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Results for “Making Difficult Health Care Decisions”

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PubMed2006

Factors relating to carer burden for families of persons with muscular dystrophy.

OBJECTIVE: To assess the burden on family carers of persons with muscular dystrophy living in their homes and to determine factors contributing to carer burden. METHODS: The study included 56 dyads of people with muscular dystrophy and their family carers. The variables for carer burden were compared by logistic regression in 2 carer groups (burden + /burden-). RESULTS: The mean age of the patients with muscular dystrophy was 32.7 years (median 26.7, range 15-65 years) and that of the carers 51 years (median 48, range 30-80 years). The carers reported the care burden using the Zarit Burden Inventory (median score 23, range 0-57/88). Multivariate analysis produced 3 adjusted explicative factors: carer characteristics related to risk of perceived burden are self-report of poor social functioning on the SF-36 (OR = 26.6 (2.6-278); p=0.006), self report of anxiety on the Hospital Anxiety Scale (OR = 7.1 (1.4-36); p=0.02) and being a carer under 48 years of age (OR = 7.8 (1.7-34.5); p=0.007). However, it was difficult to dissociate the different health variables of the carers from each other. CONCLUSION: This approach should lead to better decision-making by medical teams, patients and their carers.

Activities of Daily Living↗

PubMed2006

Randomized clinical trials for cancer screening: rationale and design considerations for imaging tests.

Since the 1960s, there have been revolutionary developments in imaging technology. Undoubtedly, these advances in imaging technology have made it possible to detect most cancers much earlier than they would have presented with clinical signs or symptoms. However, there are harms from screening, including false-positive results and overdiagnosis, and the costs of screening can be substantial. Therefore, screening for cancer must be rigorously evaluated to ensure that it provides more benefit than harm at an acceptable cost. Unfortunately, the evaluation of cancer screening is difficult and susceptible to several forms of bias. Randomized clinical trials are the most valid study design for cancer screening, but they cannot be expected to answer all the questions that arise with the implementation of screening. Decision modeling can be used to extrapolate the results of randomized clinical trials to help inform public policy and individual decision making.

Cost-Benefit Analysis↗

PubMed2005

The HIM role in patient safety and quality of care.

IOM reminds us that technology is only part of the initiative to make the nation's health system a safer one. Another significant factor is the human element. Change will occur when the culture and commitment to patient safety shift. According to IOM, change will "require a culture of safety and the active participation of all health care professionals, organizations and patients themselves." It is up to all of us to create a trusting, safe environment to look at the truth around patient safety and ensure open, blameless dealing with findings. We are letting go of a culture that no longer works. The efforts we make at a local level will play into safety in the larger environment. It is a journey--we will make patient care safer over time by taking action on what we learn from accurate and complete aggregate data. And it is a balance, with patient safety getting the greatest weight in commitments and difficult resource decisions. Patient safety will come from universal cooperation to uncover the truth--letting go of blame and finding resolution to problems, known and not yet uncovered.

Humans↗

PubMed2005

Challenges in the provision of ICU services to HIV infected children in resource poor settings: a South African case study.

The HIV/AIDS epidemic has placed increasing demands on limited paediatric intensive care services in developing countries. The decision to admit HIV infected children with Pneumocystis carinii pneumonia (PCP) into the paediatric intensive care unit (PICU) has to be made on the best available evidence of outcome and the ethical principles guiding appropriate use of scarce resources. The difficulty in confirming the diagnosis of HIV infection and PCP in infancy, issues around HIV counselling, and the variance in the outcome of HIV infected children with PCP admitted to the PICU in African studies compound this process. Pragmatic decision making will require evaluation of at least three ethical questions: are there clinical and moral reasons for admitting HIV positive children with PCP to the PICU, should more resources be committed to caring for HIV children who require the PICU, and how can we morally choose candidates for the PICU? Those working in the PICU in HIV endemic regions need to make difficult personal decisions on effective triage of admissions of HIV infected children with PCP based on individual case presentation, availability of resources, and applicable ethical principles.

