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Results for “Making Difficult Health Care Decisions”

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PubMed1998

Hypertension in the elderly: attitudes of British patients and general practitioners.

The perceptions of patients and GPs of the risk of stroke in treated and untreated elderly hypertensives, and their attitudes towards anti-hypertensive therapy were examined. To explore attitudes of patients to the management of hypertension a qualitative approach was used, employing semi-structured interviews, with subsequent thematic analysis of the transcriptions. A questionnaire study of GPs' attitudes to the same subject was also conducted. The elderly (n = 75) greatly overestimate the risks of hypertension and the benefits of treatment. Most would accept anti-hypertensive therapy despite being informed of the true risks, citing confidence in their doctor as the major determinant in their decision. GPs (n = 121) were well informed of the risks and benefits, but less than half adhere to current guidelines. GPs should be aware how much the elderly overestimate the risks of hypertension and the benefits of its treatment. When considering treating hypertension in this group, patient contributions in the treatment decision-making process should be actively encouraged, especially as many elderly hold a deferential attitude towards their doctor. Patients should be informed of the risks of their disease and the benefits of treatment in terms they understand. The use of visual aids helps patients to grasp the difficult concepts of risk and benefit.

Adolescent↗

PubMed2000

Needs for oral care among people with intellectual disability not in contact with Community Dental Services.

Previous research has found an unmet need for oral care among people with intellectual disability. The key factors which have been indicated are low expectations, fear of treatment, lack of awareness among carers and problems in accessing dental services. The withdrawal of many general dental practitioners (GDPs) from the National Health Service (NHS) may have exacerbated the latter problem in the UK. The aims of the present study were: (1) to assess the extent of unmet clinical needs in a group of adults with intellectual disability living in the community who were not in contact with the Community Dental Service (CDS); and (2) to explore their perceptions of teeth and contact with dentists to identify how oral care can be improved. Interviews were completed with subjects and/or carers and a dental examination was completed. There were higher levels of untreated caries (decay), and gingival or periodontal (gum) problems among the sample than in either the general population, or in a previous survey of CDS users at day centres and residential facilities. The subjects were largely unaware of dental problems, and used the appearance and absence of pain to judge the condition of their teeth. They depended greatly on their carers for decision-making and support with regard to visiting the dentist and tooth-brushing. Carers requested training in oral care and the use of dental services, and support in dealing with clients who have problems tolerating tooth-brushing. The subjects had experienced a wide variation in the treatment provided by dentists, but had not found it difficult to access a dentist despite recent reductions in the availability of NHS dental care. They expressed a particular need for a good relationship with their dentist and for their dentist to have personal skills in relating to people with an intellectual disability. Dental screening checks and oral care training for carers should be made easily available. Care plans should include tooth-brushing and dietary issues for all clients who have their own natural teeth. There are significant training issues for dentists in developing personal skills in total communication, disability awareness and attitudes which value people with intellectual disability.

Adult↗

PubMed1998

The British Paediatric Surveillance Unit--a pioneering method for investigating the less common disorders of childhood. Report of a seminar held in June 1995.

The British Paediatric Surveillance Unit (BPSU) of the Royal College of Paediatrics and Child Health is an 'active' case reporting scheme set up in 1986 to facilitate the investigation of uncommon childhood conditions of public health and clinical importance in the UK and Ireland. Its methodology involves the monthly mailing of a card containing a menu of up to 12 reportable conditions to all clinically active paediatricians in the British Isles. Respondents either indicate any cases seen in the past month or make a nil return. The BPSU forwards details of respondents reporting cases to the investigators, who when obtain information from the clinician. The menu changes from time to time and studies undergo a rigorous selection process. In 1995, the BPSU held an international seminar to review lessons learned during its first decade which would improve and develop surveillance of paediatric disorders. Over the 9 years to mid-1995 a total of 34 studies took place (25 completed, nine still in progress) with a high respondent response rate (e.g. 90% in 1994). Underascertainment had been addressed by seeking, in parallel, other sources of cases, e.g. death registrations, laboratory reports, other relevant clinical specialists, and by use of capture-recapture techniques. Other specialties and countries have since followed the BPSU example providing opportunity for multispeciality and international studies. The latter were valuable, but required careful planning to standardize case definitions and laboratory techniques, otherwise geographical differences in the incidence of study disorders were difficult to interpret. The BPSU has facilitated studies which increased knowledge about a range of disorders and informed national policy decisions. It also increased diagnostic awareness and showed itself able to respond to public health emergencies. Its emulation in further countries will have similar benefits.

