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PubMed2004

Women's perceptions of decision-making about hysterectomy.

OBJECTIVE: To explore women's views of decision-making relating to hysterectomy. DESIGN: Structured questionnaire and in-depth interview surveys. SETTING: A teaching hospital and a district general hospital in northeast Scotland. SAMPLE: Women scheduled for hysterectomy for benign menstrual problems. METHODS: Pre-operative questionnaires were sent to a consecutive sample of women booked for hysterectomy. A purposive sample was interviewed post-operatively. MAIN OUTCOME MEASURES: Women's experiences of, and satisfaction with, information provision, communication and decision-making processes; the relationship between views of decision-making processes and decisions made. RESULTS: One hundred and four women (66%) returned questionnaires. Most responded positively to structured questions about the process by which the decision to have a hysterectomy was reached. Almost all (97%) reported satisfaction with the decision made. Twenty women were interviewed post-operatively. A number, including some who had responded positively on the questionnaire, described aspects of the decision-making process that were suboptimal. Women's perceptions of the decision-making process, including the way their doctors communicated with them, did impinge on their views of the course of action selected. Some women had residual doubts about the appropriateness of hysterectomy. CONCLUSIONS: In a significant minority of women, there are important shortcomings in current patterns of information provision and communication relating to decision-making. These are unlikely to be picked up by conventional structured patient feedback surveys. Further efforts are required to ensure that women are adequately informed and involved in decisions about gynaecological treatments.

Adult↗

PubMed2005

A qualitative study of women's decision-making at the end of IVF treatment.

BACKGROUND: The decision not to pursue further in vitro fertilization (IVF) after one or more unsuccessful attempts is an important and often difficult one for couples. Relatively little is known about the woman's perception of this decision-making process. The aim of this study was to examine patients' perspectives of decision-making, including circumstances influencing it and satisfaction with the decision-making process. METHODS: Semi-structured interviews were conducted with a purposive sample of 25 women who had decided to end treatment after unsuccessful IVF treatment. Interviews were tape-recorded and transcribed by means of thematic analysis using the open coding technique. RESULTS: Women experienced difficulty in accepting that their infertility would remain unresolved. Many felt that they had started with unrealistic expectations of treatment success and felt vulnerable to the pressures of both the media and society. Although the decision to end treatment was difficult, it offered many women a way out of the emotional distress caused by IVF; however, the process of decision-making created a sense of 'confrontation' for the women in which they had to address issues they had previously avoided. Adoptive parents perceived less societal pressure than those who remained childless. CONCLUSIONS: Efforts to improve the psychological preparation of couples who decide to end IVF treatment should be directed towards examination of the existing system of consultation, which has certain limitations in terms of the quality of communication and the provision of post-treatment support. Further efforts to develop strategies, which facilitate the decision-making process, should be considered.

Adult↗

PubMed2002

A qualitative assessment of 1st-year internal medicine residents' perceptions of evidence-based clinical decision making.

BACKGROUND: Residents' perceptions about evidence-based clinical decision making remain largely unexplored. PURPOSE: To understand how residents perceive and use evidence-based medicine in clinical decision making. METHODS: Qualitative study using a semistructured questionnaire and focus group in a postgraduate training program in internal medicine at an academic U.S. medical center. Seventeen 1st-year internal medicine residents in their 1st postgraduate year were interviewed. Six additional 1st-year residents formed a validation group. RESULTS: The interplay of time and expertise modified how physicians-in-training incorporate evidence into clinical decision making. When time was available, the residents preferred to answer their questions by searching and critically appraising the literature. This "self-acquired" expertise empowered them to help patients by using participatory decision-making styles. When time was limited, the residents turned to experts. Residents assumed that experts practiced evidence-based medicine. This "borrowed" expertise was thought to be the most efficient way of integrating evidence and clinical expertise, but it led to the use of a parental style when answers were taken back to the bedside. CONCLUSION: The practice of evidence-based medicine empowers 1st-year residents and appears to affect their choice of decision-making style. Further research is needed to better understand the link between decision-making style and evidence-based medicine.

Decision Support Systems, Clinical↗

PubMed2003

Criteria for decision-making--what makes sense?

