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PubMed1981

[Palliative nephrostomy in kidney congestion due to kidney neoplasms. Ethical aspects in decision making].

The decision to perform a percutaneous nephrostomy in a tumor patient with bilateral ureteral obstruction or not, must be taken very carefully and critically, according to the individual prognosis. It should be stressed that under certain circumstances it thoroughly corresponds with our ethical rules and the law to renounce the technical solution in favour of a humane dying.

Attitude to Death↗

PubMed1993

Decision field theory: a dynamic-cognitive approach to decision making in an uncertain environment.

Decision field theory provides for a mathematical foundation leading to a dynamic, stochastic theory of decision behavior in an uncertain environment. This theory is used to explain (a) violations of stochastic dominance, (b) violations of strong stochastic transitivity, (c) violations of independence between alternatives, (d) serial position effects on preference, (e) speed-accuracy trade-off effects in decision making, (f) the inverse relation between choice probability and decision time, (g) changes in the direction of preference under time pressure, (h) slower decision times for avoidance as compared with approach conflicts, and (i) preference reversals between choice and selling price measures of preference. The proposed theory is compared with 4 other theories of decision making under uncertainty.

Decision Making↗

PubMed2004

Informed decision making: what is its role in cancer screening?

Interest in informed decision making (IDM) has grown in recent years. Greater patient involvement in decision making is consistent with recommendations to improve health care quality. This report provides an overview of IDM; clarifies the differences between IDM, shared decision making (SDM), and informed consent; and reviews the evidence to date about IDM for cancer screening. The authors also make recommendations for research. We define IDM as occurring when an individual understands the disease or condition being addressed and comprehends what the clinical service involves, including its benefits, risks, limitations, alternatives, and uncertainties; has considered his or her preferences and makes a decision consistent with them; and believes he or she has participated in decision making at the level desired. IDM interventions are used to facilitate informed decisions. The authors reviewed the evidence to date for IDM and cancer screening based primarily on published meta-analyses and a recent report for the Centers for Disease Control and Prevention's Guide to Community Preventive Services. IDM and SDM interventions, such as decision aids, result in improved knowledge, beliefs, risk perceptions, and combinations of these. Little or no evidence exists, however, regarding whether these interventions result in 1) participation in decision making at a level consistent with patient preferences or 2) effects on patient satisfaction with the decision-making process. These variables generally either were not assessed or were not reported in the articles reviewed. Results of interventions on uptake of screening were variable. After exposure to IDM/SDM interventions, most studies showed small decreases in prostate cancer screening, whereas four studies on breast and colorectal cancer screening showed small increases. Few data are available by which to evaluate current practices in cancer screening IDM. Patient participation in IDM should be facilitated for those who prefer it. More research is needed to assess the benefits of IDM/SDM interventions and to tailor interventions to individuals who are most likely to desire and benefit from them. There are many system barriers to IDM/SDM and few tools. More work is needed in this area as well. In addition, research is needed to learn how to incorporate IDM into ongoing clinical practice and to determine whether there are unintended negative consequences of IDM.

Community Health Services↗

PubMed2001

Beyond the gambling paradigm: internal controllability in decision-making.

Much research within decision-making has used the standard gambling paradigm, where decision outcomes depend only on chance. Many real life decisions, however, imply personal control over decision outcomes. This paper addressed the question of how internal controllability influences decision-making. Internal controllability is assumed (i) to enhance unrealistic optimism and (ii) to result in a better cost:benefit ratio. Both tendencies support each other and predict an enhanced attractiveness for internal and controllable choice options. Participants read a scenario and made a decision afterwards. Results supported the prediction: decision-makers take the option they can personally control. This finding widens the narrow perspective inherent in much previous research based on the gambling paradigm.

Adult↗

PubMed2001

Decision-making in mania: a PET study.