Adolescent↗

PubMed1998

Data warehousing as a healthcare business solution.

Because of the trend toward consolidation in the healthcare field, many organizations have massive amounts of data stored in various information systems organizationwide, but access to the data by end users may be difficult. Healthcare organizations are being pressured to provide managers easy access to the data needed for critical decision making. One solution many organizations are turning to is implementing decision-support data warehouses. A data warehouse instantly delivers information directly to end users, freeing healthcare information systems staff for strategic operations. If designed appropriately, data warehouses can be a cost-effective tool for business analysis and decision support.

Cost-Benefit Analysis↗

PubMedDate not supplied

Neonatologists and bioethics after Baby Doe.

The use of hospital ethics committees or infant care review committees has been recommended for difficult decision making. In a survey of military and civilian neonatologists, ethics committees had been established in 27 of their 28 hospitals and fewer than 50% had infant care review committees. Despite the frequently of potential cases for committee review, they were seldom consulted. Inquiry into the educational background of respondents revealed that at least 62% of neonatologists had received ethics education during their professional careers. Most made difficult decisions in conjunction with parents or used a multidisciplinary patient care conference. The use of these conferences antedated any federal regulations. Sixty-seven percent indicated that the Baby Doe regulations had affected neither their thinking about ethical issues nor their practice. In 13 different hypothetical cases in delivery room, intensive care nursery, and long-term care settings, the provision of comfort care, limited care, or withdrawal of support was noted by a sizable percentage of neonatologists; exceptions included meningomyelocele and trisomy 21. The need for ethics committee input in decision making for neonates is questionable.

Attitude of Health Personnel↗

PubMedDate not supplied

Analysis of powerlessness in nursing work.

Despite the plethora of articles on work environment and nursing power in the recent nursing literature, we have yet to improve nurses' experience of work in any significant way. In fact, as hospital budgets come increasingly under attack in the name of health care reform, nursing work is becoming even more demanding and, to many, less satisfying This article describes the experience of powerlessness by a sample of hospital staff nurses in British Columbia. It analyses the themes which characterize powerless work situations and explores the impact of these on nurses. It suggests some ways of bringing about change in these circumstances of work. The article intends to illuminate, for those who care to understand, the complexity and often insurmountable challenges that nurses encounter in the course of their nursing work. It urges us to create opportunities to make the increasingly difficult and frustrating circumstances of nursing work visible to key decision makers.

Decision Making, Organizational↗

PubMedDate not supplied

From survival to success. It takes more than theory.

Health care does not always attract change agents. As a result, norms, values, and rules become ingrained. Attempting to change this is difficult. This article will discuss how unique and personal skill sets of a leader complement elements of traditional change theory, resulting in moving organizations from minimal existence to national recognition.

Attitude of Health Personnel↗

PubMed2006

Professional liability issues and practice patterns of obstetric providers in Washington State.

