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PubMed2006

Patient preferences regarding spine surgical decision making.

STUDY DESIGN: Patient surveys to determine preferences in surgical decision making. OBJECTIVE: To evaluate spine patient preferences regarding physician and patient roles in surgical decision making and to discuss the ethical considerations that arise. SUMMARY OF BACKGROUND DATA: Since the 1980s, there has been a push toward increasing patient autonomy and self-determination, and away from the paternalism of the past. Commensurate with this shift, patients have been encouraged to take the primary active role in surgical decision making. To date, there is little empirical evidence regarding how deeply patients want to be involved in this decision-making process. METHODS: A total of 200 consecutive patients seen at our academic spine center were administered 1 of 2 questionnaires (previously validated) aimed at determining patient preferences about how clinical decision making should take place. RESULTS: Patients felt strongly that complete risk information be provided. The majority of patients felt that the physician, rather than the patient, should make the basic treatment decision, and the great majority felt that the physician should make the technical decisions regarding treatment. CONCLUSIONS: Spine surgical patients often prefer to defer surgical decision making to their surgeons. In clinical scenarios where there is little controversy and the evidence is clear, this results in little consequence, assuming that the surgeon aims to provide evidence-based care. In scenarios with greater controversy and less clear evidence, the choice of treatment offered by the surgeon may be based on factors outside of the available science, and, accordingly, efforts should be made to educate fully the patient and to help the patient make his/her own decision based on personal values regarding outcomes.

Adult↗

PubMed1991

The right to refuse treatment: an application of the economic principles of decision-making under uncertainty.

When courts do not defer to professional judgment, alternative ways must be used to make treatment decisions for persons who are deemed incompetent. Rather than impose the preferences of society on the mentally ill individual, courts have favored alternative procedures. The two most common approaches are substituted judgment and best interests. In using both the substituted judgment standard and the best interest standard the guardian of a patient who is judged incompetent to make a treatment decision tries to make the decision the patient would have made, had he been competent. The guardian must consider the individual's attitude toward risk in making this assessment. Substituted judgment can be used when clear and convincing evidence of the patient's preferences exists. The evidence would come from a study of the patient's expressed attitudes towards medical treatment and behavior before he or she became incompetent. This approach is effective only if the patient has revealed his or her preferences toward relevant medical treatment in the past. The best interest standard is used when no clear and convincing evidence of the patient's treatment preferences exists. The treatment decisions of competent patients whose characteristics are similar to the incompetent patient's, and who have faced a similar situation, can be used as a proxy for the decision the incompetent patient would have made. Using the choice function of similar people may make it possible to develop a reasonably objective basis for determining what course of action is in the patient's best interest.

Antipsychotic Agents↗

PubMed2006

Anatomy of a decision: striato-orbitofrontal interactions in reinforcement learning, decision making, and reversal.

The authors explore the division of labor between the basal ganglia-dopamine (BG-DA) system and the orbitofrontal cortex (OFC) in decision making. They show that a primitive neural network model of the BG-DA system slowly learns to make decisions on the basis of the relative probability of rewards but is not as sensitive to (a) recency or (b) the value of specific rewards. An augmented model that explores BG-OFC interactions is more successful at estimating the true expected value of decisions and is faster at switching behavior when reinforcement contingencies change. In the augmented model, OFC areas exert top-down control on the BG and premotor areas by representing reinforcement magnitudes in working memory. The model successfully captures patterns of behavior resulting from OFC damage in decision making, reversal learning, and devaluation paradigms and makes additional predictions for the underlying source of these deficits.

Animals↗

PubMed2006

Noise, cost and speed-accuracy trade-offs: decision-making in a decentralized system.

Many natural and artificial decision-making systems face decision problems where there is an inherent compromise between two or more objectives. One such common compromise is between the speed and accuracy of a decision. The ability to exploit the characteristics of a decision problem in order to vary between the extremes of making maximally rapid, or maximally accurate decisions, is a useful property of such systems. Colonies of the ant Temnothorax albipennis (formerly Leptothorax albipennis) are a paradigmatic decentralized decision-making system, and have been shown flexibly to compromise accuracy for speed when making decisions during house-hunting. During emigration, a colony must typically evaluate and choose between several possible alternative new nest sites of differing quality. In this paper, we examine this speed-accuracy trade-off through modelling, and conclude that noise and time-cost of assessing alternative choices are likely to be significant for T. albipennis. Noise and cost of such assessments are likely to mean that T. albipennis' decision-making mechanism is Pareto-optimal in one crucial regard; increasing the willingness of individuals to change their decisions cannot improve collective accuracy overall without impairing speed. We propose that a decentralized control algorithm based on this emigration behaviour may be derived for applications in engineering domains and specify the characteristics of the problems to which it should be suited, based on our new results.