Child↗

PubMed2001

[Where do we stand with BCG vaccination programme in Japan?].

The current BCG vaccination program of Japan is critically discussed based on recent knowledge, especially with regard to its epidemiological aspects, in order to put the problem into perspective for Japan's future tuberculosis control program. 1. EFFICACY AND OVERALL EFFECTIVENESS: Various indicators of BCG efficacy have been proposed, and the meticulous analysis on the variability and the quality of these indicators seems to have formed a consensus on the efficacy, as seen in the recent meta-analysis studies. However, much has been left unanswered concerning the conditions under which the efficacy is guaranteed. The impact of the vaccination program on the population should also be considered in order to make decisions on the program. Comparing the age-specific tuberculosis notification rate between Japan and the USA, where there has been no BCG vaccination program, shows that the rate for 0 to 4 year olds is clearly lower in Japan than in the USA, while it is more than five times higher for all ages in Japan than in the USA. The statistics for Japanese children are superior to those of US children with respect to the speed of decline in notification rate as well. These observations support the overall effectiveness of BCG vaccination in Japan. 2. MECHANISMS OF BCG VACCINATION EFFICACY AND ITS DURATION: Two possible mechanisms of how BCG works to prevent tuberculosis were proposed. Epidemiological models based on each mechanism were subsequently tested by simulating 20 years' development of cases in the BCG vaccination trial by BMRC. In mechanism 1, the BCG-induced immunity is assumed to boost TB immunity in inhibiting the clinical breakdown of tuberculosis during the 10 to 15 years after the vaccination. In mechanism 2, the immunity makes the infection process abort (presumably, at 90%, during the seven years after infection, for example), leading to a smaller risk of future clinical development. So far, most epidemiological models implicitly assume mechanism 1 above. In animal experimental models, however, it has been difficult to simulate the mechanisms differentially, which has been one of the drawbacks to this argument. 3. EFFECTIVENESS OF REVACCINATION: Revaccination with BCG vaccine aims to restore or to endow immunological resistance through repeating vaccination to those who have partially or totally lost the immunity acquired from the primary vaccination. Although some animal experiments support the efficacy of revaccination with BCG, studies in humans have been rare and the results are variable. The observation of Polish infants and schoolchildren is suggestive of the efficacy, but it is not randomized and of questionable value. The recent study of Malawi is a randomized trial. It demonstrated that BCG revaccination protects against leprosy, but does not protect significantly against tuberculosis. It is possible, however, that it does protect against tuberculous lymphadenitis. The two above-mentioned possible mechanisms of BCG immunity were applied to a model analysis of BCG revaccination. It was known that revaccination effectiveness is very limited under any assumption, given the current Japanese epidemiological situation of tuberculosis, so that the demerits due to revaccination, such as strong local reactions, must not be neglected but should be carefully considered. At the same time, we should remember that this model analysis assumes that the primary vaccination is given to new borns with advanced and uniform techniques, which is not always true, and revaccination may supplement the technical failure of the primary vaccination. 4. DECIDING ON THE TOTAL DISCONTINUATION OF BCG VACCINATION PROGRAMME, JAPAN: The recommendations of WHO or IUATLD on the discontinuation of the BCG vaccination program are just conventional ones and the theoretical reasonings is difficult to accept. After all, the decision making should depend on the lay decision makers' subjective judgment balancing benefit and loss in terms of costs and health incurred by the policy, as shown by Waaler and Rouillon. The current Japanese BCG vaccination program is very expensive, but brings about some, though very small, benefit. This balance was compared with that of Sweden around 1975, when the program was discontinued. The comparison clearly showed that the cost-effectiveness of the program in Japan today in superior to that of Sweden in 1975.

BCG Vaccine↗

PubMedDate not supplied

The diagnosis and management of renovascular disease: a primary care perspective. Part I. Making the diagnosis.

