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Results for “Making Difficult Health Care Decisions”

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PubMed2006

Neural networks for longitudinal studies in Alzheimer's disease.

OBJECTIVE: Alzheimer's disease affects a growing population of elderly people today. The predictions about the course of the disease is a key component of health care decision making for patients with Alzheimer's. The physician's prognosis and predicted trajectory of cognitive decline often form the basis of treatment and health care decisions taken by patients and their families. These predictions are difficult to make because of the high variability and non-linearity exhibited by individual patterns of cognitive decline. This paper presents a new method of predicting the course of a disease using longitudinal data collected through multiple clinic visits. Longitudinal databases are similar to temporal databases, with some important differences--data is collected at irregular time intervals that are patient specific and also a varying number of observations are made for each patient, depending upon the number of times the patient visited the clinic. We propose a new type of neural network called the mixed effects neural network (MENN) model that can incorporate this type of longitudinal information. MATERIAL AND METHODS: We have used longitudinal data on 704 subjects enrolled at the Layton aging and research center (LAARC) at Oregon Health and Science University. A back-propagation algorithm, modified for longitudinal data is used to obtain the weight parameters of the MENN. The modified back-propagation algorithm is further embedded in an iterative procedure that estimates the noise variance and the parameters that capture the longitudinal (temporal) correlation structure. RESULTS: We have compared the performance of the MENN with linear mixed effects models and standard neural networks (NN). MENN show better performance (misclassification rate = 0.13 and relative MSE = 0.35) as compared to standard NN (misclassification rate = 0.34 and relative MSE = 2.74) and linear mixed effects models (misclassification rate = 0.14 and relative MSE = 0.4). CONCLUSION: The results show that this method can be a useful tool for predicting non-linear disease trajectories and uncovering significant prognostic factors in longitudinal databases.

Aged↗
PubMed1999

[Decisions and attitudes in treatment of incompetent, chronically ill, aged patients. A comparison between nurses and physicians: why does no one ask the nurse?].

Health care decision making in incompetent severely ill patients presents many difficult medical, ethical, and legal problems for the physician. At the same time nurses represent the group of medical professionals who have the closest contact with the patient and who have to carry out most of the decisions and instructions. Treatment decisions and their determinants have been assessed by means of a questionnaire based on three case scenarios offering three different levels of available information of the patient's wishes (no information, DNR-order, advance directive). Responses of 191 doctors and 182 nurses have been analyzed. In both groups ethical factors and patient wishes were regarded as the most important. With an increasing level of information about the patient's will the compliance increased in both groups, being more pronounced among the nurses. The more important the will of the patient was estimated, the less difficult were the decisions, the less aggressive was the treatment level chosen, the less frequent rescuscitation was made, and the more helpful the information on patient's will were experienced. These important relationships occurred mainly in the nurses. Furthermore, age and level of dementia were related with the decisions though with less importance. The more legal aspects were regarded the more aggressive treatment options were chosen. Hospital cost were less important and did not influence the decision making. The results indicate that a more frequent use of advance directives would foster patient autonomy and at the same time lessen the burden on the medical staff. A comprehensive education of both the medical professions and the general public seems warranted.

Adolescent↗
PubMed2005

Thinking about equity in health care.

Public health care systems such as the British National Health Service typically profess two principal objectives: to improve the health of the whole population; and to reduce inequalities in health within it. Given scarce resources, these objectives are often in conflict. Much attention has justifiably been paid, by health economists, to addressing the former objective with methods of economic appraisal. My intention is to focus on the more difficult issue of the pursuit of 'equity' in health care, specifically the desire to reduce inequalities in health. This raises philosophical and policy questions about what makes some people more deserving of care than others, and whether or not society should adopt a forgiving stance towards those who have compromised their health status in some way, and offer access to treatment. Also, decision-makers may need to distinguish between the goal of raising the level of those worse-off and reducing inequality across society as a whole. Moreover, it is important to clarify what we wish to be made less unequal within the realm of health care provision. Tough decisions like these are based on value judgements and trading off one priority against another. In the interests of equity, such decisions need to be transparent and based on the preferences of society as a whole rather than covert and capricious. No manager needs reminding that resources are limited or that if more favourable treatment is accorded to some, inevitably less favourable treatment is accorded to others. Policy-making for a whole unit requires a nurse manager to offer a perspective on multidisciplinary matters and engage in wider public policy issues facing the team. As circumstances change, existing practice may be challenged as unfair, inefficient, or failing to account for important patient characteristics which make them different. Here, thinking clearly about equity is very important, and nurse managers are important as clarifiers of the thinking about what should be considered when making these difficult decisions.

