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PubMed2003

Medical decision-making and minors: issues of consent and assent.

The physician-patient relationship has been described as an egalitarian partnership in which patients and physicians work together to make healthcare decisions. Although adults receive considerable encouragement to become active participants in medical decision-making, children and adolescents often have little voice in such decisions and are granted limited access to confidential medical care. After a brief discussion of legal perspectives on informed consent, the present review examines the developmental literature on children and adolescents' capacities to make medical decisions that are informed, voluntary, and rational. The purposes and benefits of assent are identified. Remaining questions of how to evaluate capacity and balance parental and minor autonomy are explored.

Adolescent↗
PubMed1993

Evaluation of physician decision making with the use of prior probabilities and a decision-analysis model.

OBJECTIVES: To determine whether treatment decisions could be influenced by supplying probabilities and whether these decisions would be consistent with a decision-analysis model. DESIGN: Survey with case scenarios and a computerized decision-analysis model. SETTING: Family practice residency program. PARTICIPANTS: Forty family practice residents and faculty in the experimental group and six controls. INTERVENTIONS: Twelve cases scenarios of patients with hypertension and coexisting diseases were developed. Family practice physicians were asked to rank their drugs of choice for each case. In the second phase, six case scenarios included probabilities for efficacy and adverse reactions of step 1 antihypertensives. These drug selections were compared with a computerized decision-analysis model. MAIN OUTCOME MEASURES: Frequencies of matches between the drug selections of physicians and the computer model. RESULTS: The frequency of matches before probabilities were provided to physicians was low (45.6%) and there was a significant increase when probabilities were supplied (71.3%). Regardless of experience level, physicians increased their consistency with the computer model after probabilities were supplied. CONCLUSIONS: This study demonstrated that physician decision making for antihypertensive therapy can be influenced by patient-specific probability estimates. Probability data can help less experienced residents make decisions that are comparable to those of attending physicians. This study was conducted in one residency program and the generalizability to the practicing physician is unknown. These findings would suggest that educational efforts in residency programs, health maintenance organizations, or group practices may benefit from patient-specific probabilities that assist with decisions for drug therapy interventions.

Adult↗
PubMed1996

Breast cancer patients' personality style, age, and treatment decision making.

BACKGROUND: Previous studies have shown that whereas nearly all cancer patients want information, far fewer wish to make treatment decisions. Although breast cancer patients who were given a choice of lumpectomy versus mastectomy and were encouraged to make the decision were believed to do better psychologically, a 1994 study refuted this. Some authors suggest that patient personality style is an important consideration in decisional preference. METHODS: Newly diagnosed breast cancer patients (n = 76) were surveyed within 6 months of surgery. They answered seven questions about patient and physician roles in the decision-making process. Additionally, they completed the Miller Behavioral Style Scale (MBSS), which categorizes "monitors," or information seekers, and "blunters," or information avoiders. Chi-square analyses were used to explore the relationship of personality style and age to treatment decision-making preferences. RESULTS: Although 80% of women wanted a role in decision making, 74% wanted their surgeons to make a recommendation and when given, 94% followed the recommended treatment plan. Monitors and blunters were equally likely to want physician recommendations. Younger women, particularly those under age 40, were more likely to want a physician's recommendation. Of those women who had specific fears about their cancer (76%), only half of them revealed such fears to their doctors. CONCLUSIONS: The notion that health care consumers, particularly younger ones, desire an independent choice of treatment was contradicted in this study. Physicians are encouraged to provide information and to probe regarding the fears of breast cancer patients in order to reduce anxiety while recognizing that treatment recommendations are desired by most women.

Adult↗
PubMed1994

A clinician's guide to decision making capacity and ethically sound medical decisions.

