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It is amazing that so much money is spent on health care with little understanding and measurement of its effect on people's health status. But tightened health care budgets and the explosion of new and often expensive health care technologies have forced governments, providers and taxpayers to examine how best to maximize health dollars. This has led to greater reliance on economic evaluations to help make difficult choices.
Twenty-four children (aged 5 months to 18 years) who were admitted to a university hospital were observed for a total of 135 hours with the aim of describing their degree of participation in decisions concerning their own care. Grading of their participation was made by using a 5-point scale. An assessment was also made of what was considered as optimal participation in each situation. The results indicate that children are not always allowed to participate in decision making to the extent that is considered optimal. In no case was it judged that a child participated in or was forced to make a decision that was too difficult for the child. The interactions between children, parents and staff were also described in connection with discussions and decision-making processes. This showed that parents do not always support their children in difficult situations and that health care staff often inform children about what is going to happen without presenting alternatives or asking for their views. Staff may, however, find themselves facing an ethical conflict in deciding between supporting a child's view or following hospital routine. It is of great importance that children are looked upon as potentially autonomous individuals and that staff members realize that one of their core duties is to facilitate children's participation in decision making concerning their health care.
What happens when hospital CEOs decide to switch hats and become purchasers of health care rather than merely providers? As employee health benefits costs continue to climb, hospital executives will be compelled to make some difficult decisions. Some benefits consultants say that in order to effectively curb costs, they will have to move from using traditional cost-containment measures to offering managed care. Hospitals may also tap into options such as encouraging use of their own facilities and promoting employee wellness.
While evidence-based medicine has increasingly broad-based support in health care, it remains difficult to get physicians to actually practice it. Across most domains in medicine, practice has lagged behind knowledge by at least several years. The authors believe that the key tools for closing this gap will be information systems that provide decision support to users at the time they make decisions, which should result in improved quality of care. Furthermore, providers make many errors, and clinical decision support can be useful for finding and preventing such errors. Over the last eight years the authors have implemented and studied the impact of decision support across a broad array of domains and have found a number of common elements important to success. The goal of this report is to discuss these lessons learned in the interest of informing the efforts of others working to make the practice of evidence-based medicine a reality.
Subscribing to a long-term care (LTC) insurance plan for future health care and services is one of the most difficult decisions aging Americans need to make today. Although it may be difficult to predict who will need an LTC plan and for how long, various factors play an important role in determining whether to purchase LTC insurance. This article provides general information about LTC plans including private insurance, their coverage, and implications for gerontologic nurses.
Since psychiatrists may be held legally accountable for their patients' violent acts against others, psychiatrists on inpatient wards are faced with the dilemma of deciding whether or not, and when, to discharge improved but still possibly dangerous patients. This paper presents a survey of an inner-city hospital's experience with violent patients admitted over a seven-month period and describes an interdisciplinary disposition committee, composed of a senior consulting psychiatrist and other mental health professionals, established by this hospital to help make these difficult decisions. The committee carefully evaluates all identified high-risk patients according to specific criteria before such patients are discharged. Two case studies illustrate this process of evaluation.
Rationing health care in publicly funded health care systems is becoming more challenging because of the growing gap between the possibility of effective medical intervention and limited resources. This poses both an economic challenge and a political puzzle. On the basis of experience in those systems that have adopted a systematic approach to rationing, it can be suggested that the dilemmas involved should be addressed by strengthening both the information base to support decisions and the institutional framework in which decisions are taken. The contribution both of experts and of lay people is needed to inform decision-making, and the processes adopted need to allow for this as well as being transparent and accountable. In practice, rationing is likely to combine explicit and implicit decision-making and to result in the exclusion of services at the margins and the development of guidelines in the mainstream. The politics of rationing may favour muddling through and the evasion of responsibility but this will be difficult to sustain in an environment in which public awareness of decision-making in health care is growing.
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Those in health care practice and research must depend on humanism for guidance in making difficult judgments and decisions that involve the individual patient's dignity and value. But what kind of humanism will inform those choices? Pragmatic humanism tends to view dignity in terms of human functioning: One is human because he or she acts, produces, thinks, achieves. The comatose, the insane, the hopelessly senile, fetuses and the newborn may be accorded human dignity as well, but only because society grants it to them. Thus such dignity can be manipulated or diminished in the name of overall human progress or the common welfare. By contrast, personalist humanism holds that human dignity is rooted in "being human" rather than in "doing human things." An individual has full human value simply by being a living person. This humanism suggests that health care providers must use their capabilities even for nonproductive patients. This may be difficult in the face of today's cost-benefit analyses. But if the individual's basic value is not defended, human dignity will vary in direct ratio to a person's social usefulness. And that would be obscene.
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A family's coping repertoire may be challenged when the result of a standard prenatal maternal serum alpha-fetoprotein screening is not within a normal range. Abnormal screening results can cause families to experience anxiety and confusion at a time when they may need to make difficult decisions. The nurse's role is to provide information and emotional support and to coordinate health care services for optimal family coping.