Algorithms↗

PubMed1980

The decision-making process: implications for the medical school organization.

In this article, the authors make use of some contemporary models of decision-making to show how the process of decision-making can become more self-conscious, and thus both more enlightened and more assured. The approach is an examination of several models examined both from the perspective of the steps in the process itself, as well as general observations about the decision-making process. The practical focus is on the medical school organization with its unique characteristics. This article also examines the decision-making process through a comparison of two types of organizational structure (pyramidal and matrix) found in most medical schools. Certain constants emerge from this article that positively enhance good decision-making. These elements are: (1) the rapidity of change; (2) the critical need for a wide range of alternatives; (3) an understanding of both the organizational structure and human factors involved; and (4) the necessity of involving others in the decision-making process. By analyzing various modes of decision-making and presenting options, this article should be of real assistance to administrators.

Academic Medical Centers↗

PubMed2004

[The process of shared decision making in chronic pain patients. Evaluation and modification of treatment decisions].

Conditions affecting the musculoskeletal system are the cause of approximately 25% of absenteeism from work. Fibromyalgia syndrome is an exemplary condition of chronic widespread pain which most physicians consider difficult to manage. The physician-patient relationship is burdened with resignation and frustration on both sides. Initial agreement regarding the aims of treatment is rare. The patient's active involvement in the decision making process is expected to improve the physician-patient relationship. One aspect of this shared decision making process is the evaluation and possibly modification of treatment decisions. In the present study 39 consultations of physicians who had undergone special communication training were examined as to whether these physicians actually exercised the option of revising their treatment decisions. In 87.2% of the consultations the therapy decisions were modified within three months after the first encounter. Patients considered to be "difficult" were less likely to modify their decisions. The shared decision making process usually takes more than one consultation.

Chronic Disease↗

PubMed2000

Intergenerational risk decision making: a practical example.

There is no such thing as intergenerational decision making, at least not yet. In fact, there is no such thing as intragenerational decision making in the context of maximizing overall social good given resource limitations, there are just decisions being made in an ad hoc fashion. Even if one assumes that there is such a thing as intragenerational decision making, no uniform standard or guidance exists to make societal decisions for the common good. Risks to society are judged unevenly within the same agency and across agencies. Decisions are made in isolation and not weighed in the societal context of what is intra or intergenerationally important. The National Academy of Public Administration (NAPA) has set forth a framework for intergenerational decision making that provides a consistent and fair basis for making tough decisions in order to address difficult issues such as the long-term disposal of nuclear wastes. NAPA recognizes that there is an intergenerational obligation that must encompass broader questions than the narrow issue of waste disposal since resources are finite and needs are great. The fundamental principles are based on sustainability with the overarching objective that "no generation should needlessly, now or in the future, deprive its successors of the opportunity to enjoy a quality of life equivalent to its own." Coupled with this objective are four supporting principles of trusteeship, sustainability, chain of obligation, and precaution. The NAPA process also recognizes that no decision can be final and that a "rolling future" view is better than making decisions for "all time." It attempts to balance the needs of the present with those of the future in an open and transparent process that is aimed at producing a decision, not just endless analysis. The U.S. Congress and president should develop a rational standard by which to judge laws that involve intra and intergenerational issues relative to the overall societal good. Present regulations need to be evaluated relative to a uniform level of risk and benefit to assess where the limited money available can do the most good for both the present and future generations in the context of NAPA sustainability principles. It is hoped that decision makers will take a serious look at this process since it can work to resolve stakeholder stalemate.

Journal Article↗

PubMed2006

The role of the ventromedial prefrontal cortex in abstract state-based inference during decision making in humans.