Renovascular disease is a complex disorder, the most common causes of which are fibromuscular dysplasia and atherosclerotic disease. It usually presents in one of three forms: asymptomatic renal artery stenosis, renovascular hypertension, or ischemic nephropathy. This complexity often makes diagnostic and management decisions difficult. This review will be presented in two parts. In Part I, the authors will discuss when to consider and how to go about making the diagnosis. In Part II (in a future issue of The JCH), the authors discuss the management of renovascular disease. The clinical index of suspicion remains paramount in setting the diagnostic strategy. Although it is subject to certain limitations, conventional contrast angiography is usually considered the gold standard in confirming the diagnosis. In addition, there are a number of available noninvasive tests that can aid in decision making. These tests can be divided into those that detect the anatomic presence of a stenosis and those that identify the functional consequences of the renal artery obstruction. No one study is appropriate for every patient. A diagnostic algorithm is proposed at the conclusion of this review.

Algorithms↗

PubMed2003

Discrepant attitudes about teamwork among critical care nurses and physicians.

OBJECTIVE: To measure and compare critical care physicians' and nurses' attitudes about teamwork. DESIGN: Cross-sectional surveys. SETTING: Eight nonsurgical intensive care units in two teaching and four nonteaching hospitals in the Houston, TX, metropolitan area. SUBJECTS: Physicians and nurses who worked in the intensive care units. MEASUREMENTS AND MAIN RESULTS: Three hundred twenty subjects (90 physicians and 230 nurses) responded to the survey. The response rate was 58% (40% for physicians and 71% for nurses). Only 33% of nurses rated the quality of collaboration and communication with the physicians as high or very high. In contrast, 73% of physicians rated collaboration and communication with nurses as high or very high. By using factor analysis, we developed a seven-item teamwork scale. Multivariate analysis of variance of the items yielded an omnibus ( [7, 163] = 8.37; p <.001), indicating that physicians and nurses perceive their teamwork climate differently. Analysis of individual items revealed that relative to physicians, nurses reported that it is difficult to speak up, disagreements are not appropriately resolved, more input into decision making is needed, and nurse input is not well received. CONCLUSIONS: Critical care physicians and nurses have discrepant attitudes about the teamwork they experience with each other. As evidenced by individual item content, this discrepancy includes suboptimal conflict resolution and interpersonal communication skills. These findings may be the result of the differences in status/authority, responsibilities, gender, training, and nursing and physician cultures.

Adult↗

PubMedDate not supplied

Evidence-based nursing practice: to infinity and beyond.

BACKGROUND: Medical errors are in the news almost daily, frequently after patients have experienced ineffective and unsafe protocols. As a result, patients and family members lose trust in the healthcare system. Nursing practice is changing almost daily with advances in nursing research and improvements in technology and practice. Reading, understanding, and managing these large amounts of information have become difficult for most nurses and organizations. METHODS: This article provides an historical background for evidence-based practice and methods for assimilating research into practice. RESULTS: Systematic reviews and other decision-making models are discussed using specific questions for establishing policy guidelines. CONCLUSION: Evidence-based practice encompasses implementing the best-known practices into the clinical setting using a scientific approach. As a result, safe, high-quality, and cost-effective care will be more likely to occur consistently.

Attitude to Health↗

PubMedDate not supplied

Modifying blood bank processes for efficiency and effectiveness: a case study.

Among the lessons to be learned in the case study is that the use of quality tools provides the opportunity for success. It will take longer than the group intends to implement change effectively. However, it is better to take smaller steps and be successful than to take giant steps and struggle or fail. Failure to communicate is often the reason that change is difficult. When staff are asked to make changes, the rationale for the change is often essential to acceptance. The quality improvement process requires documentation of goals, decision steps, implementation procedures, and monitoring outcomes. Success breeds success. Sharing the information with everyone from hospital support staff in the laboratory and maintenance department to direct patient care givers at the clinic site or the patient bedside makes everyone a part of the success.

Blood Banks↗

PubMed2005

Physicians' perspectives on caring for cognitively impaired elders.

