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PubMed2001

Analysis of complex decision-making processes in health care: cognitive approaches to health informatics.

Decision making by health care professionals is often complicated by the need to integrate ill-structured, uncertain, and potentially conflicting information from various sources. In this paper cognitive approaches to the study of decision making are presented within the context of a variety of complex health care applications. In recent years it has become increasingly accepted that in order to build information systems that can support complex decision making it will be necessary to more fully understand human decision-making processes. Methodological approaches are described that aim to explicate the decision making and reasoning skills of subjects as they perform activities involving the processing of complex information. The paper begins by presenting the theoretical foundations for cognitive analyses of decision making, including discussion of major approaches to the study of decision making in a range of real-world domains, including medicine. Applications of cognitive approaches are then illustrated, including a description of a study in which subjects were asked to "think aloud" in providing treatment decisions for complex medical cases. The resulting protocols were then analyzed for subjects' use of decision strategies and problems in reasoning. Extension of cognitive approaches to the study of group decision-making processes is also described. Recent approaches are discussed which borrow from advances in the study of human-computer interaction and which utilize video analysis of decision-making activities involving information technologies. Using these approaches it has been found that health care information systems, such as computerized patient record systems, may have inadvertent effects on human decision making. Implications of a cognitive approach to improving our understanding of complex decision making are discussed in the context of developing appropriate computer-based decision support for both individuals and groups.

Cognitive Science↗

PubMed1999

A consensus-based approach to providing palliative care to patients who lack decision-making capacity. ACP-ASIM End-of-Life Care Consensus Panel. American College of Physicians-American Society of Internal Medicine.

Making palliative care decisions for a patient who lacks decision-making capacity presents several challenges. Other people, such as family and caregivers, must choose for the patient. The goals and values of these decision makers may conflict with those of each other and with those of the patient, who now lacks the capacity to participate in the decision. This paper presents a case study of a patient with severe Alzheimer disease who has two common clinical problems: neurogenic dysphagia and aspiration pneumonia. The case study describes a consensus-based decision-making strategy that keeps what is known about the patient's wishes and values in the foreground but also expects guidance from the physician and elicits input from family members and other people who care for and have knowledge about the patient. The steps of this process, including key clinical prompts and potential transition statements, are outlined and described. The overall goal of the case commentary is to demonstrate that physicians can guide a highly emotional and personal process in a structured manner that has meaning for the patient, family, physician, and other caregivers.

Advance Care Planning↗

PubMed1997

How consumers and policymakers can use systematic reviews for decision making.

Systematic reviews can be a very useful decision-making tool because they objectively summarize large amounts of information, identify gaps in medical research, and identify beneficial or harmful interventions. Consumers can use systematic reviews to help them make health care decisions. Policymakers can use systematic reviews to help them make decisions about what types of health care to provide. Despite the potential value of systematic reviews, little evidence of their direct impact on the decisions made by consumers and policymakers is available. We discuss strategies for optimizing the use of systematic reviews by increasing the awareness and identification of reviews, learning to critically evaluate the findings of reviews, and overcoming barriers to the incorporation of reviews into the decision-making process. In addition, the participation of consumers and policymakers in the design, conduct, and reporting of systematic reviews can help to produce reviews that are relevant and understandable to target audiences. Because decisions that involve health care policies and issues are complex processes in which information (such as that provided by systematic reviews) plays only a part, strategies for increasing the use of systematic reviews should be evaluated for their usefulness in the decision-making process.

Decision Making↗

PubMed2002

Decision making in perioperative transfusion.

Clinical decision making in transfusion medicine has received greater attention in recent years driven by concern about the potential hazards, especially since the recognition that HIV can be transmitted by homologous blood transfusion. These concerns about the risks of homologous transfusion has precipitated interest in the appropriateness of many transfusions and in the decision making processes in transfusion medicine. There has been increasing expenditure on the blood supply side to address the real or perceived potential infectious hazards. This has at times been to the detriment of the patient demand side of the homologous donor blood chain. This imbalance is now being addressed with the development of evidence based clinical guidelines for individual blood components, transfusion monitoring systems and quality assurance programmes. In this review of the process of clinical decision making in transfusion medicine and the factors involved in the ensuring a patient receives a safe and effect transfusion are addressed. The responsibilities of the patient's clinical carers are emphasised.

Blood Transfusion↗

PubMed1999

Acceptable regret in medical decision making.