Rational medical decision-making increasingly demands the acquisition of critical appraisal skills through application of the principles of evidence-based medicine and clinical epidemiology. Moreover, mastery of information technology to reduce time constraints and data overload is necessary. Ultimately, decision-making has to take into account patient preferences in order to establish real communication to optimise shared decision endeavours.

Decision Making↗

PubMed2005

MDMA affects both error-rate dependent and independent aspects of decision-making in a two-choice prediction task.

Decision-making, i.e. selecting an action from a number of alternatives when the outcome is uncertain, is a complex process that is important for everyday life. 3,4-Methylenedioxymethamphetamine (MDMA), also known as 'Ecstasy', is a widely used recreational drug that is known to increase serotonin (5-HT) and, to a lesser extent, dopamine (DA) in animals. This study examined whether MDMA alters decision-making in a way that depends on the degree of success and outcome.Forty-two normal, healthy volunteers were given placebo or 1.5mg/kg p.o. MDMA in a randomized crossover design. Subjects completed the two-choice prediction task 120min after administration of the drug. Decision-making characteristics were obtained at 20% error rate, 50% error rate or 80% error rate.MDMA affected decision-making via a process that is dependent on success or failure. Administration of MDMA increased the degree to which the previous response predicted the current response (mutual information) and the average response sequence predictability (average dynamical entropy) at low error rates. MDMA increased the degree to which the previous stimulus influenced the selection of the current response at 20%, 50% or 80% error rate. MDMA did not significantly alter basic response characteristics such as response latency or switching. Self-assessment of the psychological state induced by MDMA did not predict the MDMA induced decision-making patterns. These results support the hypothesis that acute administration of MDMA affects success-related response selection during decision-making.

Adult↗

PubMed2003

Evidence-based decision-making in psychopharmacology.

hen evaluating patients and making treatment decisions, physicians do not always have all the information necessary and may have to make judgments using limited information. This judgment is often intuitive in nature. The processes by which these judgments are made is of great theoretical and practical interest. In the 1960s, Amos Tversky and Daniel Kahnemann revolutionized the concept of human judgment. They introduced the notion that when individuals make judgments under uncertainty they use a limited number of cognitive processes. These processes are efficient and generally accurate, but can sometimes lead to errors or biases. In this review we discuss the nature of these processes and their potential effects on decision making.

Decision Making↗

PubMed2002

Environmental vulnerability indicators for environmental planning and decision-making: guidelines and applications.

Environmental decision-making and policy-making at all levels refers necessarily to synthetic, approximate quantification of environmental properties such as vulnerability, conservation status, and ability to recover after perturbation. Knowledge of such properties is essential to informed decision-making, but their definition is controversial and their precise characterization requires investments in research, modeling, and data collection that are only possible in the most developed countries. Environmental agencies and governments worldwide have increasingly requested numerical quantification or semiquantitative ranking of such attributes at the ecosystem, landscape, and country level. We do not have a theory to guide their calculation, in general or specific contexts, particularly with the amount of resources usually available in such cases. As a result, these measures are often calculated with little scientific justification and high subjectivity, and such doubtful approximations are used for critical decision-making. This problem applies particularly to countries with weak economies, such as small island states, where the most precious environmental resources are often concentrated. This paper discusses frameworks for a "least disappointing," approximate quantification of environmental vulnerability. After a review of recent research and recent attempts to quantify environmental vulnerability, we discuss models and theoretical frameworks for obtaining an approximate, standardizable vulnerability indicator of minimal subjectivity and maximum generality. We also discuss issues of empirical testing and comparability between indicators developed for different environments. To assess the state of the art, we describe an independent ongoing project developed in the South Pacific area and aimed to the comparative evaluation of the vulnerability of arbitrary countries.

Conservation of Natural Resources↗

PubMed2000

Challenges of decision making for families of children with single or multiple chronic conditions.