The importance of patient involvement in medical decision making is indisputable. Yet, decision making concerning medical treatment options is a difficult task for most patients. In order to study decision-making processes in health care, O'Connor developed the decisional conflict scale (DCS). The DCS assesses the level of 'decisional conflict' that patients experience while making health care decisions, and encompasses the following three subscales: (1) uncertainty about choosing among alternatives; (2) factors contributing to uncertainty; (3) perceived effectiveness of the decision. The aim of the present study is to investigate the reliability and validity of the Dutch version of the DCS. A written version of the DCS was administered in two samples of Dutch cancer patients. One sample consisted of cancer patients faced with the decision whether or not to undergo palliative chemotherapy (N=29). The other sample included women with early stage breast cancer who had to choose between mastectomy or lumpectomy followed by radiation therapy (N=141). The response rates were 76% and 91%, respectively. The reliability coefficients of the three subscales were 0.52, 0.80, 0.84, and 0.74, 0.83, 0.83 in the two samples, respectively. Construct validity was partly supported. Criterion validity was substantiated. In evaluating the factorial validity, it was found that the original three-factor model had to be rejected (chi(2)(87)=293, root mean square error of approximation (RMSEA)=0.137). A subsequent exploratory factor analysis suggested an alternative four-factor model. The psychometric properties of the DCS were partly confirmed in Dutch cancer patients. Improved 'wording' of certain items, e.g. to avoid double negatives, could further increase the factorial validity of the DCS. Then, this scale may be a valuable tool for studies that address the quality of medical decision making.
This article is part of an integrated research project called The Organization of Primary Health Care (a perspective for nursing practice). Its objective is to investigate the perception of nursing personnel concerning their practice in family-centered primary health care. This article presents a case study focuses on nursing personnel workers from the Family Health Program (PSF), in the city of Batatais. Data collection was done through semi-structured interviews with those professionals. Thematic analysis of the data was realized in which initial categorization was done with the help of the Ethnograph software. The topics identified in the workers' narratives were: comprehensiveness, health care, bonding and active case-frading. These themes suggested that the work in family-centered care is difficult, therefore it leads to a more comprehensive health care practice in which decision-making is shared with clientele.
A voluntary survey of California patients' feelings about their hospital care is drawing wider support, even though half of the state's facilities still are not signing up. The Patients' Evaluation of Performance in California results help consumers make the difficult decision of where to seek care.
One parent's experience with her daughter in a neonatal intensive care unit (NICU) and pediatric intensive care unit (PICU) setting sheds light on parental involvement in end-of-life decision making. For this parent, collaborative decision making was facilitated in an environment where the parents had gotten to know the health care providers over time. Health care provider style was a factor in providing parents with access to information needed to participate in decisions. Regular meetings away from the bedside facilitated parental information gathering and joint decision making. This parent also used outside advice in making key decisions. In contrast, interaction with a minimally communicative and authoritarian style health care professional added greatly to this parent's stress in an already difficult circumstance. These are her own words.
Pregnant women are often faced with complex decisions about whether to undergo medical treatment or continue working in an occupational setting that is permeated with hazardous chemicals. The task for these women is to weigh the benefits of these activities against the potential risks that they may have on the developing embryo. Scientific uncertainty with respect to the teratogenicity of drugs and chemicals in humans leaves health care professionals and their pregnant patients with little predictive information. Cognitive research has shown that it is difficult for people to make complex decisions, particularly when the risks are uncertain. Although the problems inherent in counseling pregnant women regarding teratogenic risk are not new, little time has been devoted to the empiric assessment of how people perceive teratogenic risk and how teratogenic risk information can be best communicated. This article explores the variables that have been found, through psychometric research, to influence people's perception of risk and how cognitive models derived from these studies may be applicable to teratogen information counseling. Understanding the variables that shape the perception of teratogenic risk can help health care professionals improve how they communicate these risks to their patients. Improved teratogenic risk communication will result in better management of pregnancies and reduction of costly litigation that ensues when risks are not properly communicated and understood.
BACKGROUND: A common dilemma that confronts physicians in clinical practice is the allocation of scarce resources. Yet the strategies used by physicians in actual situations of resource constraint have not been studied. This study explores the strategies and rationales reported by physicians in situations of resource constraints encountered in practice. METHODS: A national survey of US internists, oncologists, and intensive care specialists was performed by computer-assisted telephone interviews. As part of this survey, we asked physicians to tell us about a recent ethical dilemma encountered in practice. A subset of respondents reported difficulties regarding resource allocation. Transcripts of open-ended responses were coded for content based on consensus. RESULTS: Of the 600 physicians originally identified, 537 were eligible and 344 participated (response rate, 64%). Internists do not make allocation decisions alone but rather engage in negotiation in their resolution. Furthermore, these decisions are not made as dichotomous choices. Rather they often involve alternative solutions in the face of complexities of both the health care system and situations where limited resources must be allocated. Justice is not commonly the justification for rationing. CONCLUSION: Physicians' experiences in situations of resource constraints appear to be more complex than the normative literature on health care rationing assumes. In addition, reasoning about justice in health care seems to play only a small part in clinical decision making. Bridging this gap could be an important step in fostering fair allocation of resources in difficult cases.
Decision making near the end of life can be complex and laden with emotion for families and health care providers. Families and patients can prepare themselves for these difficult moments by thinking ahead about the patient's wishes and preparing clear documents that express those wishes. Health care providers can prepare themselves by being familiar with those documents, considering the goals of treatment, remembering the principles on which health care ethics are founded and knowing decision-making models that will help them to think through treatment plans and the best options for patient taking into consideration the goals of treatment.