Competence, or decision making capacity, refers to a patient's ability to understand a situation and to make a choice in light of that understanding. It requires the physician to disclose adequate information so that the patient is able to understand and choose. The standard for determining competence is that a person is deemed competent to make medical decisions if the person is capable of giving informed consent. The crucial ethical issue is whether the patient understands and appreciates the nature of the treatment, the risks and benefits, the alternatives and the consequences. Although there is no universally accepted test of a patient's capacity to consent to treatment, the "knowledge and understanding" test offers clinicians a simple competence test that can be administered at the bedside. The physician first identifies the information needed for the patient to give informed consent. Then the physician determines the patient's understanding and appreciation of that information by means of five objective questions. Ultimately, talking to the patient is the only way to determine if the patient is capable of making a medical decision. Of particular ethical interest, however, is rehabilitation medicine's efforts to exempt itself, in the early stages of rehabilitation, from the "moral force" of informed consent. Relying on its unique characteristics as a medical specialty, and on the fact that some of its patients have suffered sudden onset of severe impairment, rehabilitation medicine appears poised to espouse the "thank you theory" of medical practice. In addition, physiatrists may have a professional obligation to fully inform patients when potentially beneficial treatment is withheld from them, such as when they are denied access to or terminated from rehabilitation.

Comprehension↗
PubMedDate not supplied

Treatment decision making: who should decide?

Why is someone other than a competent adult patient considered to be the person to make important treatment decisions? Since one's values influence decision making, who other than the patient should make these significant decisions? The author argues that competent adult patients should make treatment decisions because of the moral nature of these decisions. Recommendations for facilitating the patient's active involvement include increasing one's understanding of values, autonomy, and decision making; identifying personal values; creating a supportive environment; educating patients about their role in decision making; and advocating for patient involvement in treatment decisions.

Adult↗
PubMed1996

Allocating health care: cost-utility analysis, informed democratic decision making, or the veil of ignorance?

Assuming that rationing health care is unavoidable, and that it requires moral reasoning, how should we allocate limited health care resources? This question is difficult because our pluralistic, liberal society has no consensus on a conception of distributive justice. In this article I focus on an alternative: Who shall decide how to ration health care, and how shall this be done to respect autonomy, pluralism, liberalism, and fairness? I explore three processes for making rationing decisions: cost-utility analysis, informed democratic decision making, and applications of the veil of ignorance. I evaluate these processes as examples of procedural justice, assuming that there is no outcome considered the most just. I use consent as a criterion to judge competing processes so that rationing decisions are, to some extent, self-imposed. I also examine the processes' feasibility in our current health care system. Cost-utility analysis does not meet criteria for actual or presumed consent, even if costs and health-related utility could be measured perfectly. Existing structures of government cannot creditably assimilate the information required for sound rationing decisions, and grassroots efforts are not representative. Applications of the veil of ignorance are more useful for identifying principles relevant to health care rationing than for making concrete rationing decisions. I outline a process of decision making, specifically for health care, that relies on substantive, selected representation, respects pluralism, liberalism, and deliberative democracy, and could be implemented at the community or organizational level.

Advisory Committees↗
PubMed1990

Problems in the decision making process: a review.

Decision making is an integral part of the intensive care nurse's role, but many factors can disrupt this process. It is important that the nurse has an understanding of how defective decision making patterns can develop. Experience, the role of the nurse, uncertainty and conflict all exert major influences on the decision making process. The conditions that determine what type of decision making pattern emerges are; the seriousness of the risks as a result of the decision; if there is hope of finding a better solution; and how much time is available to search for the solution. The patterns that may emerge include vigilance, complacency, defensive avoidance and hypervigilance. Vigilance is said to be the optimum pattern, this is when all alternatives to the decision are analysed and interpreted in an unbiased manner. Defensive avoidance is the decision makers attempt to avoid or postpone the stress of the decision. It is manifested by procrastination, shifting of responsibility or rationalisation. Hypervigilance, or panic, represents a frantic search for a solution and a shifting back and forth between alternatives with a failure to see obvious faults in the possible solutions.