OBJECTIVE: To describe recent changes in obstetric practice patterns and liability insurance premium costs and their consequences to Washington State obstetric providers (obstetrician-gynecologists, family physicians, certified nurse midwives, licensed midwives). METHODS: All obstetrician-gynecologists, rural family physicians, certified nurse midwives, licensed midwives, and a simple random sample of urban family physicians were surveyed about demographic and practice characteristics, liability insurance characteristics, practice changes and limitations due to liability insurance issues, obstetric practices, and obstetric practice environment changes. RESULTS: Fewer family physicians provide obstetric services than obstetrician-gynecologists, certified nurse midwives, and licensed midwives. Mean liability insurance premiums for obstetric providers increased by 61% for obstetrician-gynecologists, 75% for family physicians, 84% for certified nurse midwives, and 34% for licensed midwives from 2002 to 2004. Providers' most common monetary responses to liability insurance issues were to reduce compensation and to raise cash through loans and liquidating assets. In the 2 years of markedly increased premiums, obstetrician-gynecologists reported increasing their cesarean rates, their obstetric consultation rates, and the number of deliveries. They reported decreasing high-risk obstetric procedures during that same period. CONCLUSION: Liability insurance premiums rose dramatically from 2002 to 2004 for Washington's obstetric providers, leading many to make difficult financial decisions. Many obstetric providers reported a variety of practice changes during that interval. Although this study's results do not document an impending exodus of providers from obstetric practice, rural areas are most vulnerable because family physicians provide the majority of rural obstetric care and are less likely to practice obstetrics. LEVEL OF EVIDENCE: III.

Adult↗

PubMed1999

Complementary therapies and cancer care: an overview.

The use of complementary therapies by patients with cancer is increasingly common, despite limited evidence for their efficacy and safety. The widespread use of complementary therapies has major implications for research and practice. In this paper, we provide an overview of the current state of knowledge regarding issues related to the use of complementary therapies by patients with cancer. So far, complementary therapies have not been defined very well, which makes it difficult to assess the precise extent of their use. The difference in philosophy underlying conventional and complementary treatments appears to contribute to the attractiveness of complementary therapies. Conventional medical practitioners are beginning to recognize the importance of many of the elements of this philosophy, which is evidenced in the patient-centered model. Explaining how patients with cancer make the decision to use complementary therapies has been the subject of many studies. However, as yet, no formal theory of decision making has been developed. Communication between patients and physicians about complementary therapies is an important part of the patients' decision-making process. Many gaps can be identified in knowledge of complementary therapy use by patients with cancer. Not only is there a need to increase knowledge by conducting more research and improving the research infrastructure, but attention should also be paid to information dissemination, education, and planning and development of health policies.

Communication↗

PubMed2001

Suffering in deference: a focus group study of older cardiac patients' preferences for treatment and perceptions of risk.

OBJECTIVES: To explore older people's experiences of health care in relation to their medical condition (ischaemic heart disease), their understanding of health risks, treatment preferences, and the impact of different treatments on their quality of life. DESIGN: Qualitative study based on five focus groups. SETTING: Five local heart support groups across London. PARTICIPANTS: 38 patients aged 56 and over who were members of local heart support groups, diagnosed with ischaemic heart disease. MAIN OUTCOME MEASURE: Analysis of patients' narratives to identify key themes and issues using the framework method of qualitative data analysis. RESULTS: Cardiac patients would prefer to follow the cardiologist's recommendation for treatment, based on their medical expertise. If offered a choice, many said they would prefer to take medication, at least initially, as they would rather not undergo surgery. However, they accepted that, depending on their medical condition, they might not have a choice. Other factors that participants said affected their choice of treatments included their state of health, treatment outcomes, families' feelings, their age, and the previous number of operations they had undergone. They found it difficult to discuss risk in terms of numbers; most felt that a 3% risk of death from surgery was low. Instead, they discussed risk in terms of likelihood of treatment restoring quality of life. Patients expressed the fear that medication was not a cure and that surgical revascularisation is a traumatic experience that does not necessarily last forever. Participants felt that they needed further information on the impact of surgery and medication to make a more informed choice. Other barriers they felt they had faced in being treated were problems in accessing cardiologists and age discrimination. CONCLUSION: It was apparent from these focus groups that few patients were involved in medical decision making about their treatment. Most preferred the doctor to make the decision and did want to be involved. Despite their experiences as cardiac patients, they required much more information about treatment options for their condition before being able to make informed choices, where appropriate. Improved access to specialist care (cardiologists) and equal treatment by age are also required before patients' preferences can be elicited in practice.

Aged↗

PubMed2000

Clinical trials of cost effectiveness in technology evaluation.