When a child is diagnosed with a chronic illness, families begin a constant cycle of decision making. Many of these decisions surround health care treatment. These families can be divided into two groups: those with children newly diagnosed with a chronic condition and those with children who have a preexisting illness. If a new diagnosis represents a family's entrance into the medical community, the decision-making process can be confusing and difficult. For the family of a child with a preexisting condition, making repeated decisions about treatments can be additionally stressful and anxiety provoking because of their medical history. How do families with a child with a preexisting medical condition differ in their decision making? What factors affect their decisions? The nurse practitioner has a critical role interacting with both types of families and guiding the decision-making process. Therefore, understanding the family and their previous experience is crucial to determine how nurse practitioners can best tailor interventions to promote effective decision making.

Adolescent↗

PubMedDate not supplied

Intervention booster: adding a decision-making module to risk reduction and other health care programs for adolescents.

A generic adolescent intervention booster of the decision-making module, "Choices for Tomorrow: Decision Making as a Life Tool," is described for patient education. The intent of the intervention booster is refinement of adolescent decision-making skills by teaching a life tool for making lifestyle decisions (such as smoking and alcohol use) and other health-related decisions. An overview of the module is presented. The module includes a curriculum, a 17-minute life-action videocassette, a participant's workbook, and two instruments to measure outcomes. The theoretical framework is based on the health/choice model, the Janis and Mann conflict model of decision making, and the Piagetian cognitive framework related to adolescent development. The decision-making module can be used alone or as a "booster" to supplement the content of new or existing intervention programs that are aimed at health promotion and maintenance during adolescence. Because the module was originally developed for adolescents who have survived cancer, a population that often experiences cognitive impairment from treatment, it includes cognitive remediation strategies (such as memory aids). The decision-making module can also be used in other learning situations with healthy or chronically ill adolescents and/or their parents.

Adolescent↗

PubMed2006

Teaching evidence-based decision-making.

Evidence-based decision-making is important in surgery, but the nature of the work makes it difficult. Teaching it requires an interactive approach with a clinical team willing to consider it seriously,and to derive practical solutions. Decision-making and its influences must be understood, so that surgeons have a realistic idea of the role of evidence. Cognitive factors are particularly important.Strategies developed in the context of this knowledge are more likely to be adopted and used. Experts must be involved in searching for evidence and members of the management team in the learning process, the former to provide expertise on searching,the latter to ensure that the reasons for proposed changes are understood and treated sympathetically by those with financial control.

Attitude of Health Personnel↗

PubMedDate not supplied

Decision making in determining eligibility of culturally and linguistically diverse learners: Reasons given by assessment personnel.

Assessment personnel from the southern borderlands area of Texas participated in analyzing one of four different hypothetical cases. Respondents were expected to defer making eligibility decisions due to language proficiency, environment, culture, or lack of data. When data were lacking, the investigators proposed that respondents would recognize the need for additional information and defer making a decision. Differences in eligibility decisions were found when the respondents analyzed cases in which a significant discrepancy existed and in cases in which language proficiency information was provided. Experience in assessment was significant in the determination that additional information was needed to reach a decision, F(2, 87) = 3.99, p < .05. A majority of the respondents (83%) made an eligibility decision using insufficient data.

Adult↗

PubMed1986

The law and intensive care. The role of the courts in the ethical decision-making process.

As intensive care decision making has become more complex in light of continuing technologic advances, our legal system has become increasingly involved in defining the legal parameters of the decision-making process. Although the law differs substantially from state to state, certain standards of broad applicability appear to be emerging. The medical community must strive to ensure that it is responsive to the legitimate need of government to set appropriate standards, in order to forestall the imposition of unnecessarily restrictive standards.

Adult↗

PubMed1981

Decision making in an interdisciplinary team.

Decision making in an interdisciplinary team occurs at the interface between groups with varied backgrounds, orientations, interests, and goals. Most interdisciplinary teams attempt to identify the complex set of variables influencing their decisions and then utilize this knowledge to maximize efficiency in health care delivery. Models of information and decision analysis developed by general systems theory are suggested as a method for advancing the understanding of where, when, and how decisions are made by the interdisciplinary team. A university-affiliated psychiatric service in a private general hospital is studied. Here the following forces meet, complement, compete, and collide: the community, university, hospital administration, private practitioners, insurance companies, consultation and liaison psychiatrists, university staff psychiatrists and residents, nurses, aides, social workers, activities personnel, patients and their families, the patient group, the ward milieu. Considering these factors, we describe: (1) the flow of information and feedback loops into, within, and out of the psychiatric service; (2) the location of decision nodes; (3) decision-making echelons. The general systems theory concepts utilized in this analysis are proposed as pragmatic tools for improving interdisciplinary team function.