Conflict, Psychological↗
PubMed2004

Role strain and ease in decision-making to withdraw or withhold life support for elderly relatives.

PURPOSE: To describe the concepts of role strain and role satisfaction (renamed ease in decision-making following analysis) experienced by family caregivers when making decisions to withdraw or withhold life support for elderly relatives in a variety of settings. METHODS: Semi-structured interviews were conducted with 17 family caregivers to obtain descriptions of their experiences when making decisions about life support for elderly relatives. Content analysis was used to analyze the data. FINDINGS: Role strain was complex, dynamic, and multidimensional, and it evolved over time before, during, and after decision-making about life support. Role satisfaction, the concept name used at the beginning of the study, did not match descriptions or the experience of family caregivers, and a revised name, ease in decision-making, was selected. CONCLUSIONS: The concepts of role strain and ease in decision-making have not previously been used in studies of decisions about life support. Both role strain and ease in decision-making augment the existing literature on role strain in family care by providing a more complete picture of caregivers' responses during their experience of making life-support decisions. Research focused on the measurement of strain and ease in decision-making is needed to understand their interrelationship as well as their association with such variables as caregiver grief and health.

Adaptation, Psychological↗
PubMedDate not supplied

Ethical decision-making in nursing: implications for continuing education.

Staff nurses make ethical decisions daily. It is important that nurses know how to manage those decisions appropriately so that clients' ethical rights are honored without compromising the nurse's own moral conscience. In this phenomenological study, 19 staff nurses described their experiences in making ethical decisions in their practices. The interviews were transcribed and analyzed using Giorgi's phenomenological steps. The description of the nurses' experiences identified two distinct components of the ethical decision-making process: deliberation and integration. The findings suggest that nurses need to: a) recognize the ethical nature of their work, b) discern which ethical decisions are theirs to make, and c) acknowledge their authority to make ethical decisions in their practices. These findings have important implications for the continuing education of nurses regarding ethical decision-making.

Decision Making↗
PubMed1984

Mingling decision making metaphors.

Organizational decisions provide conceptual playing fields wherein scientists adhering to rival theories based on different metaphors skirmish in-decisively. Organizational decisions, however, are also empirical arenas wherein practitioners espousing discordant theories-in-use reconcile their differences pragmatically. Practitioners' decision-making metaphors encountered while studying capital budgeting suggest how disjoint perspectives are assimilated and shifts from instrumental to symbolic actions are triggered. Implications for decision theories are discussed, and potential benefits of incorporating practitioners' knowledge into organizational science are considered.

Budgets↗
PubMed1998

Sociomedical models and the epistemology of risk: the shortcomings of medical decision-making research.

Sociomedical decision-making models have provided the framework for understanding individual choice regarding health risks and have had an enormous impact on the practice of health education. Recently, some scholars have questioned the usefulness of these models and have called for a new perspective. While some newer decision-making models appear to be unique, it will be shown here that these new approaches remain firmly grounded in value-expectancy tradition. By examining sociomedical decision-making models with regard to their underlying theory of human action and epistemological assumptions, the similarity of various models will be exposed. The intent of this analysis is to illuminate the inherent limitations of traditional medical decision-making models and to provide a framework for developing a new approach.

Attitude to Health↗
PubMed2005

Individual differences in causal learning and decision making.

In judgment and decision making tasks, people tend to neglect the overall frequency of base-rates when they estimate the probability of an event; this is known as the base-rate fallacy. In causal learning, despite people's accuracy at judging causal strength according to one or other normative model (i.e., Power PC, DeltaP), they tend to misperceive base-rate information (e.g., the cause density effect). The present study investigates the relationship between causal learning and decision making by asking whether people weight base-rate information in the same way when estimating causal strength and when making judgments or inferences about the likelihood of an event. The results suggest that people differ according to the weight they place on base-rate information, but the way individuals do this is consistent across causal and decision making tasks. We interpret the results as reflecting a tendency to differentially weight base-rate information which generalizes to a variety of tasks. Additionally, this study provides evidence that causal learning and decision making share some component processes.

