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Results for “Making Difficult Health Care Decisions”

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PubMed2006

Determinants of first- and second-generation antipsychotic drug use in clinically unstable patients with schizophrenia treated in four European countries.

The present study investigated the use of antipsychotics in a sample of clinically unstable patients with schizophrenia who were recruited in four European sites. The study aimed: (i) to test whether the length of previous antipsychotic exposure was associated with the choice of antipsychotic medication; (ii) to test whether the severity of illness was associated with the use of second-generation antipsychotic agents (SGAs) or with the concomitant use of both first-generation antipsychotics (FGAs) and SGAs; and (iii) to investigate differences between study sites. Participants were recruited from patients under the care of psychiatric services serving geographical catchment areas in Croydon (UK), Verona (Italy), Amsterdam (The Netherlands) and Leipzig (Germany). Clinically unstable patients with a clinical diagnosis of schizophrenia and a research diagnosis of schizophrenia, established using the Item Group Checklist of the Schedule for Clinical Assessment in Neuropsychiatry, were enrolled. Sociodemographic and clinical data, including current antipsychotic drug therapy, psychopathology, adherence, insight, side-effects, attitudes towards medication and quality of life, were gathered. Three hundred and ninety patients were analysed in total. Almost 60% received SGAs, less than one-third FGAs, and less than 15% received both drug classes. Those receiving SGAs were younger and with a shorter length of antipsychotic drug therapy, whereas those receiving both drug classes were more often separated or widowed, unemployed and with a long history of antipsychotic drug therapy. The distribution of patients receiving FGAs, SGAs and both drug classes by illness-related variables showed that patients receiving both drug classes were more severely ill and complained of more side-effects. Using patients receiving FGAs as the reference category, multinomial logistic regression analysis showed that the length of antipsychotic treatment was negatively correlated with receiving SGAs, and that the severity of illness and being separated/widowed were positively correlated with receiving both drug classes. Compared with patients in Leipzig, patients in Amsterdam, Croydon and Verona were less frequently treated with SGAs and with combinations of both drug classes. Consistent with current clinical uncertainty with respect to what pharmacological treatment should be provided, patients with a long history of antipsychotic exposure were receiving FGAs, SGAs and combinations of both drug classes. Physicians tended to reserve polypharmacy for difficult-to-treat patients (i.e. for managing situations where, despite the lack of an evidence base, there is a pressing need to provide clinical answers).

Adolescent↗

PubMed2005

Evidence-based medicine in surgical decision making.

There are now five classic steps for analysis of diagnostic and therapeutic medical decision-making policies: (1) formulate a clear clinical question based on a particular patient's problem; (2) search the literature for relevant clinical articles; (3) evaluate the evidence for its validity and usefulness; (4) implement useful findings into clinical practice; (5) audit the validity of the process. The clinician must have the necessary skills to appraise critically the information retrieved. Rather than focusing on the discussion and conclusion sections of articles, the reader should concentrate on the review of the methods and results sections to formulate an opinion regarding the strength of evidence presented in the paper. The process is intellectually demanding and difficult to achieve. This particular step in the validation of evidence implies that each clinician must be methodologically and statistically sound, an "expert," capable of analyzing the method used in that particular publication to achieve the published result.

Decision Making↗

PubMed1993

Intensive care: situations of ethical difficulty.

Twenty enrolled nurses (ENs), 20 registered nurses (RNs) and 20 physicians working in intensive care in northern Sweden narrated 255 stories about their experience of being in ethically difficult care situations. The ENs' stories mainly concerned problems relating to relationship ethics, the stories narrated by the physicians mainly concerned problems relating to action ethics, while the RNs' stories gave equal attention to both kinds of problems. The most common theme of both the RNs' and the physicians' stories was that of too much treatment. An obvious similarity between the ENs, RNs and physicians was that they saw themselves as equally lacking in influence in ethically difficult care situations. The only apparent difference between the three groups, however, was that the ENs brought up relationship problems more often than the others. Thus, the differences between the RNs and the physicians were fewer than usually reported in the literature. This might be related to the specialization of intensive care.

Adult↗

PubMed1982

Three models of group choice.