Poor decision-making is often observed clinically in the manic syndrome. In normal volunteers, decision-making has been associated with activation in the ventral prefrontal cortex and the anterior cingulate gyrus. The aim of this study was to evaluate task-related activation in bipolar manic patients in these regions of the prefrontal cortex using PET. Six subjects with mania, 10 controls and six subjects with unipolar depression (an affective patient control group) were scanned using the bolus H(2)(15)O method while they were performing a decision-making task. Activations associated with the decision-making task were observed at two levels of difficulty. Task-related activation was increased in the manic patients compared with the control patients in the left dorsal anterior cingulate [Brodmann area (BA) 32] but decreased in the right frontal polar region (BA 10). In addition, controls showed greater task-related activation in the inferior frontal gyrus (BA 47) than manic patients. A positive correlation (r(s) = 0.88) between task-related activation in the anterior cingulate and increasing severity of manic symptoms was found. Depressed patients did not show significant task-related differences in activation compared with control subjects in the regions of interest. In conclusion, these patterns of activation point to abnormal task-related responses in specific frontal regions in manic patients. Moreover, they are consistent with neuropsychological observations in patients with lesions in the ventromedial prefrontal cortex, who show similar difficulties with decision-making and provide early evidence for context-specific neural correlates of mania.

Adult↗

PubMed2002

Turning gap acceptance decision-making: the impact of driver distraction.

PROBLEM: A number of studies have found that use of in-car phones by drivers can interfere with the cognitive processing necessary for making appropriate and timely vehicle control decisions. However, the specific linkage between communication-based distraction and unsafe decision-making has not been sufficiently explored. METHOD: In a closed-course driving experiment, 39 subjects were exposed to approximately 100 gaps each in a circulating traffic stream of eight vehicles on an instrumented test track that was wet about half the time. The subjects were at the controls of an instrumented car, which was oriented in a typical left-turn configuration (traffic-crossing situation in North America) and with parking brake on and the transmission in neutral. The subjects were instructed to press on the accelerator pedal when they felt that a gap was safe to accept. Their performances were monitored and incentives were provided for balancing safe decision-making with expeditious completion of the task. For half of the gap exposures (randomly assigned), each subject was required to listen and respond to a complex verbal message. RESULTS: When not distracted, the subjects' gap acceptance judgment was found to be significantly influenced by their age, the gap size, the speed of the trailing vehicle, the level of "indecision," and the condition of the track surface. However, when distracted, the subjects did not factor pavement surface condition into the decision process. On wet pavement, the subjects were judged to have initiated twice the level of potential collisions when distracted by the messages that they did when not distracted. DISCUSSION: Listening/responding to verbal messages may reduce the capacity of drivers to process adequately all the important information necessary for safe decision-making. The effects of the messages in our study seemed to cause the subjects to misjudge gap size and speed information when operating under the additional disadvantage of adverse pavement condition. SUMMARY: Attention to complex messages while making decisions about turning through gaps in an on-coming vehicle stream was associated with significantly increased unsafe decision making by subjects in our experiment when the additional complexity of wet surface condition was introduced. IMPACT ON INDUSTRY: While the results reflected a somewhat artificial situation where the measure was signaled intention to act rather than the act itself, nevertheless, they do strongly suggest a scenario in which mental distraction could contribute to crash risk. With the rapid proliferation of telematics in the vehicle market, even with the laudable objectives represented by the Intelligent Transportation Systems initiative, there is a danger of the primary task of the driver being subordinated to a perceived need to enhance information flow to/from the external "world." Industry and governments need to work together to ensure that apparently desirable in-vehicle communication improvements do not compromise safety.

Accidents, Traffic↗

PubMed1999

An embedded decisional model of stress and coping: implications for exploring treatment decision making by women with breast cancer.

Treatment decision making by women with breast cancer has been recognized to be an inherently stressful process. However, past decisional theory and research has failed to fully elucidate the personal, transactional, and relational nature of choice behaviour. The purpose of this paper is to explore an embedded decisional model of stress and coping that locates key assumptions of Janis & Mann's (1977) conflict-theory model of decision making within Lazarus & Folkman's (1984) transactional framework. Through combining decisional and stress and coping theories, a model is developed that addresses the theoretical limitations of the conflict-theory model and provides greater specificity within decision-making research. The paper examines the complexity of treatment decision making within the context of the constructs of causal antecedents, primary appraisal, secondary appraisal, coping, and adaptational outcomes. Examples specific to women with breast cancer are provided to illustrate the potential application of the embedded model. The implications of this inclusive and comprehensive decisional theory for future knowledge development and research in the area of treatment decision making are also discussed.

Adaptation, Psychological↗

PubMed2000

Contingent Weighting in Self-Other Decision Making.