Many real-life decision-making problems incorporate higher-order structure, involving interdependencies between different stimuli, actions, and subsequent rewards. It is not known whether brain regions implicated in decision making, such as the ventromedial prefrontal cortex (vmPFC), use a stored model of the task structure to guide choice (model-based decision making) or merely learn action or state values without assuming higher-order structure as in standard reinforcement learning. To discriminate between these possibilities, we scanned human subjects with functional magnetic resonance imaging while they performed a simple decision-making task with higher-order structure, probabilistic reversal learning. We found that neural activity in a key decision-making region, the vmPFC, was more consistent with a computational model that exploits higher-order structure than with simple reinforcement learning. These results suggest that brain regions, such as the vmPFC, use an abstract model of task structure to guide behavioral choice, computations that may underlie the human capacity for complex social interactions and abstract strategizing.

Action Potentials↗

PubMed2002

Decision-making and addiction (part I): impaired activation of somatic states in substance dependent individuals when pondering decisions with negative future consequences.

Some substance dependent individuals (SDI) suffer from a decision-making impairment akin to that seen in neurological patients with lesions of the ventromedial (VM) prefrontal cortex. The somatic-marker hypothesis posits that decision-making is a process that depends on emotion and that deficits in emotional signaling will lead to poor decision-making. In this study, we tested the hypothesis that SDI who perform disadvantageously on a decision-making instrument, the gambling task (GT), have a deficit in the somatic signals that help guide their decision in the advantageous direction. Since deficits in decision-making/somatic markers can also result from dysfunctional amygdala, we asked indirectly (i.e. via tests sensitive to VM or amygdala dysfunction) whether such a deficit in SDI is restricted to VM dysfunction or includes the amygdala. Using the GT, and skin conductance response (SCR) as an index of somatic state activation, we studied groups of SDI (n=46), normal controls (n=49), and VM patients (n=10). A subgroup of SDI showed defective performance on the GT coupled with impaired anticipatory SCR, but normal SCR to punishment, and normal acquisition of conditioned SCR to an aversive loud sound. This supports the hypothesis that the poor decision-making in some SDI is associated with defective somatic state activation that is linked to a dysfunctional VM cortex. Thus, the dysfunctional VM cortex underlying the "myopia" for the future in some SDI may be one of the principle mechanisms underlying the transition from casual substance taking to compulsive and uncontrollable behavior.

Adult↗

PubMed2006

Barriers and facilitators to implementing shared decision-making in clinical practice: a systematic review of health professionals' perceptions.

BACKGROUND: Shared decision-making is advocated because of its potential to improve the quality of the decision-making process for patients and ultimately, patient outcomes. However, current evidence suggests that shared decision-making has not yet been widely adopted by health professionals. Therefore, a systematic review was performed on the barriers and facilitators to implementing shared decision-making in clinical practice as perceived by health professionals. METHODS: Covering the period from 1990 to March 2006, PubMed, Embase, CINHAL, PsycINFO, and Dissertation Abstracts were searched for studies in English or French. The references from included studies also were consulted. Studies were included if they reported on health professionals' perceived barriers and facilitators to implementing shared decision-making in their practices. Shared decision-making was defined as a joint process of decision making between health professionals and patients, or as decision support interventions including decision aids, or as the active participation of patients in decision making. No study design was excluded. Quality of the studies included was assessed independently by two of the authors. Using a pre-established taxonomy of barriers and facilitators to implementing clinical practice guidelines in practice, content analysis was performed. RESULTS: Thirty-one publications covering 28 unique studies were included. Eleven studies were from the UK, eight from the USA, four from Canada, two from The Netherlands, and one from each of the following countries: France, Mexico, and Australia. Most of the studies used qualitative methods exclusively (18/28). Overall, the vast majority of participants (n = 2784) were physicians (89%). The three most often reported barriers were: time constraints (18/28), lack of applicability due to patient characteristics (12/28), and lack of applicability due to the clinical situation (12/28). The three most often reported facilitators were: provider motivation (15/28), positive impact on the clinical process (11/28), and positive impact on patient outcomes (10/28). CONCLUSION: This systematic review reveals that interventions to foster implementation of shared decision-making in clinical practice will need to address a broad range of factors. It also reveals that on this subject there is very little known about any health professionals others than physicians. Future studies about implementation of shared decision-making should target a more diverse group of health professionals.