PURPOSE: This study aims to develop an in-depth understanding of the issues important to primary care physicians in providing care to cognitively impaired elders. DESIGN AND METHODS: In-depth interviews were conducted with 20 primary care physicians. Text coded as "cognitive impairment" was retrieved and analyzed by use of grounded theory analysis techniques. RESULTS: A patient's impaired ability to provide an accurate history and to participate in self-care hindered the usual process of care, often resulting in greater medical uncertainty and feelings of inadequacy and frustration for the physician. Shifting the goal of care from "curing" the patient's illness to "caring" for the patient's quality of life was also problematic. The doctor-patient relationship changed dramatically as others became involved in care, often with attendant ethical dilemmas related to patient autonomy and the locus of decision making. Many physicians described a deep sense of loss and grief as the personhood of patients faded. The increased complexity and prominent social and emotional issues were difficult to manage in the context of the current model of practice. IMPLICATIONS: Profound changes occur in the process of care with cognitively impaired patients. The increased complexity mandates an expanded model of care that addresses the prominent psychosocial and ethical aspects of care as well as the medical ones.

Adult↗

PubMed1991

The deontological decision-making model as a bioethical tool.

Ethical decisions are difficult to handle and truly challenge everyone involved in the process. Nurses must appreciate the difficulty encountered when dealing with ethical decisions and begin their own investigations of other available decision-making models to choose one that best fits their own ethical beliefs and values.

Adult↗

PubMed2004

GPs' perceptions of the role of DEXA scanning: an exploratory study.

BACKGROUND: Current recommendation are that women with clinical indicators of low bone mineral density should be offered a DEXA (dual energy X-ray absorptiometer) scan to help assess the need for treatment, but little is known about GPs' attitudes towards DEXA scans. OBJECTIVE: Our aim was to explore GPs' beliefs about diagnosis and management of osteoporosis, including the role that DEXA scanning can play. METHODS: Semi-structured interviews with five GPs in the North Staffordshire area were used to explore how GPs make decisions about diagnosis and treatment of osteoporosis, including the use of scans and the application of potential clinical risk factors to decisions about screening and treatment. RESULTS: The decision-making process about whether and who to scan is complex and was influenced by a range of factors including issues of diagnosis, treatment, patient pressure and 'external' factors such as practice protocol and the perceived local availability of scans. CONCLUSIONS: GPs found it difficult to decide who and when to scan despite guidelines for primary care. Perceived local availability of DEXA scans is important and has implications for raising awareness.

Absorptiometry, Photon↗

PubMed1977

Interfacing national health insurance and income maintenance: why health and welfare reform go together.

The current debate on national health insurance has not given sufficient attention to the impact of various proposals upon income maintenance programs. Health and welfare benefits are difficult to coordinate and frequently work at cross purposes. Health care benefits are one of several in-kind forms of income that can affect the economic behavior and well-being of welfare recipients. As an in-kind form of income, subsidized health insurance for low income persons can undermine the objectives of public assistance, particularly the willingness to work, by making some individuals worse off when income rises. Five national health insurance proposals are analyzed to determine how each will interface with cash transfer programs. Most of these proposals perpetuate many of the benefit coordination problems that now exist with the Medicaid program. The article concludes by delineating some of the difficult policy decisions that must be made if health and welfare reforms are to be meaningful.

Aid to Families with Dependent Children↗

PubMed1991

Risk stratification and outcome assessment of the adult cardiac surgical patient.

Comparisons between institutions are already occurring, and comparisons between individual providers may also become a reality. In spite of the negative views of such comparisons, they are likely to be mandated because of pressure from health care regulators, insurers, and patients. Despite awareness of the importance of demographic variables and concurrent medical problems in influencing outcome, valid comparisons are presently difficult to conduct in the open heart surgical population. Current methods of risk stratification each have limitations. A method for risk assessment based on multivariate analysis from a large group of patients that can be prospectively validated at multiple institutions would be valuable, not only for mortality rate comparisons, but also for patient counseling, research, and hospital management uses. Caution must be applied when using risk assessment in individual patients. Physicians need to be involved in the development of such severity stratifying systems, since inclusion of inappropriate or medically irrelevant data can influence the outcome of multivariate analyses. Ongoing research and evolution of scoring systems also need to occur since therapy changes over time. It is likely that models will need to be developed for application preoperatively, at ICU admission, and for the complex, long-term patient at 7 days or beyond, in order to fully inform medical decision-making.

