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PubMed1998

Bioethics education in a clinical pastoral education program.

Notes that contemporary health care delivery and the interface of clinical professionals with patients and families are marked by complexity and pluralism and that within this modern matrix patients, families, professionals, and administrators frequently struggle with difficult ethical issues. Observes that these realities have significant implications for chaplains and for chaplains-in-training, a factor which has received the attention of the Bioethics Committee of the Professional Chaplains Association through its Bioethics Committee and resulting in a set of guidelines for the chaplain's appropriate roles in bioethical issues and for their role on bioethics committees. Describes the establishment of a bioetchics modulate at the Cleveland Clinic Foundation (CCF) in which chaplain residents are enabled to function as professional peers with other healthcare professionals and as competent chaplains with patients and families in bioethical decision making. Reports on the methods and the results of a pilot study based on the model described.

Chaplaincy Service, Hospital↗

PubMed2004

Presentation of medical guidelines on a computer.

Free-text forms of medical guidelines that are used in medical care are often cumbersome and difficult to memorize. Therefore a system that is able to present guidelines in a user-friendly manner has been designed. Guidelines are at first formalized by means of the popular GLIF3 model. Subsequently, the GLIF3 model is coded in XML. The system uses patient data and an XML-coded GLIF3 model graph evaluating the conditions of decision steps. If some conditions cannot be evaluated, (due to the unavailability of required data items), the system stops and highlights a branch from the root of the decision tree to the final step. Then, the user can input missing data into the system so that the system can continue to provide visualization. Thus, the presentation of guidelines is data-driven, making its use easier. The visualization system and the Electronic Health Record can be integrated in a system that can, during examination of a patient, suggest subsequent medical actions according to medical guidelines. Such a system has been designed and is now under development.

Decision Support Systems, Clinical↗

PubMed1992

Ethical issues.

The HIV virus and the associated worldwide pandemic pose enormous biomedical, clinical, and social dilemmas for health care providers, biomedical researchers, policy analysts, and the public at large 10 years after its discovery. Many of these dilemmas and challenges are captured in the difficult ethical issues the HIV epidemic has highlighted for primary care physicians. Given the vanishingly small risk to primary care providers of acquiring HIV infection in office practice and the rapidly increasing prevalence of the virus, a clear ethical obligation to care for HIV-infected patients exists for primary care physicians. Primary care providers should be sensitive to the potentially sensitive nature of patient risk status and HIV testing results and balance confidentiality in the medical record with the "need to know" the patient's clinical status by other health care professionals. Every attempt should be made by the primary care provider to encourage HIV-infected patients to act responsibly toward their intimate sexual partners and inform them of their HIV status to take appropriate precautions against acquiring the virus. Primary care providers should also model responsible shared decision making and goal setting with HIV-infected patients early in the course of the disease, laying the foundation for subsequent decision making later in the course of the illness. Finally, considerable controversy exists about the responsibilities of HIV-infected providers to inform patients of their status; professional and public policy in this area is in rapid flux. Undoubtedly, the HIV epidemic will continue to challenge us and force careful examination of many of the critical dilemmas in modern biomedical ethics.

Acquired Immunodeficiency Syndrome↗

PubMed2003

Pregnancy termination following prenatal diagnosis of serious heart disease in the fetus.

BACKGROUND AND AIMS: The fetal diagnosis of complex congenital heart disease (CHD) leads to a crisis for the affected couple. How much more so when a decision is made to terminate the pregnancy? In making that decision do the parents understand the anomaly, its consequences and possible outcome and does that information influence their decision process? METHODS AND SUBJECTS: Questionnaires were developed. They were forwarded to parents seen in a private obstetric ultrasound practice, diagnosed with, or specifically referred, because of the diagnosis of a complex cardiac anomaly in the fetus. The diagnosis was subsequently confirmed by ultrasound examination in the presence of a paediatric cardiologist, in all but one patient. Once confirmed, both the obstetric ultrasonologist and cardiologist explained the anomaly, both working off each other, the obstetrician acting as the parent's advocate, asking and "demanding" explanations in lay terms, clarifying the nature of the anomaly, its possible consequences in the newborn and childhood, the need for intervention, and the short- and long-term risks, concentrating on quality of life issues. The parents were given the opportunity to meet with the cardiologist separately to clarify the diagnosis and management, before coming to a final decision to continue or terminate the pregnancy. RESULTS: Over a 3-year period, 40 such patients were included in the study, of which 13 opted for termination. The anomalies were complex and included hypoplastic left heart syndrome, univentricular heart and atrioventricular septal defect. The three autopsies carried out confirmed the prenatal diagnosis. Completed questionnaires were received from nine couples, two being lost to follow up and two refusing to complete the questionnaire despite telephone contact. All nine responses stated the explanation given was "very clear" or "clear", the detail covered was "just right", and their understanding of the diagnosis was "good " to "excellent". Eight stated they were very distressed following the diagnosis, and seven experienced great difficulty in arriving at a decision. In contrast, two stated that the decision was "easy" or "very easy". The reasons for termination included concern for the welfare of the affected child, other siblings in the family and because of the distress of the parents themselves. Intellectual disability was given as an additional reason in the three who had associated chromosomal abnormalities. CONCLUSIONS: Although the numbers were small, it would appear that the above approach used by an obstetric ultrasonologist and cardiologist, working together, explaining complex congenital heart disease in lay terms and focusing on the need for intervention, functional outcome and quality of life issues, provided the parents with a reasonable understanding of the anomaly. Nevertheless, the decision to terminate, very difficult for nearly all the couples, seemed to be based on the perceived distress of the affected infant/child, the siblings and parents themselves. While three couples were grateful for an opportunity to respond, two refused, suggesting the need for more detailed follow up and support for those parents who decide to terminate an apparently wanted pregnancy.