Journal Article↗

PubMed1992

Content and process in clinical decision-making by nurse practitioners.

Clinical decision-making is the process nurses use to gather information, evaluate it and make a judgment that results in the provision of patient care. This research sought to increase our understanding of clinical decision making by nurse practitioners. The sample consisted of 27 nurse practitioners; 6 OB/GYN nurse practitioners, 11 experienced family nurse practitioners and 10 inexperienced family nurse practitioners. All subjects cared for the same patient who was presented via computer and interactive video. Findings indicated that nurse practitioners use a process of clinical decision-making in which diagnostic hypotheses drive data acquisition. The OB/GYN nurse practitioners were more likely to develop lists of diagnostic hypotheses which reflected the patient's chief complaint, while both experienced and inexperienced family nurse practitioners were more likely to acquire subjective and objective data that did not appear to be hypothesis driven.

Computer Simulation↗

PubMed2006

Nurse-patient interaction and decision-making in care: patient involvement in community nursing.

AIM: This paper reports a study to identify the extent to which community nurses incorporate patient involvement in decision-making into their everyday clinical practice. BACKGROUND: The complexity underlying the concept of patient participation is not always recognized. It links the notions of 'passive patient' and 'active participant', hence its usage along with those of similar terms such as 'partnership', 'involvement' and 'collaboration' is often ambiguous. The literature on this subject is fairly extensive and often contradictory; it encompasses the participation of potential as well as actual patients. Hierarchical structures have been proposed to offer an understanding of the current nature of patient participation, and these have sometimes linked the level of participation to the quality of the nurse-patient relationship. Much work has been done in the area of cancer care, where it has been noted that the role of 'passive patient' may in itself be a deliberate choice. METHODS: The approach was ethnographic and data were collected during 2000 and 2001 by participant observations with 22 nurses and 107 patients; 137 interactions were observed in all. Detailed field notes were kept and then carefully interpreted. The approach to rigour was primarily concerned with ensuring credibility. FINDINGS: The extent to which nurses involved patients in making decisions about their care, and the manner in which this was achieved, varied considerably. Collectively, the behaviour of participants is presented as the 'involving-non-involving continuum', with five typologies of behaviour: 'completely involving'; 'partially involving'; 'forced involving'; 'covert non-involving' and 'overt non-involving'. The findings highlight that caring for people in their own home does not necessarily mean that patients are involved in care and treatment decisions. CONCLUSION: This observation study of the extent to which community nurses involved patients in decision-making in nursing care offers some useful insights into one aspect of nursing work. The implications of the study are far-reaching. The findings suggest that it could be important for nurses and their managers to devote more time to relationship-building in nursing practice. They also offer a perspective--the involving-non-involving continuum--that could usefully be incorporated into nurse education at both pre- and postregistration levels.

Activities of Daily Living↗

PubMed2006

Theoretical foundations for interventions designed to promote informed decision making for cancer screening.

BACKGROUND: Decision aids are currently being developed and evaluated for use in cancer-screening decisional settings. PURPOSE: The purpose of this article is to review and discuss the theoretical basis of interventions to promote informed decision making in cancer screening. METHODS: We reviewed interventions cited in Briss et al. and Rimer et al. to identify their theoretical basis, intervention content, measurement strategies, and outcomes. RESULTS: Few interventions had a strong, decision-oriented conceptual basis. This was apparent in their intervention content, the measurement strategy, and the choice of outcomes for the study. CONCLUSIONS: We recommend that more research occur into the basis of decision making in cancer screening and that future interventions use this research to rigorously design and evaluate decision aids to help people make choices about cancer screening.

Choice Behavior↗

PubMed2002

Health decision aids to facilitate shared decision making in office practice.

For medical decisions with more than one reasonable option, patient participation in decision making is often necessary to optimally match management decisions with patient preferences. Health decision aids are designed to facilitate shared decision making by helping patients and their physicians choose among reasonable clinical options. Although these aids vary in content, common denominators are the presentation of more than one reasonable strategy for a clinical management question and a description of the possible outcomes of the various options. Although the number of published randomized trials assessing the impact of health decision aids on the quality of medical decisions is limited (but growing), various types of decision aids do generally appear to inform patients about their treatment options better than "usual care" can. Little evidence is available to determine whether one type of decision aid is optimal, but more complicated programs seem to have larger effects. The cost-effectiveness of decision aids has not been studied, although it is enticing to think that the pattern of more conservative decisions by users of some decision aids could reduce medical care costs in a manner that is dictated by patient preferences.