The notion of group responsibility has received some vary fruitful examination in recent years. But there still remains an important commonsense objection to this notion. Moral responsibility for an action is ordinarily linked to and held to depend upon the action's being the product of an act of choice on the part of the agent. The thrust of the objection here is that it is extremely difficult to understand how intentional acts like acts of choice can be properly attributed to a group. The notion of a group "consciousness" does not seem a very satisfactory resolution of this problem. In this paper I shall propose that there are actually three distinct processes, as well as many hybrid combinations of them there, by which groups "make choices." That is, when we look at the activities of groups, we discover three different kinds of analogues to the act of choice of the individual person. I shall be illustrating each of these models with examples of health care decisions. In addition, I shall also try to illustrate how the level of personal moral responsibility of each of the individuals making up the group, i.e., each one's responsibility for the group's action, can be seen to flow from the particular role that an individual plays within the process of "group choice" that is involved. In this way, I hope to shed light not only on the topics of group choice, group responsibility, and the interplay of personal and group responsibility, but also to show concretely the valuable role that these themes can play in our understanding of the moral elements of the health care setting.

Choice Behavior↗

PubMed1989

The answer to "What are my chances, doctor?" depends on whom is asked: prognostic disagreement and inaccuracy for critically ill patients.

Physicians often must make prognostic judgments for critically ill patients, but we know little about how well they can perform this task. We prospectively measured disagreements among different physicians' quantitative prognostic judgments for 269 sequential admissions to an ICU, and evaluated the accuracy and discriminating ability of judgments made by different types of physicians. Many (44.7%) patients provoked one or more disagreements of at least 20 percentage points among the three possible pairings of physicians. Many patients whom one physician thought were certain to survive did not inspire such certainty in another of their doctors. The critical care attendings thought the changes of survival were less than or equal to 80% for 23, and between 81% and 95% for another 46 of 85 patients whom the patients' own attendings thought were certain to survive. There were some differences in the accuracy of the different physicians' estimates. All doctors showed excellent overall discriminating ability, but discriminated less well for postoperative patients. Lack of consensus about how to judge prognosis for critically ill patients may make it difficult to decide whom to admit to ICUs. These results underscore the need for valid predictive models to aid in decision-making for critically ill patients.

Adult↗

PubMed1994

Contributions of psychologists to inpatient care of persons with chronic mental illness.

Treatment of chronic mentally ill inpatients in public settings can be a difficult endeavor due to lack of adequate resources and problems in recruiting and retaining qualified staff. Psychologists can make a valuable contribution in state mental hospitals, offering a range of services that may be unknown to other disciplines. The authors describe seven areas in which clinical psychologists can facilitate quality patient care, including assessment, psychotherapy and rehabilitation, behavior modification, ward treatment programming, student and staff training, research, and administration. They also discuss ways to deal with conflicts that develop between personnel from various mental health disciplines, such as those around issues of control, prescription privileges for nonphysicians, and clinical decision making.

Behavior Therapy↗

PubMedDate not supplied

Building true collaborations. A senior support network illustrates a successful partnership of healthcare and social service providers.

The relationship between Catholic Social Services (CSS) of the Diocese of Scranton and Mercy Health Partners--Northeast Region, which joined forces last year to develop a senior support network for residents of Wilkes-Barre and the Borough of Kingston, PA, illustrates how collaboration grows out of cooperation and coordination of services. The network is a project of the Neighborhood-Based Senior Care National Initiative, which works to develop collaborations between Catholic health systems and Catholic Charities agencies to help poor communities meet the needs of aging persons. Barriers to successful collaboration may stem from cultural misunderstandings, differences in organizational stability and decision-making processes, attitudes toward money, and even professional vocabularies. Organizations that trust and respect each other can overcome these barriers. The Wilkes-Barre project began simply, but its success established a pattern of cooperation between CSS and Mercy Health Partners, which led to further coordination of referral programs, development of community health profiles, and cross-organizational training. After nine months on the Wilkes-Barre project, CSS and Mercy Health Partners are now developing a Program of All-Inclusive Care for the Elderly (PACE). Effective collaboration between healthcare providers and social service agencies is a long, sometimes difficult, process that requires organizational commitments of time and resources. Organizations must not yield to the temptation to take shortcuts to achieve short-term gains.

Aged↗

PubMed2000

Comparing cost-effectiveness analyses for the clinical oncology setting: the example of the Gynecologic Oncology Group 111 trial.

For the practicing oncologist, balancing quality of care with cost containment has become an unavoidable challenge. The development of new technologies, increased patient awareness, growth of managed care, and aging of our population represent conflicting interests in this endeavor. Medical literature has recently been inundated with economic analyses in an effort to approach some of these difficult questions, but often times it is difficult to see how this research applies to any particular oncologist's practice. This article identifies many of the key issues raised in the critical evaluation of cost-effectiveness analyses as they relate to the practicing oncologist. We offer suggestions on the interpretation of these studies to the clinical setting, using the recently published Journal of Clinical Oncology articles on cost-effectiveness analyses of paclitaxel-cisplatin as first-line therapy for ovarian cancer as examples.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1997

Health professional decision-making in the ICU: a review of the evidence.