Three studies are presented that examine the decision-making processes that lead advisors to have preferences distinct from personal decision makers (Kray & Gonzalez, 1999). Advising and personal decision making were hypothesized to invoke different interpersonal frames, which lead to different weighting of decision attributes. Alternatively, advisors might simply exert less effort in decision making for others than do personal decision makers. In Study 1, the contingent weighting of attributes was examined in two decision-making tasks (choice vs. matching). Advisors were more likely to choose in a manner consistent with "what most people would prefer" than personal decision makers, but no differences in preferences were observed in the matching task. Advisors subsequently reported experiencing less regret and blame and more strongly preferred the chosen alternative than did personal decision makers. In Study 2, advisors considered more decision attributes to be important in the abstract compared to personal decision makers, and the choice pattern of Study 1 was replicated. In Study 3, advisors and personal decision makers generated more considerations when making a decision compared to individuals making decisions in the abstract. Finally, the preferences of personal decision makers were more consistent with their reported attribute importance judgments than were those of advisors. In total, the results suggest advisors incorrectly infer others' preferences, rather than suffer from a deficit of motivation, when giving advice. Copyright 2000 Academic Press.

Journal Article↗

PubMed2003

Using risk communication to disclose the outcome of a participatory decision-making process: effects on the perceived acceptability of risk-policy decisions.

It has been suggested that public participation during decision making about risks can lead to more widely accepted risk policies. This article discusses an experiment to determine if this is true when people are made aware of the fact that a participatory decision-making process has taken place only through information disclosed during a subsequent risk communication effort. The results from this experiment showed that, after receiving information during risk communication that cast risk policies about space exploration as the product of a participatory decision process, participants in the study felt more supportive of the resulting decisions than did participants in a control group. This result coincided with the participants in the study group perceiving the risks associated with the decision to be lower and the benefits higher. Responses from these participants also showed that they were more satisfied with the decision-making process than they were with the outcome of the decision itself Therefore, it may be premature to view the objective of participatory decision-making approaches-and the risk communication efforts that discuss them-as a means of making risk policies more widely acceptable to the public at large. Rather, it may be better to view the benefits of these approaches in terms of their ability to help lead to higher quality decisions that are the product of more widely accepted decision processes.

Journal Article↗

PubMed2003

Shared decision making in psychiatry.

OBJECTIVE: In other medical fields, 'shared decision making' (a strategy for including patients in therapeutic decision processes) has been studied for several years now. This survey presents the potential of shared decision making for psychiatry. METHOD: Literature search. RESULTS: Research in other medical fields shows that shared decision making positively influences patients' satisfaction as well as health outcomes. The application of shared decision making to psychiatry is still in the initial stage. CONCLUSION: Evidence that shared decision making can be successfully practiced in psychiatry would contribute to an improved inclusion of psychiatric patients in therapeutic decisions and thereby help to implement basic rights of a group of patients who have not sufficiently benefited from consumer empowerment in other medical fields.

Antipsychotic Agents↗

PubMed2005

Health-related decision-making by older adults and their families: how clinicians can help.

Helping frail and vulnerable individuals and their families to make the best health-related decision is difficult even in the best of circumstances. Decision-making as a discrete action is often discussed in the health care literature, but the concept that decision-making is a process is largely ignored. Understanding the basic elements of the decision-making process used by older adults and their family, or support individual(s) may help health care team members offer more substantial and meaningful assistance to the individuals who are trying to make tough health-related decisions. Full information needs to be available so all participants involved in the process can make reasonable decisions. The decision-making process is highly contextual and is based on how realistic the decision-making goals are and how congruent the experiences versus perceived expectations are, as well as the quality of options available.

Aged↗

PubMed2003

Women's perceptions about treatment decision making for ovarian cancer.