When faced with medical decisions involving uncertain outcomes, the principles of decision theory hold that we should select the option with the highest expected utility to maximize health over time. Whether a decision proves right or wrong can be learned only in retrospect, when it may become apparent that another course of action would have been preferable. This realization may bring a sense of loss, or regret. When anticipated regret is compelling, a decision maker may choose to violate expected utility theory to avoid regret. We formulate a concept of acceptable regret in medical decision making that explicitly introduces the patient's attitude toward loss of health due to a mistaken decision into decision making. In most cases, minimizing expected regret results in the same decision as maximizing expected utility. However, when acceptable regret is taken into consideration, the threshold probability below which we can comfortably withhold treatment is a function only of the net benefit of the treatment, and the threshold probability above which we can comfortably administer the treatment depends only on the magnitude of the risks associated with the therapy. By considering acceptable regret, we develop new conceptual relations that can help decide whether treatment should be withheld or administered, especially when the diagnosis is uncertain. This may be particularly beneficial in deciding what constitutes futile medical care.

Brain Ischemia↗

PubMed1983

Decision-making among emergency room residents: preliminary observations and a decision model.

Emergency room residents face a range of clinical decisions and often call on senior residents or faculty members for help. The individual clinical decision process has frequently been analyzed, but little attention has been given to the social process in clinical decision-making. Based on data from interviews and over 100 hours of direct observation at two large urban general hospitals with busy emergency rooms staffed by medical and surgical residents, the authors suggest there are five basic decision situations. In each situation, the residents appeared to follow implicit decision patterns about involving other medical and surgical staff in the final clinical decision. The decision situations are nonacute, routine acute, nonroutine acute, multispecialty acute, and crisis. These situations call for individual, consultive, or consensual patterns in making decisions. The consequences of these patterns are explored. Improving residents' decision-making should contribute to improved understanding of the resident's role, better resident supervision, and better emergency room functioning.

Critical Care↗

PubMed2006

Predicting preferences: a neglected aspect of shared decision-making.

In recent years, shared decision-making between patients and doctors regarding choice of treatment has become an issue of priority. Although patients' preferences lie at the core of the literature on shared decision-making, there has not been any attempt so far to link the concept of shared decision-making with the extensive behavioural literature on people's self-predictions of their future preferences. The aim of the present review is to provide this link. First, we summarize behavioural research that suggests that people mispredict their future preferences and feelings. Secondly, we provide the main psychological accounts for people's mispredictions. Thirdly, we suggest three main empirical questions for inclusion in a programme aimed at enriching our understanding of shared decision-making and improving the procedures used for putting it into practice.

Decision Making↗

PubMed2000

Expert decision making in relation to unanticipated blood glucose levels.

How people (N = 22) with long-standing Type I diabetes make everyday self-care decisions, specifically in regard to unanticipated blood glucose levels (UBGLs) was investigated using grounded theory. Participants differentiated between decisions made in familiar and typical situations and those made in novel situations. Decisions made in familiar situations were straightforward, arising from a confident appraisal of the cause of the UBGL. The primary focus of decision making in response to an UBGL in familiar situations was the decision about the course of action. The focus in unfamiliar situations was the appraisal of the cause of the UBGL. It was characterized by the participants' lack of confidence and by a non-linear progression in which the individual retraced previous phases of the decision-making process or proceeded to tangential steps. Participants matched the features of previously encountered situations to construct a story that explained the events in order to generate some plausible hypotheses. A number of contextual and mediating variables were identified as influencing the decision-making process and the decisions they made. The findings of this research demonstrate that the decision maker's familiarity with the situation influences the nature of the decision-making processes that are used.

Adult↗

PubMed2005

Reimbursement decisions in health policy--extending our understanding of the elements of decision-making.

Previous theoretical and empirical work on health policy decisions about reimbursement focuses on specific rationales such as effectiveness, economic considerations and equal access for equal needs. As reimbursement decisions take place in a social and political context we propose that the analysis of decision-making should incorporate factors, which go beyond those commonly discussed. As an example we chose three health technologies (sildenafil, rivastigmine and statins) to investigate how decisions about reimbursement of medicines are made in the United Kingdom National Health Service and what factors influence these decisions. From face-to-face, in-depth interviews with a purposive sample of 20 regional and national policy makers and stakeholders we identified two dimensions of decision-making, which extend beyond the rationales conventionally cited. The first dimension relates to the role of 'subjectivity' or 'the personal' in the decisions, including personal experiences of the condition and excitement about the novelty or potential benefit of the technology-these factors affect what counts as evidence, or how evidence is interpreted, in practice. The second dimension relates to the social and political function of decision-making and broadens what counts as the relevant ends of decision-making to include such things as maintaining relationships, avoiding organisational burden, generating politically and legally defensible decisions and demonstrating the willingness to care. More importantly, we will argue that these factors should not be treated as contaminants of an otherwise rational decision-making. On the contrary we suggest that they seem relevant, reasonable and also of substantial importance in considering in decision-making. Complementing the analysis of decision-making about reimbursement by incorporating these factors could increase our understanding and potentially improve decision-making.