End-of-life decisions in the ICU are often complex and emotionally charged. Intensivists can correct the physiologic abnormalities of acute and chronic illness with drugs and technology, and prolong life in many situations. Understanding and attending to the psychological and emotional needs of not only patients but also their families are part of the delivery of compassionate critical care. The process of communicating and decision-making on the ICU team and in family units has been a domain of active research over the past decade. Studies on do-not-resuscitate orders, and advanced and delayed directives comprise a portion of this work. This article contains a brief summary of selected research evidence on these difficult end-of-life issues.

Advance Directives↗

PubMed2003

[Pharmacoeconomic aspects of the treatment of onychomycosis].

The clinical management of severe onychomycosis is known to be a long and difficult task. When deciding which treatment to prescribe to our patients we may be tempted to use the efficacy rate as the only objective measurement or on the other hand to assess treatment costs only by looking at the drug acquisition cost. The role of pharmacoeconomics is to provide a method that evaluates outcomes and costs at the same time; it is an aid to better decision making. Cost effectiveness studies take into account the efficacy of each treatment regimen balanced against the global cost of treatment. So we can assess the number of patients cured for a given health care budget. Two recent studies presenting the results of a combination therapy of an antifungal therapy and antifungal lacquer give us the opportunity to illustrate some pharmacoeconomic principals.

Humans↗

PubMed2006

Everyday ethical problems in dementia care: a teleological model.

In this article, a teleological model for analysis of everyday ethical situations in dementia care is used to analyse and clarify perennial ethical problems in nursing home care for persons with dementia. This is done with the aim of describing how such a model could be useful in a concrete care context. The model was developed by Sandman and is based on four aspects: the goal; ethical side-constraints to what can be done to realize such a goal; structural constraints; and nurses' ethical competency. The model contains the following main steps: identifying and describing the normative situation; identifying and describing the different possible alternatives; assessing and evaluating the different alternatives; and deciding on, implementing and evaluating the chosen alternative. Three ethically difficult situations from dementia care were used for the application of the model. The model proved useful for the analysis of nurses' everyday ethical dilemmas and will be further explored to evaluate how well it can serve as a tool to identify and handle problems that arise in nursing care.

Aged↗

PubMed1996

. . . and a time to die: the medicine of old age.

Most deaths in Britain occur in old age, and old people dying have as many symptoms as do the young. Management is complicated by diagnostic difficulty, by the frequency of mental disorder (sometimes treatable) and of severe disability, and by the difficulty in ascertaining patients' feelings. Decisions about the management of dying are inevitable, and multifactorial, and views of others may be helpful. Cardiopulmonary resuscitation is not indicated if futile, and may or may not be wanted by the patient. Withholding or withdrawing life-prolonging treatment may be justified if the totality of life gained (length and quality) is not justified by the burden of treatment. Decisions are most difficult when the prognosis is poor but not definitely fatal. Palliative care is important, not only in cancer. Euthanasia is seldom requested at present, and in The Netherlands is carried out less in old people than young. It would do little for the most serious problems of old age.

Aged↗

PubMed1994

Why do doctors find some patients difficult to help?

Almost all doctors encounter difficulties in managing some patients. Previous studies have examined the characteristics of such patients: we have additionally studied the reasons why hospital doctors find these patients 'difficult to help'. Three clinics (two medical and one surgical) were studied. The consultants rated 60 (22%) of 293 attenders s severely or extremely difficult to help. Difficulty was associated with greater patient distress (odds ratio 3.9; 95% CI 2.0-7.7), less patient satisfaction (2.6; 1.3-5.0) and chronic attendance (5.0; 1.4-17.3). An interview study of 40 'difficult' patients indicated that doctors considered psycho-social factors more important in difficult patients (3.2; 1.3-7.7). Objective differences between the doctor's and the patient's aims for care also occurred more frequently for difficult patients (2.8; 1.1-7.2). Three common types of difficulty were identified; medically unexplained symptoms; co-existing social problems; and severe untreatable illness. A review of the management aims for patients whom doctors find 'difficult to help', combined with improved access to psycho-social care, could improve both the quality and the cost-effectiveness of hospital out-patient services.

Adolescent↗

PubMed2006

A consumer decision support system for common health ailments in South Africa.

Access to health services is difficult in many rural areas of South Africa. A basic computerised decision support system (CDSS) has been developed to assist consumers to reduce the number of unnecessary visits to health care facilities. Consumers are prompted to enter details of their symptoms, and the CDSS assesses the likelihood of their suffering from one of ten common ailments, such as tuberculosis or hypertension. Advice is given on whether the consumer should seek care from a health care professional.