This article discusses models of efficacy, design of clinical trials and the role of mathematical modeling in diagnostic technology evaluation and determination of cost-effectiveness. A multi-tiered model of efficacy, which views diagnostic imaging as part of a global process of patient management and outcome, has been described. The first tier involves imaging efficacy, which must be determined by clinical trial. Direct comparison of new and established modalities in a single study population has major advantages over randomized controlled trials, which are extremely costly and time-consuming and are not appropriate for most evaluations of diagnostic modalities. Selection of patients for inclusion in the trial, interpretation and verification of results, and determination of a reference standard are all possible sources of bias, which need to be identified and controlled. Decision analysis modeling can be used to assess diagnostic, therapeutic, patient-outcome and cost efficacy, once imaging efficacy has been evaluated by clinical trial. Decision analysis is easier and less expensive to perform than clinical trials, and results are easily generalizable to other settings. Disadvantages arise from the nondescriptive nature of modeling and lack of transparency, which make it difficult to evaluate the appropriateness of decision tree structures and input data. Modeling is an unavoidable fact of life in technology evaluation, since the resources that would be required for full evaluation of imaging modalities by clinical trial are not available.

Bias↗

PubMed2001

The longitudinal primary care clerkship at Harvard Medical School.

The primary care clerkship (PCC) at Harvard Medical School was established in 1997. The goals are to provide students with longitudinal experiences with patients and to include modern themes in the curriculum: managing illness and clinical relationships over time; finding the best available answers to clinical questions; preventing illness and promoting health; dealing with clinical uncertainty; getting the best outcomes with available resources; working in a health care team; and sharing decision making with patients. The PCC, a required course in the clinical years, meets one afternoon a week for nine months. Students spend three afternoons per month in primary care practices, where they see three to five patients per session and follow at least one patient ("longitudinal patient") over time. Classroom sessions, in both large- and small-group formats, promote a common educational philosophy and experience, and reinforce habits of problem-based learning established in the preclinical years. The students rated 74% of their preceptors excellent, especially praising their ability to facilitate and support good interpersonal relationships with patients, their ability to encourage students' independent evaluation of patients (as opposed to shadowing), and their enthusiasm for teaching. Students saw their longitudinal patients a mean of 4.8 times; 83% saw their patients at least three times. The PCC complements the curriculum of block clerkships in hospitals, and because the two are offered concurrently, students are required to come to terms with two substantially different cultures within medicine. Other medical schools are beginning to develop longitudinal clerkships to ensure that students have essential educational experiences that are difficult to achieve in block, hospital-based clerkships.

Attitude of Health Personnel↗

PubMed2002

Consumer-driven, patient-centered health care in the age of electronic information.

Americans are turning in increasing numbers to the Internet for information related to their health. Access to information that was previously difficult, if not impossible, for consumers to obtain has helped drive a shift in traditional roles for patients and physicians. Technology has made possible additional avenues for communication that can enhance new relationships. Ample opportunities exist for librarians to participate in a collaborative practice role, helping to serve the needs of both consumers and physicians as consumer-driven, patient-centered health care evolves to meet its full potential.

Access to Information↗

PubMed2002

Ethics in perioperative practice--accountability and responsibility.

Though often difficult, ethical decision making is necessary when caring for surgical patients. Perioperative nurses have to recognize ethical dilemmas and 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 third of a nine-part series that will help perioperative nurses relate the ANA code to their own area of practice, the author looks at the fourth provision statement, which addresses nurses' accountability and responsibility.

Adult↗

PubMed2001

Evaluation of legal competency in patients with frontal lobe injury.

In recent decades, the relationship of the patients and health care provider has evolved into an informed, collaborative effort to recover from illness. The movement of patients from passive to active participants in treatment planning has caused an increasing need for patients to be competent, to successfully perform often complex analysis of available options, risks inherent in these options, and potential benefits of choosing one course of action over another. While competency is determined by the courts, the courts rely heavily on the opinions of health care providers with expertise regarding mental and emotional processes. Thus, knowledge of both legal standards of competency and of the mental and emotional processes which support competency have become increasingly important. Competency has been held to be comprised of perception and comprehension of a relevant body of information; memory and recall of relevant information well enough to support further mental evaluation of the information; the capacity to identify personal options implicit in the information and to logically deliberate among the available options based on relative potential risks and the benefits; and the capacity to make an enduring decision based on prior logical deliberation. The assessment of competency is even more difficult in the patient with executive dysfunction. Neuropsychological assessment, which is traditionally used to assess cognitive functioning, has not been as helpful in the quantification of the patient's ability to solve problems in a logical manner. This paper will outline the requisite steps in assessing competency and review the current data available on the neuropsychological assessment of frontal lobe dysfunction in competency determination.