Abortion, Eugenic↗

PubMed1996

The assessment of diagnostic imaging technologies: a policy perspective.

Diagnostic imaging technologies are essential in health care but have high costs and poorly defined benefits. Formulation and implementation of policy on their procurement and use is made difficult by the complexity of the diagnostic process, and the limitations of available data and assessment methodology. Informed policy decisions will need to be based on a synthesis of imperfect data from a variety of perspectives, and supplemented by effective dissemination and feedback of information. A list of attributes for consideration in the policy formulation process is presented.

Australia↗

PubMed2003

Women's hysterectomy experiences and decision-making.

The goal of the study was to examine women's experiences with gynaecologic symptoms and how they decided to undergo hysterectomy. For this purpose, twenty-nine women were interviewed in hospital within three days of undergoing hysterectomy. The interviews elicited information about the nature of the problem that caused the women to seek medical help, actions taken to solve their problem, their relationship with their gynaecologist, information seeking patterns and decision-making about hysterectomy. Although findings revealed that the symptoms women suffered had a negative impact on their lives, most women delayed seeking medical help and attributed their symptoms to factors other than a physical problem in their reproductive system. Most of the participants' information about the symptoms and possible treatments came from their consulting other women with similar problems. The women reported that their gynaecologist did not initiate a comprehensive discussion about other treatments and their advantages and disadvantages. Only women who had informed themselves about other treatments actively discussed alternatives to hysterectomy with their physicians. The women's decision-making process about undergoing hysterectomy was difficult and depended primarily on the women's illness experiences, age, wish for future children, information they gathered from their gynaecologist and from other women. The findings are discussed in relation to the importance of information provision by gynaecologists and its effects on women's decision-making about hysterectomy.

Adult↗

PubMed2005

Dealing with the uncertain and the unexpected: a report on the first kidney transplantations in Aden, Republic of Yemen.

First kidney transplantations were performed in Aden, Jemen in 2003. A difficult medical environment and unrehearsed decision-making process in a country of scant resources were the background of this undertaking. A brief report is given on the medical situation, training and preparedness of the Yemeni medical community for transplant procedures. Initial impressions of psychological aspects of first-ever organ transplantation in this Islamic country are presented.

Arabs↗

PubMed2001

What triggers requests for ethics consultations?

OBJECTIVES: While clinical practice is complicated by many ethical dilemmas, clinicians do not often request ethics consultations. We therefore investigated what triggers clinicians' requests for ethics consultation. DESIGN: Cross-sectional telephone survey. SETTING: Internal medicine practices throughout the United States. PARTICIPANTS: Randomly selected physicians practising in internal medicine, oncology and critical care. MAIN MEASUREMENTS: Socio-demographic characteristics, training in medicine and ethics, and practice characteristics; types of ethical problems that prompt requests for consultation, and factors triggering consultation requests. RESULTS: One hundred and ninety of 344 responding physicians (55%) reported requesting ethics consultations. Physicians most commonly reported requesting ethics consultations for ethical dilemmas related to end-of-life decision making, patient autonomy issues, and conflict. The most common triggers that led to consultation requests were: 1) wanting help resolving a conflict; 2) wanting assistance interacting with a difficult family, patient, or surrogate; 3) wanting help making a decision or planning care, and 4) emotional triggers. Physicians who were ethnically in the minority, practised in communities under 500,000 population, or who were trained in the US were more likely to request consultations prompted by conflict. CONCLUSIONS: Conflicts and other emotionally charged concerns triggers consultation requests more commonly than other cognitively based concerns. Ethicists need to be prepared to mediate conflicts and handle sometimes difficult emotional situations when consulting. The data suggest that ethics consultants might serve clinicians well by consulting on a more proactive basis to avoid conflicts and by educating clinicians to develop mediation skills.