Decision Making, Organizational↗

PubMed2003

Cancer patients' decision-making regarding treatment and nursing care.

BACKGROUND: Patient participation in decision-making has produced many debates among health care professionals. The research evidence concerning patient participation in decision-making is not clear, and shows conflicting results. AIMS: To identify to what extent cancer patients participate in decision-making and to what extent background characteristics, information obtained and relationships with staff explain cancer patients' participation in decision-making. DESIGN/METHOD: A structured questionnaire based on earlier research and qualitative interviews was designed. The questionnaire was completed by 273 cancer patients who were inpatients or outpatients in haematology, oncology clinics and other clinics at two university hospitals in Finland. The questionnaire consisted of five areas: (1) demographic data; (2) mood; (3) information obtained; (4) relationships with staff; and (5) decision-making. The scale used was ordinal. The data were analysed using descriptive statistics and nonparametric tests such as Mann-Whitney U-test, Kruskall-Wallis, and Wilcoxon matched-pairs signed-rank tests. RESULTS: The majority of the respondents perceived that they had participated in making treatment decisions at least to some extent, together with the physician. In decision-making about nursing care, respondents felt that they had participated most in decisions about personal hygiene, rest and sleep. Respondents' physical condition, marital status, age and time since diagnosis, as well as information obtained and relationships with staff, were associated with participation in decision-making. CONCLUSION: This study provided evidence that some cancer patients participated in decision-making and felt participation to be important. Staff played a crucial role in patient participation in decision-making. In future, staff should work to improve cancer patients' opportunities to participate in decision-making in order that those who wish to be involved can do so.

Adolescent↗

PubMed1991

Strategies for improving dialysis decision making.

It is important that every professional involved with guiding ESRD patients through the maze of dialysis decision making critically analyze his or her own behaviors, possible biases and thought processes influencing discussions with patients. Health care professionals need to continue to strive to improve their skills for assuring optimal assistance to their patients in making decisions about the best types of treatments for them. In this era of evermore challenging patients and technologies, the skills for informing patients and assisting them with effective decision making about issues such as medical management, dialysis, transplantation or treatment termination are vital for assuring quality care.

Counseling↗

PubMedDate not supplied

A survey of gynecologists' attitudes regarding decision making in the management of non-cancerous conditions that frequently result in hysterectomy.

OBJECTIVE: To explore attitudes of practicing gynecologists regarding making treatment decisions for patients with benign uterine conditions frequently treated with hysterectomy. DESIGN: Mailed survey. PARTICIPANTS: 66 gynecologists practicing in the Greater Rochester, New York, area. INTERVENTIONS: After reading brief vignettes, respondents indicated how they would treat patients with chronic pelvic pain, uterine leiomyomas, and abnormal uterine bleeding, and rated the importance of 24 considerations in making their treatment decisions on a 1-to-5 scale ranging from not important to extremely important. RESULTS: Fourteen considerations (58%) had group mean importance ratings higher than 3. Exploratory factor analysis identified four factors that accounted for 96% of the variance. Respondent gender, practice type, graduation from a U.S. vs a non-U.S. medical school, and opinion regarding roles of doctor and patient in making treatment decisions were associated with significant differences in factor scores. CONCLUSIONS: Gynecologists' attitudes toward hysterectomy decisions are complex, multifactorial, and variable. Depending on the extent to which these attitudes affect treatment decisions, differences among gynecologists in their clinical decision making processes could account for a substantial amount of the regional variability in hysterectomy use.

Aged↗

PubMed2004

Shared decision-making in nursing education.

Shared decision-making is an effective management strategy that may have positive implications for nurse educators facing curricular and course delivery issues. Use of shared or participative decision-making recognizes that decisions made for the overall good of the organization should include those integrally involved, i.e., faculty, students and administration. Ultimately, effective student learning should be the outcome of decisions related to curricular and content delivery. In this anecdotal paper, the authors present shared decision-making (SDM) as a management strategy that may be effectively utilized in a range of situations in educational settings. An exemplar is presented regarding changes in course delivery methods at two sister schools of nursing. Strategies to promote successful implementation, as well as challenges in initiating SDM, are discussed. The information presented in this paper can benefit nurse educators by offering a collaborative approach to the issues of evolving nursing curricula and content delivery.