Brain Injuries↗

PubMed1999

Practice guidelines and tort reform: the legal system confronts the technocratic wish.

Recent scholarly writing has argued that the advent of managed care within the health policy arena can be seen as a contemporary manifestation of a broader set of concerns focusing on how objective decision procedures become politically legitimated--what one recent commentator has characterized as a faith in the technocratic wish. In the 1990s, this faith in objective decision procedures has manifested itself through the emergence of outcomes assessment and the development of practice guidelines. Notably, a few states have sought to couple the practice guidelines movement with tort reform by enacting demonstration projects permitting physicians to introduce evidence that they followed practice guidelines as an affirmative defense. In this article, I argue that even though the introduction of practice guidelines may promote the policy objective of cost-effectiveness in the delivery of health care services, their use to establish culpability in actual cases may be more difficult because the structure of legal reasoning focuses on the particular facts in the case at hand rather than appealing to abstract decision procedures. By highlighting the potential difficulties of invoking practice guidelines in the adjudication of actual malpractice cases, I demonstrate how a process of ongoing political negotiation will be necessary if the technocratic faith in practice guidelines is to become justified in reality.

Cost-Benefit Analysis↗

PubMed2004

Long-term care counselor: an electronic decision-support tool.

With the American population aging at a steady pace, the need to help individuals, families, and aging/health care professionals in making often-difficult long-term care decisions is increasing. Finding accurate, impartial information is also critically important, especially information that is personalized to the individual rather than for the general public. The Long-Term Care Counselor (LTCC) is a free and confidential, web-based, decision-support tool developed by The National Council on the Aging (NCOA) to meet this particular need. It is part of the Centers for Medicare and Medicaid Service's (CMS) long-term care information initiative and is found via the official Medicare website at http://www.medicare.gov/ longtermcare/static/ltccounselor.asp. The LTCC helps individuals, caregivers, and professionals to find information relevant to particular circumstances based on the age, health, level of activity, finances, or personal preferences of the person.

Aged↗

PubMed2005

[Evidence-based medicine: a discussion of the most frequently occurring criticisms].

Since the introduction of evidence-based medicine (EBM) into the field of health care in the early nineties some major criticisms have appeared in scientific literature. One of the most commonly heard objections to EBM is loss of therapeutic freedom. However even with the advent of EBM the physician continues to look for solutions that are tailored to the patient. The available evidence is often inadequate, there are many inconsistencies and contradictions in the research material and the published outcomes are distorted by publication bias. There is resistance to the opinion that randomized clinical trials (RCTs) provide the best foundations on which to build clinical policies. There must always be room for views expressed in other types of study. EBM is primarily for academics and does not take clinical expertise into account. However as the results of scientific research are becoming increasingly available to a wider public, patients are able to challenge the decisions made by their health-care practitioners and push them to provide the motivation for their decisions. Many health-care practitioners have commented that they always have to take the results of scientific research into account. One strength of EBM in this is the transparent manner in which the overview of the literature develops and the systematic approach to results from scientific study. After all, there is insufficient evidence that the EBM process works effectively and that it therefore improves patient care. It is true to say that patients who receive treatment of which the efficacy has been proven experience better treatment results than other patients. Setting up a definitive randomized study to answer this question would be difficult if not impossible. EBM is an aid to support clinical decision making. The development of principles on which to base this way of thinking and acting and the quest for suitable research designs and the most objective research results in order to be able to answer all the questions posed by caregivers, is not yet complete. EBM is just one of the weapons in the armoury of the caregiver in the battle for the optimal provision.

Decision Making↗