Community Participation↗

PubMed2002

"Choice" in end-of-life decision making: researching fact or fiction?

PURPOSE: The contribution of bioethics to clinical care at the end of life (EOL) deserves critical scrutiny. We argue that researchers have rarely questioned the normative power of autonomy-based bioethics practices. Research on the ethical dimensions of EOL decision making has focused on an idealized discourse of patient "choice" that requires patients to embrace their dying to receive excellent palliative care. DESIGN AND METHODS: Our critique is based on a comprehensive review of empirical research exploring bioethics practices at the EOL. In addition we will provide a brief review of our own ethnographic, longitudinal study of the decision-making experience of dying patients, their families, and their health care providers. RESULTS: There is little or no empirical evidence to support the autonomy paradigm of patient "choice" in EOL decision making. What we found is that (a). prognostication at the EOL is problematic and resisted; (b). shared decision making is illusory, patients often resist advance care planning and hold other values more important than autonomy, and system characteristics are more determinative of EOL care than patient preferences; and (c). the incommensurability of medical and lay knowledge and values and the multifaceted and processual nature of patient and family decision making are at odds with the current EOL approach toward advance care planning. IMPLICATIONS: It is exceedingly difficult to identify, study, and critique normative assumptions without creating them, reproducing them, or obliterating them in the process. However, a fuller account of the morally significant domains of end-of-life care is needed. Researchers and policy makers should heed what we have learned from empirical research on EOL care to develop more sensitive and supportive programs for care of the dying.

Acquired Immunodeficiency Syndrome↗

PubMed1980

Development, application, and evaluation of an "action-reaction" planning method.

It is difficult to design and implement new public policies and programs, at least partially owing to the fact that few useful methods are available to help shape the planning, decision-making, and implementation processes required for change. Planning often tends to focus on wishful thinking rather than on a realistic assessment of the probable outcomes. In this article we describe an action-reaction approach to planning that explicitly recognizes the restrictions on program impact arising from the system in which change is being attempted. A hypothetical example shows the application of this method to the design of a health-care delivery program. The article concludes with a discussion of the long-term uses of the data base that may be compiled with this method.

Budgets↗

PubMed2000

[Cost-effectiveness of imaging procedures in knee injuries].

It is clear to experts in the health care industry that with regard to medical decision-making, considering costs of medical devices is not a good index, but it is highly important to include medical aspects. This approach guarantees an advance and an appropriate method. We present a cost-effectiveness analysis to target the optimal strategy of how to use medical diagnostic devices in cases of knee injuries. Today, one of the more common medical emergency referrals seen worldwide is in the area of orthopedics, knee injuries in particular. They can harm soft tissue, bone tissue, or both simultaneously. The diagnosis of soft tissue injury is difficult at best. Among the devices helping the clinician make an accurate diagnosis are MRI and ultrasound (US). We conclude that US is superior to MRI in this condition. This is especially true when the orthopedic examination leads to the suggestion of arthroscopy. The results were not modified, and a sensitive study of the parameters that influence the decision-making process was undertaken. Decision-makers should not consider medical outcome alone, but should take into account the costs. A clinical study should validate the assumption on which this study was based.

Cost-Benefit Analysis↗

PubMed1998

Towards a modified cardiopulmonary resuscitation policy.

This article proposes a modification of a hospital cardiopulmonary resuscitation (CPR)/do not resuscitate (DNR) policy that prescribes CPR for all unless a DNR order is agreed to by patient and physician. Rather than maintaining CPR as an intervention that can be avoided only by a negative order, the proposed modified policy supports a positive order, i.e., perform CPR when beneficial unless the patient refuses. To provide a clinical basis for an ethical discussion comparing the current policy with the modified proposal, a brief review of the outcome of CPR in terms of survival to discharge is presented. Two principal observations were made. First, regarding overall survival, there is an element of harm for an important proportion of those who initially respond to CPR but fail to survive to discharge, spending time in the intensive care unit only to have a subsequent arrest and death in hospital. Second, a set of point estimates of survival to discharge in relation to 11 pre-arrest diagnostic characteristics shows their close correlation. The modified proposal should provide a more realistic framework within which to evaluate the needs and wishes of patients at this difficult and emotional time. This concept is implemented by establishing the CPR status of all patients as one component of their positive treatment regimen, rather than having CPR as an intervention to be avoided only by the DNR order. The author discusses the current and proposed policy relative to their effect on patient selection, discussion with patients about CPR, the dilemma that results when the patient insists on CPR when it is not recommended and the protection of patient autonomy.

Cardiopulmonary Resuscitation↗