Canada↗

PubMedDate not supplied

Decision making in a multidisciplinary cancer team: does team discussion result in better quality decisions?

To establish whether treatment recommendations made by clinicians concur with the best outcomes predicted from their prognostic estimates and whether team discussion improves the quality or outcome of their decision making, the authors studied real-time decision making by a lung cancer team. Clinicians completed pre- and postdiscussion questionnaires for 50 newly diagnosed patients. For each patient/doctor pairing, a decision model determined the expected patient outcomes from the clinician's prognostic estimates. The difference between the expected utility of the recommended treatment and the maximum utility derived from the clinician's predictions of the outcomes (the net utility loss) following all potential treatment modalities was calculated as an indicator of quality of the decision. The proportion of treatment decisions changed by the multidisciplinary team discussion was also calculated. Insofar as the change in net utility loss brought about by multidisciplinary team discussion was not significantly different from zero, team discussion did not improve the quality of decision making overall. However, given the modest power of the study, these findings must be interpreted with caution. In only 23 of 87 instances (26%) in which an individual specialist's initial treatment preference differed from the final group judgment did the specialist finally concur with the group treatment choice after discussion. This study does not support the theory that team discussion improves decision making by closing a knowledge gap.

Aged↗

PubMed1994

An exploratory study into a methodology for the examination of decision making by nurses in the clinical area.

This study was undertaken to explore decision making in the clinical area and why it is that some nurses make seemingly irrational decisions. In the past simulations and decision frames have been used by psychologists and clinician researchers to examine decision making, although none of these methods were reported to have been used in the clinical area. In the study 11 subjects were observed in the clinical area for 2 hours each and a total of 18 decisions were made by these subjects. Each observation was followed by an interview in which the decisions were further explored and three simulations and four decision framed questions were also employed as comparative tools. The subjects were also asked about their decision making strategies. The method of using observation to collect data was effective and the effect of experience was highlighted as one of the main factors influencing decision making. The other methods proved useful as tools to examine particular aspects of decision making. The effect of experience on decision making has wide reaching effects on future nurse education, as well as having professional implications in the area of autonomy, accountability and responsibility. Further research in this area is then recommended.

Clinical Nursing Research↗

PubMed1991

Physician participation in hospital strategic decision making: the effect of hospital strategy and decision content.

An exploratory study examined variation in the participation of physicians in hospital strategic decision making as a function of (1) strategic decision content or (2) hospital strategy, or both. The findings revealed that who participates is a function of decision content while how physicians participate is a function of decision content and the interaction of decision content and hospital strategy.

Decision Making, Organizational↗

PubMedDate not supplied

Technology assessment and coverage decision making.

In the health care decision-making cascade, technology assessment renders the initial evaluative judgement about the contribution of a technology to patient care. As such, it has a major impact on coverage policy, clinical guidelines and utilization management. This impact necessitates that technology assessment have a scientific, defensible process. There are four basic components of a scientific, defensible process for both clinical and coverage decision making. These are: 1. Outcomes data that are derived preferably from controlled clinical trials and that support the safety and effectiveness of a specific indication 2. Evidence of acceptance by the practicing medical community of specific applications of a technology 3. A rigorous, evaluative process that synthesizes and analyzes outcomes data and expert opinion 4. Consistency in the use of terminology, as it is translated from the technology assessment process to coverage policy The process must be designed to assure scientific and methodological defensibility. Also, it must be designed to facilitate and substantiate the medical and coverage decision-making processes. Finally, it must be designed to enable and expedite the implementation of the managed care philosophy (i.e., outcomes-based decision making) within a particular health plan.

Cost-Benefit Analysis↗

PubMed1985

Non-patient decision-making in medicine: the eclipse of altruism.

Despite its virtues, lay decision-making in medicine shares with professional decision-making a disturbing common feature, reflected both in formal policies prohibiting high-risk research and in informal policies favoring treatment decisions made when a crisis or change of status occurs, often late in a downhill course. By discouraging patient decision-making but requiring dedication to the patient's interests by those who make decisions on the patient's behalf, such practices tend to preclude altruistic choice on the part of the patient. This eclipse is to be regretted not just because widescale altruism has the capacity to provide important social goods and correct injustices in distribution, but for intrinsic reasons as well. It is argued that preserving the possibility of altruism obliges patients--and future patients--to make decisions about dying and other medical matters in advance, thus avoiding that displacement of decision-making onto lay and professional second parties which results in altruism's eclipse.

Altruism↗