Adult↗

PubMed1992

Some problems with cost-benefit analysis in health care.

...Arnold's article is very ambitious. He suggests rules that could be followed in order to decide whether health care should be rationed. He notes that explicit assessments of costs and benefits using the same monetary unit are rarely used. The main reason, it seems to me, is that the method of cost-benefit analysis is relatively difficult to apply in the context of health care. Arnold does not address the difficulties that are related to his approach. Thus, my impression is that the interest of his provocative article lies more in its ability to foster a useful debate than in the methodology itself. In this brief commentary, I will merely list some of the theoretical problems that occurred to me while reading this article....

Clozapine↗

PubMed1999

Evidence-based medicine and the real world: understanding the controversy.

Controversy has surrounded the 'paradigm' of evidence-based medicine since its introduction in 1992 as a new approach to the teaching and practice of medicine. Here, we address two questions: (1) is evidence-based medicine a good thing?; and (2) why has so much controversy arisen? In addressing these questions, we propose that the discussion surrounding evidence-based medicine should no longer be about whether the application of evidence in clinical practice is a good thing, because it obviously is. Instead, the debate ought to focus on the more difficult question of how to enhance its acceptability among busy clinicians practising in the 'real world'. For the future, we optimistically anticipate an enhanced adoption of evidence-based medicine, as clinicians will become increasingly capable of efficiently accessing existing and forthcoming evidence resources.

Decision Making↗

PubMed1995

Clinical decision making during assessment for involuntary psychiatric admission.

Twenty-four clinicians (five psychiatrists, five registered nurses, and 14 counselors) participated in a psychophenomenological study of the decision-making process in assessing clients for involuntary psychiatric hospital admission. In interviews, the clinicians were asked to describe a situation in which the admission assessment was especially difficult. Analysis of the interviews identified nine essential structural elements of the decision-making process: systematic and individualized process, state-mandated criteria, investigation of alternatives, decision not made alone, intuitive reasoning, connection with the client, caution, and inability to control all contingencies.

Commitment of Persons with Psychiatric Disorders↗

PubMed2004

Results of a survey regarding irradiation of internal mammary chain in patients with breast cancer: practice is culture driven rather than evidence based.

PURPOSE: To examine the self-reported practice patterns of radiation oncologists in North America and Europe regarding radiotherapy to the internal mammary lymph node chain (IMC) in breast cancer patients. METHODS AND MATERIALS: A survey questionnaire was sent in 2001 to physician members of the American Society for Therapeutic Radiology and Oncology and European Society for Therapeutic Radiology and Oncology regarding their management of breast cancer. Respondents were asked whether they would treat the IMC in several clinical scenarios. RESULTS: A total of 435 responses were obtained from European and 702 responses from North American radiation oncologists. Respondents were increasingly likely to report IMC irradiation in scenarios with greater axillary involvement. Responses varied widely among different European regions, the United States, and Canada (p < 0.01). European respondents were more likely to treat the IMC (p < 0.01) than their North American counterparts. Academic physicians were more likely to treat the IMC than those in nonacademic positions (p < 0.01). CONCLUSION: The results of this study revealed significant international variation in attitudes regarding treatment of the IMC. The international patterns of variation mirror the divergent conclusions of studies conducted in the different regions, indicating that physicians may rely preferentially on evidence from local studies when making difficult treatment decisions. These variations in self-reported practice patterns indicate the need for greater data in this area, particularly from international cooperative trials. The cultural predispositions documented in this study are important to recognize, because they may continue to affect physician attitudes and practices, even as greater evidence accumulates.

Breast↗