Attitude to Health↗
PubMed2002

Ethics in perioperative practice--promoting health, welfare, and safety.

Though often difficult, ethical decision making is necessary when caring for surgical patients. Perioperative nurses have to recognize ethical dilemmas and should be prepared to take action based on the ethical code outlined in the American Nurses Association's (ANA's) Code of Ethics for Nurses with Interpretive Statements. In this eighth of a nine-part series that is designed to help perioperative nurses relate the ANA code to their own area of practice, the author looks at the eighth statement, which emphasizes nurses' responsibility to promote the health, welfare, and safety of all people.

Codes of Ethics↗
PubMed1997

[Physicians' attitude in the treatment of incompetent patients. Comparison between East and West Germany].

BACKGROUND: Health care decision-making in incompetent severely ill patients presents a number of difficult medical, ethical and legal problems for the physician. The factors and the degree to which various factors contribute to such decisions have rarely been investigated. SUBJECTS AND METHODS: 310 physicians from the state of Baden-Württernberg (Western Germany) and the state of Mecklenburg (eastern Germany) were asked by means of a questionnaire to rate the importance of eight factors in their health care decisions in the elderly. RESULTS: Both, ethical concerns and patients' wishes emerged as the most important factors for decisions in both subsamples. However, significant differences in the degree to which the factors hospital costs, patients' and family wishes, the level of dementia and the patients' age contribute to their decisions could be found between the answers of the doctors of the two lands. CONCLUSIONS: The socialization of the physicians in different health care and social systems seems to be one of the most important reasons for different health care decisions in old and incompetent patients.

Adult↗
PubMed1998

Regionalization of health services in Canada: a critical perspective.

Since the introduction of universal health insurance in Canada in the late 1960s, the federal and provincial governments have been concerned with cost savings, efficiency of service delivery, equity in service provision, enhanced citizen participation, and increased accountability of decision-makers. A plethora of government royal commissions and task forces have recommended a similar range of options for addressing these concerns. Central to the reforms has been a proposed regionalized health system with an intermediary body responsible for functions previously assigned to local or central structures. For its supporters, regionalization offers a means of better coordinating and integrating health care delivery and controlling expenditures, and promises a more effective provision of services and an avenue for citizen participation in health care decision-making. All provincial governments except Ontario have introduced regional structures for health care, with the hope that these changes will increase efficiency, equity, and responsiveness. However, despite the alleged benefits, regionalization presents significant challenges. It faces obstacles to integrating and coordinating services in a manner that produces economies of scale; it requires an enhanced level of information that may be difficult to achieve; it is unlikely to involve citizens in health care decision-making; and it may actually lead to increased costs.

Budgets↗
PubMed2002

Learning to plan? A critical fiction about the facilitation of professional and practice development plans in primary care.

A shift from continuing medical education towards professional and organisational development policies, coupled with the introduction of accountability frameworks (clinical governance), has generated interest in professional and practice development plans (PPDPs) in general practice. The problems of implementing this change in an independent contractor-based service remain unexplored and the aims of this study were to focus on the facilitator's experience of the issues that hampered or fostered development in general practice. Facilitators of PPDPs were asked to document their experience of supporting 12 practices in an all Wales feasibility study. In order to maintain organisational anonymity while reporting accurate accounts of the obstacles encountered, a method known as critical fiction was employed. This method allowed the authors to write detailed reflective accounts that were then fictionalised. The culture of general practice reflects the development of an independent contractor service that has developed into partnerships that employ some professionals (practice nurses, managers and administrative staff) and collaborate with others in variable arrangements (community nurses, health visitors, midwives and others). Developing organisation-wide systems in so-called 'primary health care teams' is a difficult exercise, given the ethos of autonomous decision-making processes and the lack of experience of 'whole systems' approaches in primary care. The potential for multiprofessional synergy and the evidence that systematic changes lead to sustained health care improvements are well established. But the implementation issues of these concepts have not been addressed. Existing educational policies are based in uniprofessional paradigms and the protected time requirements and funding streams required for PPDPs have not been clarified.