Decision Making↗

PubMed1999

Combining qualitative interviews with video-recorded consultations: gaining insight into GPs' decision-making.

BACKGROUND: Studies of GPs' decision-making are important for facilitating our understanding of GPs' consulting behaviours. We have used a novel combination of semi-structured interviews and video-recorded consultations to research the influences on decisions made by GPs during their consultations. OBJECTIVE: We describe the use of GPs' video-recorded consultations as a stimulus for focused, semi-structured interviews and to discuss how this research method compares with other approaches for studying GPs' decision-making during consultations. METHODS: GPs' surgery sessions were video-recorded and later they were shown video recordings of themselves consulting with smokers before participating in semi-structured interviews about these consultations. Interviews aimed to describe the factors which GPs perceived to influence their decisions to discuss or not discuss smoking with patients. DISCUSSION: This technique can be used to research decisions, which are made frequently by GPs. It is probably most appropriate for gaining insight into decision-making during mundane consultations, to which GPs would otherwise give little thought.

Decision Making↗

PubMed2005

Consensus decision making in animals.

Individual animals routinely face decisions that are crucial to their fitness. In social species, however, many of these decisions need to be made jointly with other group members because the group will split apart unless a consensus is reached. Here, we review empirical and theoretical studies of consensus decision making, and place them in a coherent framework. In particular, we classify consensus decisions according to the degree to which they involve conflict of interest between group members, and whether they involve either local or global communication; we ask, for different categories of consensus decision, who makes the decision, what are the underlying mechanisms, and what are the functional consequences. We conclude that consensus decision making is common in non-human animals, and that cooperation between group members in the decision-making process is likely to be the norm, even when the decision involves significant conflict of interest.

Journal Article↗

PubMed1997

[Components of decision-making among hemodialysis patients].

UNLABELLED: The purpose of this descriptive study was to identify the components of decision-making among the dialysis patients. Subjects were a Convenience sample of hemodialysis patients who agreed to participate this study. The data was collected through semi-structured interviews was recorded on the tape and transcribed. Decision-making episodes were picked and interpreted by researchers. Data was analysed based on the Grounded Theory Approach. RESULT: Subject were 21 patients from 4 hospitals. The mean age was 51.1 and the mean duration after the hemodialysis was 9.1 years. The number of episode of decision-making were 136. Six components of decision-making were extracted such as . The subject were making decision by examining and judging the situation and oneself, and then setting the goal. They were selecting situation and themselves. After all, the outcomes of decision-making were evaluating. Seven type of decision-making, erection type, reality-oriented type, elaborate type, dogmatic type, passive type, chance type, resistant type were extracted. DISCUSSION: The factors which were related to the quality of decision-making were discussed such as the ability to examine the reality and control own wishes and needs, and the commitment for the decision-making. The nursing approach to facilitate the patients to make the decision were mentioned.

Decision Making↗

PubMed2000

The best interest principle as a standard for decision making in the care of neonates.

In neonatal care, decisions are made on behalf of newborn infants by their parents or, in some instances, health professionals. This paper examines how the best interest standard is the most appropriate focus for decision-making concerning neonates. The components of surrogate decision-making are discussed from the perspective of the neonate's interests and the contribution of the various persons involved in caring for neonates. An argument is presented for the use of best interests when making decisions and the interpretation of best interests is explored. By examining the ethical approaches using best interests, an argument is put forward for caring as an expression of best interests. How some nurses use the best interest standard in their practice is described. The unique perspective nurses may have because of their philosophy, circumstances, experience and concern for neonates is discussed. Examples are used from the literature to support the argument for nurses being in roles and relationships where the neonate's interests are the basis of practice. How nurses classify infants on the basis of their future outcome is used to illustrate how nurses can apply the best interest standard. Ethical approaches of care and cure are used to show the best interest standard as applied to neonates. Caring as an expression of best interests is recommended for nursing decisions and actions using infant outcomes as a focus for caring and best interests.

Australia↗