OBJECTIVES: To identify in women with advanced epithelial ovarian cancer who had just undergone surgery the extent to which they (1) perceived that they had treatment options, (2) understood the treatment related risks and benefits, and (3) preferred to participate in the treatment decision-making process. METHODS: This qualitative study included women who underwent initial surgery for stage 3 or 4 ovarian cancer and who had received less than two cycles of chemotherapy. In depth semistructured interviews were conducted with 21 patients between June 1999 and February 2001. The interviews were content analyzed according to the themes that arose in the interview. RESULTS: Five themes were identified. (1) Knowledge of treatment benefits and risks. Women understood that the treatment had both survival and quality of life benefits. Women could clearly articulate the risks of chemotherapy. (2) Readiness to make a decision. When making treatment decisions, women described being overwhelmed by the effects of concurrent drugs like analgesics, the severity of the illness, unexpected diagnosis of cancer and grief, and feeling pressured into a decision. (3) Perception of a treatment choice. Most women felt that they made their treatment decision; however, most women did not perceive that they had a treatment choice. Thus, treatment decision making is really a process of coming to terms with the disease and the recommended treatment. (4) Physician-patient relationship. All women suggest that their doctor knew the right treatment for them and they felt confident in their cancer physician. (5) Social supports. Women described supports through decision-making processes that included individuals who advocated for them, faith, and past experience with the cancer system. Hindrances to decision making included people who were negative, the cancer label, and employers. CONCLUSIONS: Women with advanced epithelial ovarian cancer did not describe the treatment decision-making process as shared; rather they described an interaction that was directed largely by the physician. These women attribute this form of decision-making to their advanced age, severity of illness, immediate ramification of treatment choices, and lack of advocacy for a different model of interaction. Thus, the onus is on the physician to ensure that there is an environment for shared decision-making in the event that the patient is interested in such an interaction.

Aged↗

PubMedDate not supplied

Decision-making phenomena described by expert nurses working in urban community health settings.

Decision making by expert community health nurses was explored using qualitative research methods. Each subject described a crucial incident, a clinical situation where their independent decision making made a positive difference in a client's outcome. Subjects were given instructions to record a crucial incident in writing. After completing each written incident, subjects were asked five interview questions related to the incident. Subject's verbal responses to questions were audiotaped. Content analysis methods were used to analyze data. Findings suggest that decision making in clinical practice in both a rational and intuitive process. Themes emergent from data describing decision making included the following: focus, type, and purpose of the decision making; characteristics of the decision maker; sequencing of events; data collection methods; facilitators and barriers to decision making; and nursing roles in the decision-making process. Conclusions of the study include recommendations for continued research of decision making using qualitative methods allowing flexibility necessary to explore phenomena representing the essence of nursing practice. A clearer understanding of decision making is essential now and in the next century as nurses increase independent practice roles in community health settings.

Community Health Nursing↗

PubMed2003

Role of knowledge and ability in student nurses' clinical decision-making.

Little is known about the acquisition of decision-making skills in nursing students as a function of experience and academic ability. Knowing how experience and academic skills interact may help inform clinical education programs and formulate ways of assessing students' progress. The aims of the present study were to develop a problem-solving task capable of measuring clinical decision-making skills in novice nurses at different levels of domain-specific knowledge; and to establish the relative impact on decision-making of domain-specific knowledge and general ability as determinants of the acquisition of decision-making skills. Three types of clinical problems of increasing complexity were developed. Sixty second-year and third-year student nurses with high and low academic scores were studied in terms of their ability to generate hypotheses for a hypothetical case, recognize disconfirming information and the need to access additional information, and diagnostic accuracy. The results showed that general academic ability and knowledge function partly independently in the acquisition of expertise in nursing. Academic ability affects decision-making in low complexity tasks, but as case complexity increases, domain-specific knowledge and experience determines decision-making skills. There are important differences in the way novices with different levels of knowledge and ability make clinical decisions and these can be studied by systematically increasing the complexity of the decision task. These results have implications for the way in which clinical education is structured and evaluated.

Clinical Competence↗

PubMed2007

Shared decision-making, gender and new technologies.

Much discussion of decision-making processes in medicine has been patient-centred. It has been assumed that there is, most often, one patient. Less attention has been given to shared decision-making processes where two or more patients are involved. This article aims to contribute to this special area. What conditions need to be met if decision-making can be said to be shared? What is a shared decision-making process and what is a shared autonomous decision-making process? Why make the distinction? Examples are drawn from the area of new reproductive medicine and clinical genetics. Possible gender-differences in shared decision-making are discussed.

Cooperative Behavior↗

PubMed1999

Shared decision making in clinical medicine: past research and future directions.