Attitude of Health Personnel↗
PubMed2005

Practical approaches to prescribing contraception in the office setting.

Caring for the contraceptive needs of an adolescent young woman can be a challenge on many levels. Adolescents are often called young adults, but they are not adults developmentally. Therefore, adult strategies for contraceptive teaching, decision-making, and compliance are often inappropriate and unsuccessful. Health care providers are faced with increasing constraints in the office that can make it difficult to find the time to counsel the adolescent appropriately. Parental involvement in contraceptive decision making, compliance, and continuation will be different with each adolescent and her family. Although this interaction can be a problem, it is also an area where the clinician may make a positive impact for the adolescent and her family.

Adolescent↗
PubMed2003

Evidence-based medicine meets goal-directed health care.

Evidence-based medicine and goal-directed, patient-centered health care seem, at times, like parallel universes, though, at a conceptual level, they are perfectly compatible. Part of the problem is that many of the kinds of information required for decision making in primary care are often unavailable or difficult to find. Several case examples are used to illustrate this problem, and reasons and solutions are suggested. The goal-directed health care model could be helpful for directing the search for evidence that is relevant to the decisions that patients and their primary care physicians must make on a regular basis.

Evidence-Based Medicine↗
PubMedDate not supplied

The use of advance directives with adolescents.

Adolescents and their families are sometimes touched by circumstances that force them to have to make difficult "end-of-life" decisions. The American Academy of Pediatrics (AAP) supports giving children a voice in their health care decision-making, but how teens want to be involved in this is not known. The purpose of this study was to explore if adolescents were interested in and comfortable with advance directives (ADs) discussions. Teens between 15 and 18 years of age (N = 107) participated in this interview study. Results of the study yielded a wide range of information about adolescents and ADs. Participants were able to pass a test used for demonstrating decision-making competency. They were willing to answer questions related to their own health care treatments as they envisioned themselves in a coma, and those responses are similar to those reported for adults. The vast majority of participants felt it was "somewhat important" or "very important" for someone their age to have a living will. Most of the adolescent participants did not report feeling uncomfortable discussing these issues.

Adolescent↗
PubMed1991

Building the framework for dealing with ethical issues.

Making ethical decisions is difficult. Professional and personal values enter heavily into what one member of the health care team considers the "right" decision, and these values may interfere with the decision-making process of the team. As team members begin to realize how their ethical values affect the decision, they may be better able to resolve the conflict within the team. An understanding of each member's ethics and values also can serve to enhance decision making. Nurses are just beginning to view themselves as part of the ethical decision-making team. In order to take an ethical stance, nurses need to have a better understanding of ethical principles to use in the decision-making process. Nurse needs to develop a sound philosophical base in ethics through study and continuing education to be an active part of the health care team making ethical decisions. Nurses have an obligation to move away from the emotional response to ethical dilemmas toward using a more sound basis for these decisions.

Attitude of Health Personnel↗
PubMed2002

The influence of clinical supervision on ethical issues in home care of people with mental illness in Sweden.

AIM: To investigate in what ways clinical supervision can influence district nurses', psychiatric nurses' and mental health care workers' ethical decision-making in home care of people with mental illnesses. BACKGROUND: Nursing staff frequently have to make difficult ethical decisions when caring for mentally disturbed patients in the home. METHODS: This study is a descriptive, correlational study. Data was collected by a cross-sectional survey that focused on psychiatric nurses, district nurses and mental health care workers (n = 660). RESULTS: Health care professionals, who received supervision as support in their clinical nursing work, perceived that they felt more secure in decision-making, felt safer in their relationship with the patient and had gained a deeper insight into the meaning of security for the patient as well as for the carer. Furthermore, they regarded taking over responsibility for the patient, when necessary, as their moral right and that care and treatment in the patient's home could mean that the patient's integrity was violated. CONCLUSIONS: The results emphasize the need for clinical supervision as support for nursing staff, as it leads to their acquiring a greater sense of self-esteem. There is also a need to clarify the professional role of nurses through integration of theoretical and clinical knowledge. The importance of supervision is illustrated by means of previous studies.