Decision Making↗

PubMed1995

Decision-making models of Finnish nurses and public health nurses.

This study described nursing decision-making models and variables related to these models. For this purpose a 56-item Likert-type questionnaire was constructed according to the Dreyfus model of skill acquisition as applied to nursing by Benner and information processing theory. The target group consisted of 100 registered nurses working in inpatient clinics and 100 public health nurses working in preventive health care. The decision-making variables explored were nurses' experience, education and knowledge as well as the nature of the nursing task and context. The results revealed four different types of decision-making: (a) unquestioning/questioning decision-making, (b) creative-diversive decision-making, (c) patient/nurse-oriented decision-making, and (d) rule- and situation-based decision-making. The most important factors related to decision-making were experience and the nature of the nursing task and context.

Analysis of Variance↗

PubMed2003

Manufactured but not imported: new directions for research in shared decision making support and skills.

Significant conceptual work on shared decision making has taken place but there are still significant challenges in achieving it in routine clinical practice. This paper outlines what research has identified to date that may promote shared decision making, and the further research that is required to enable continuing progress. Greater understanding of the models of decision making and instruments to identify them in practice are still required. Specifying consumer competences, developing instruments to assess these and interventions to enhance them may also be important. Clarifying all these aspects may enable those charged with training professionals to improve the content of professional development programmes. This may be particularly important in the field of cancer treatments where the stakes are high-patients usually desire much information but their desire for involvement in decision making is more variable. The consequences of getting this balance right or wrong are significant with much to be gained or lost. Continued development and evaluation of decision aids and decision explorers that use interactive technology will also be important in identifying how to progress with consumer involvement. If we can learn these lessons, then wider implementation of shared decision making or consumer involvement may become a nearer prospect.

Clinical Competence↗

PubMed1991

Information overload: CEOs seek new tools for effective decision making.

The amount of data available to hospital CEOs is growing exponentially. But these numbers are worthless if executives can't use them to make effective decisions. As one CFO puts it, "Information systems are only helpful so long as you have the management processes that allow you to use the data."

Chief Executive Officers, Hospital↗

PubMed1994

Controversial decisions regarding treatment and DNR: an algorithmic Guide for the Uncertain in Decision-Making Ethics (GUIDE).

We describe an algorithm to aid clinicians in making ethical decisions regarding interventions. Logically sequenced questions about competency, advance directives, treatment benefit, and patient and family preferences guide the decision maker to nine specific scenarios. Each scenario includes guidelines for action based on legal and ethical consensus.

Algorithms↗

PubMed2006

Deciding how to decide: ventromedial frontal lobe damage affects information acquisition in multi-attribute decision making.

Ventromedial frontal lobe (VMF) damage is associated with impaired decision making. Recent efforts to understand the functions of this brain region have focused on its role in tracking reward, punishment and risk. However, decision making is complex, and frontal lobe damage might be expected to affect it at other levels. This study used process-tracing techniques to explore the effect of VMF damage on multi-attribute decision making under certainty. Thirteen subjects with focal VMF damage were compared with 11 subjects with frontal damage that spared the VMF and 21 demographically matched healthy control subjects. Participants chose rental apartments in a standard information board task drawn from the literature on normal decision making. VMF subjects performed the decision making task in a way that differed markedly from all other groups, favouring an 'alternative-based' information acquisition strategy (i.e. they organized their information search around individual apartments). In contrast, both healthy control subjects and subjects with damage predominantly involving dorsal and/or lateral prefrontal cortex pursued primarily 'attribute-based' search strategies (in which information was acquired about categories such as rent and noise level across several apartments). This difference in the pattern of information acquisition argues for systematic differences in the underlying decision heuristics and strategies employed by subjects with VMF damage, which in turn may affect the quality of their choices. These findings suggest that the processes supported by ventral and medial prefrontal cortex need to be conceptualized more broadly, to account for changes in decision making under conditions of certainty, as well as uncertainty, following damage to these areas.

Adult↗