CONTENT: Shared medical decision making is a process by which patients and providers consider outcome probabilities and patient preferences and reach a health care decision based on mutual agreement. Shared decision making is best used for problems involving medical uncertainty. During the process the provider-patient dyad considers treatment options and consequences and explores the fit of expected benefits and consequences of treatment with patient preferences for various outcomes. This paper reviews the literature on shared medical decision making. Several questions are considered. Although several studies suggest that patients do not want to be involved in decision making, these studies typically fail to separate decisions about technical aspects of treatment from preferences for outcomes. There is considerable evidence that patients want to be consulted about the impact of treatment. Studies on the acceptability of shared decision making for physicians have produced inconsistent results. Shared decision making is more acceptable to younger and better-educated patients. It remains unclear whether shared decision making requires expensive video presentations or whether the same results can be obtained with simpler methods, such as the decision board. We conclude that shared medical decision making is an important development in health care. More research is necessary to identify the effects of shared decision making on patient satisfaction and health outcomes. Further, more research is necessary in order to evaluate the most effective methods for engaging patients in decisions about their own health care.

Adult↗

PubMed2000

An international feasibility study of parental decision making in pediatric oncology.

PURPOSE/OBJECTIVES: To describe parental decision making about treatment options for children with cancer and determine the feasibility of a similar but larger international study. DESIGN: Exploratory. SETTINGS: A pediatric catastrophic illness research hospital in the United States and children's hospitals in Australia and Hong Kong. SAMPLE: A convenience sample of 43 parents (5 fathers and 38 mothers ages 23-59 years). METHODS: Six open-ended interview questions posed to parents during private individual interviews. Content analysis techniques were used. MAIN RESEARCH VARIABLES: Parental perceptions of (a) factors considered in the decision-making process, (b) behaviors of healthcare professionals that affected the process, and (c) satisfaction with the process. Feasibility of a larger study was estimated by considering ease of access to parents, number of refusals to participate, understanding of the interview questions, and level of interest at each setting. FINDINGS: Access to parents was possible at all sites. Refusal to participate was reported only at the U.S. site. Certain factors (e.g., getting information from the healthcare team, trusting staff) were important to all parents considering end-of-life decisions. Site-specific factors included considering alternative therapies (at the Australian site) and strengthening faith (at the U.S. site). CONCLUSIONS: A larger international study of parental decision making is feasible. Sufficient similarities in parental decision making exist across these sites to justify future efforts to identify universal decision-making factors that, in conjunction with site-specific differences, could be helpful in developing guidelines for healthcare professionals who assist parents in making treatment-related decisions for a sick child.

Adolescent↗

PubMed2005

Colorectal cancer screening attitudes and practices preferences for decision making.

BACKGROUND: The availability of several effective screening options for colorectal cancer (CRC) screening calls for involving patients in decision making about CRC screening. The current study examined (1) participant characteristics associated with their preferences for participation in CRC screening decision making, (2) correspondence between participant preferences for decision making and their usual participation in decision making, and (3) associations between participant decision-making preferences and CRC screening practices and attitudes. METHODS: Data were obtained using a random, population-based telephone survey, conducted during August 2001 and April 2002, of 2119 community-living adults aged 50 to 75 years (56% female) residing in Long Island, NY. RESULTS: Overall, 77% reported that preferences for CRC screening decision making matched how screening decisions were usually made (simple kappa coefficient=0.67 [0.64-0.69]). Fifteen percent preferred to make screening decisions themselves, while 25% preferred to make decisions after considering their physician's opinion; nearly 50% preferred to share decision making, and 16% preferred that their physician make all screening decisions. Less education was associated with preferring that the physician make all screening decisions. Preferring physician involvement in screening decision making was associated with greater odds of citing no physician recommendation as a barrier to CRC screening, when compared to those who preferred no physician involvement. Preferring no physician involvement in decision making was associated with lower odds of reporting a recent CRC screening exam, as well as lower odds of endorsing positive attitudes and greater odds of endorsing negative attitudes toward CRC screening, when compared to participants who preferred physician involvement in decision making. Their attitudes also reflected intentions not to screen for CRC if they were asymptomatic, as well as the perception that they were not at personal risk for CRC. CONCLUSIONS: Several factors were identified as significantly associated with preferences for decision making and deserve further exploration for their application to clinical practice.

Aged↗