Decision Making↗
PubMed1985

Models of care for persons with progressive cancer.

A need exists for a living-dying model that encompasses hospice care and alternative programs of care for the terminally ill. The existing medical and rehabilitative models are focused in directions that do not allow implementation of continuity of care directed toward supporting patients during the plateaus of their illnesses. Today, society has evolved to value the patient as a consumer of health care who can participate through making informed choices among the rich alternatives of care available. Yet the knowledge and technology base of health care delivery today increases at such a rapid rate that it almost seems out of control. This paradox makes it difficult for the patient-consumer to have access to information necessary for involvement in informed decision making. Greater numbers of consumers of health care are active in assuming responsibility for maintaining wellness. At the same time, they are seeking health care programs outside the medical model, as well as within the medical model. The "high-tech" atmosphere has been tempered with an emphasis on humanism, perhaps as a response to the infusion of machinery into our lives. As health care costs have escalated, concern has mounted that health care costs be contained, and that the poor and the elderly not be further curtailed in access to health care resources. There is tremendous potential among nurses for leadership in the creation of services that support quality of life for cancer patients and families. Nurses, as a collective, must be willing to engage in the politics of negotiation for reallocation of health care resources toward person-centered services and to establish a power base for influencing these decisions at the local, state, and national level of government and within various organizations offering health care services. As person-centered services are established, nurses must also move toward formalizing emergent practices into standards of care. Consumers deserve the protection of practice standards that are developed and sanctioned by the profession. It is also critical to test practice, both as it emerges, and after it has been formalized into standards. Nurses must continue to question the tenets of their practice. For example, what are the outcome effects of monitoring and supporting patients during the chronic phase of the living-dying interval? Is either the severity or the number of problems in the terminal phase reduced by these interventions? Changes in the provision of health services in this past decade have been extensive and broadly based.(ABSTRACT TRUNCATED AT 400 WORDS)

Attitude to Death↗
PubMed1994

The nurse's role on ethics committees and as an ethics consultant.

Nurses share in the moral responsibility of their institution to ensure that the best ethical decision-making process is in place to meet patient needs, uphold the philosophy of the institution, and preserve the integrity of the profession. With health care reform under way, clinical ethical decision making will be even more difficult and complex than it is now. As members of ethics committees, nurses have a role to share their unique perspective. Nursing's prolonged contact with the patient, therapeutic communication skills, and goal-oriented approach facilitate the ethical decision-making process and make nurses well-suited to participate on ethics committees. This article discusses the role of the nurse on an ethics committee and, briefly, the advanced practice nurse as an ethics consultant.

Communication↗
PubMed1993

Environments that support ethical nursing practice.

Creating an ethical work environment in a health care organization is both necessary and difficult. In the process of providing care, nurses often make decisions with ethical implications. This decision making is enhanced when the work environment supports an ethical approach. Nursing can implement strategies to support ethical decision making.

Decision Making↗
PubMed2004

[The evaluation of decision making capacity in health care and its relationship to informed consent].

The decision making capacity of patients will acquire special relevance with the introduction of informed consent in clinical practice and the new normative that will appear in the future when the bills about health services are approved in the Congress. This paper reviews the concept of decision making capacity in the context of health care and its legal background in Chile. The main problems that arise from the comprehension, use and assessment of decision making capacity, are analyzed. The assessment of this capacity is, in most cases, subjective since there are no criteria, protocols or standards to be used. In courts of justice, the exercise capacity assessment is requested to experts. These specilized physicians will evaluate the mental health of the subject and its implications in the capacity to make decisions. In practice, it is difficult to integrate the concept of capacity from the law or health care perspective. It is concluded that the elaboration of criteria, standards and procedures to evaluate the decision capacity of patients, is mandatory.

Chile↗