Cognition↗
PubMed1985

Contraceptive decision-making in urban, black female adolescents: its relationship to cognitive development.

Contraceptive education and accessible contraceptive methods have not reduced significantly the incidence of adolescent pregnancy. The cognitive development of adolescents makes contraceptive decision-making difficult. This study examined how cognitive development affected contraceptive decision-making among 86 urban black female adolescents attending three family planning clinics. Hierarchical multiple regression analyses revealed that the stage of cognitive development was the best predictor of contraceptive decision-making. Age and relevant sexual knowledge added to the explanation of decision-making variance. Potential nursing implications include: (1) screening of stage cognitive development prior to rendering care, (2) continuation of contraceptive education and (3) presentation of contraceptive education at appropriate cognitive levels.

Adolescent↗
PubMed1997

Nurse-physician collaboration and satisfaction with the decision-making process in three critical care units.

OBJECTIVE: To assess and compare levels of nurse-physician collaboration and satisfaction with the decision-making process as reported by critical care nurses, resident physicians (residents), and attending physicians (attendings) in making decisions to transfer individual patients out of the critical care unit, and to assess if satisfaction predicts nurse retention. DESIGN: Longitudinal descriptive correlational study using self-reporting instruments. SETTINGS: A university hospital's surgical ICU, a community teaching hospital's medical ICU, and a community hospital's mixed ICU. SUBJECTS: Eighty-one nurses, 23 residents, and 37 attendings from the surgical ICU; 44 nurses and 51 residents from the medical ICU; 25 nurses and 45 attendings from the community hospital's ICU, reporting on the transfers of 473, 465, and 494 patients, respectively. MAIN OUTCOME MEASURES: Healthcare providers' reported levels of collaboration and satisfaction with the decision-making process, the correlations between collaboration and satisfaction, and nurse retention. RESULTS: Nurses and physicians within sites (except attendings from the surgical ICU) reported similarly moderate amounts of collaboration, but nurses reported less satisfaction with decision making than did physicians in all sites. Collaboration was related to satisfaction with decision making for all providers, but more strongly for nurses. The strength of the relationship for nurses was similar in all sites. Nurses' satisfaction with decision making did not predict their retention. CONCLUSIONS: Collaboration between nurses and physicians is a more important component of satisfaction with decision making for nurses than for physicians. Any interventions to change the amount of collaboration in practice must take account of this difference.

Adult↗
PubMed2004

Prefrontal cortex and decision making in a mixed-strategy game.

In a multi-agent environment, where the outcomes of one's actions change dynamically because they are related to the behavior of other beings, it becomes difficult to make an optimal decision about how to act. Although game theory provides normative solutions for decision making in groups, how such decision-making strategies are altered by experience is poorly understood. These adaptive processes might resemble reinforcement learning algorithms, which provide a general framework for finding optimal strategies in a dynamic environment. Here we investigated the role of prefrontal cortex (PFC) in dynamic decision making in monkeys. As in reinforcement learning, the animal's choice during a competitive game was biased by its choice and reward history, as well as by the strategies of its opponent. Furthermore, neurons in the dorsolateral prefrontal cortex (DLPFC) encoded the animal's past decisions and payoffs, as well as the conjunction between the two, providing signals necessary to update the estimates of expected reward. Thus, PFC might have a key role in optimizing decision-making strategies.

Animals↗
PubMed2006

Seeing at a glance, smelling in a whiff: rapid forms of perceptual decision making.

Intuitively, decisions should always improve with more time for the accumulation of evidence, yet psychophysical data show a limit of 200-300 ms for many perceptual tasks. Here, we consider mechanisms that favour such rapid information processing in vision and olfaction. We suggest that the brain limits some types of perceptual processing to short, discrete chunks (for example, eye fixations and sniffs) in order to facilitate the construction of global sensory images.

Animals↗