality.

Times are tough and will become even tougher. Retrenchment issues will be foremost in many operational settings. Failure to understand baseline quality standards will make it extremely difficult to know where to cut and how to regroup without adversely affecting patient attitudes and service. Practice patterns are changing rapidly and the astute administrator needs to be prepared to participate freely in decisions affecting quality, service and costs.

Group Practice↗

PubMed2000

The difficult choice of chemotherapy in patients with unresectable non-small-cell lung cancer.

The aims of this study were: to assess the attitude of non-small-cell lung cancer (NSCLC) patients to being treated with chemotherapy, determining whether and how much it differs from that expressed by patients with benign diseases or by healthy people; and to investigate how the information received about the treatment may influence the patients' decisions. A three-item self-assessment questionnaire measuring willingness to be treated with chemotherapy and presented according to three different scenarios (with an optimistic, neutral, and pessimistic physician's presentation) was administered to 104 NSCLC patients, 129 other patients with respiratory diseases (RDP), 140 health care providers (HCP) and 120 students (STU). Guttman's coefficient of reproducibility confirms the hierarchical structure of the three scenarios ranging from an optimistic to a pessimistic view. Relative to the other groups, cancer patients showed: (a) a consistently higher degree of uncertainty about whether to accept or reject chemotherapy; (b) the lowest acceptance rate in the optimistic and neutral scenario and, in contrast, the highest in the pessimistic scenario; (c) the highest percentage of constant answers, independently of the scenario presented, particularly as regards the answers "I don't know" (NSCLC = 25%, RDP = 9%, HCP = 2%, STU = 5%) and "Yes, I accept" (NSCLC = 29%, RDP = 31%, HCP = 19%, STU = 16%). Answer patterns differed markedly between cancer patients, the HCP, and the STU group, and in most cases the difference was statistically significant at a confidence level of 0.001. The differences between NSCLC and RDP patients were less marked, and not always statistically significant. The choice between accepting and rejecting chemotherapy is very difficult for patients with NSCLC, much more so than for healthy people, and it is often independent of the way the information is provided.

Adolescent↗