Attitude of Health Personnel↗

PubMed1994

Adult respiratory distress syndrome and new modes of mechanical ventilation: reducing the complications of high volume and high pressure.

Reported survival rates for severe adult respiratory distress syndrome (ARDS) patients vary from 9% to 84%. Animal study results have suggested that application of the high pressures needed to deliver commonly used tidal volumes (10 to 15 mL/kg) may induce an overexpansion of the remaining small fraction of compliant ARDS lung still capable of gas exchange. Conventional ventilatory therapy might thus superimpose an iatrogenic lung injury on the ARDS lung. These considerations have led to pressure-limited mechanical ventilation strategies, including pressure-controlled, inverse-ratio ventilation. Caution should be exercised, however, since there are no convincing data that any particular ventilatory support mode is superior for the support of ARDS patients. Well-controlled, randomized clinical trials are needed. Because of the phenomenon of information input overload, it seems reasonable to question our ability to come to the "right therapeutic decision" when dealing with multivariate problems in severely ill patients. Since ARDS patients provide clinicians with complicated, multifactorially determined problems, the identification of patient outcome changes due to specific interventions (e.g., a new mechanical ventilation mode) is difficult. Computerized protocols eliminate unnecessary variation in clinical care. They standardize clinical care and impose control on the clinical care process. By standardizing therapy, protocols may significantly reduce the random and nonrandom noise (bias) introduced into the clinical environment by clinical care team members. This is especially important fo the many pertinent clinical questions addressed by clinical trials that cannot be double blinded. Conclusions from protocol-controlled clinical trials should be more credible and more likely to lead to action than those of the past.

Animals↗

PubMed2000

Criteria for selecting and using non-steroidal anti-inflammatory drugs in primary health care.

BACKGROUND: Numerous non-steroidal anti-inflammatory drugs (NSAIDs) are commercially available in Spain. This makes proper selection and use of these drugs difficult for GPs. OBJECTIVE: To find out the criteria which GPs use to choose among the drugs in this group and to evaluate other criteria related to the clinical management of NSAIDs. METHOD: A survey questionnaire was distributed among all the GPs of the reformed network in the health area of Tarragona (Spain). RESULTS: The doctors questioned chose a limited number of NSAIDs. Major preferences were diclofenac and piroxicam. The main criteria for selection were: efficacy and safety of the drug; previous and/or current gastrointestinal pathology of the patient; the difference between acute and chronic use; and the type of inflammatory process. There were a large number of combinations of routes of administration. The histamine H2 antagonists were the prophylactic drugs which were used most for gastropathy. CONCLUSION: Sometimes the main criteria for choosing between the drugs in this study do not reflect the drugs that are used in clinical practice. Some of the criteria used by GPs for selecting and using NSAIDs should be reviewed.

Anti-Inflammatory Agents, Non-Steroidal↗

PubMed1994

Knowledge of medical charges.

Ignorance of medical charges by decision-makers could handicap cost control programs. By written survey, we determined the ability and confidence of 267 adults, including 85 health care workers, to estimate four medical charges: epidural anesthesia for childbirth, outpatient hernia surgery, dipyridamole-thallium heart stress test, and a one month supply of nicotine drug patches. Only 36% of the estimated charges fell within 50% of the actual charges for the four medical services. Accuracy did not differ among physicians, non-physician health care workers and consumers; estimates varied greatly with many being extremely low or high. Respondents rated medical charges significantly more difficult to estimate than non-medical. Seventy percent of respondents felt that most physicians do not know enough about medical charges to give good advice and 92% felt that they did not know enough about medical charges to make satisfactory choices.

Administration, Cutaneous↗

PubMed1999

Public spending on health care: how are different criteria related?

At least nine different criteria are relevant for decisions about public spending for health care. These include economic efficiency criteria (public goods, externalities, catastrophic cost, and cost-effectiveness), ethical reasons (poverty, horizontal and vertical equity, and the rule of rescue), and political considerations (especially demands by the populace). Sometimes one criterion should be examined before another one is considered; that is, they are hierarchically related. Sometimes two criteria will not be compatible but will conflict, forcing difficult choices--particularly between efficiency and equity. Properly thought-out choices of which health care interventions to finance with public funds therefore depend not only on looking at all these criteria, but also on treating them in the appropriate sequence and taking account of their possible inconsistencies. Public funds should finance public and semi-public goods that are cost-effective and for which demand is inadequate; cost-effective interventions that preferentially benefit the poor; and catastrophically costly care, when contributory insurance will not work or there are good reasons to finance insurance publicly.

Cost-Benefit Analysis↗

PubMed1991

Development of an institutional policy on artificial hydration and nutrition.

The issues involved in deciding whether to use artificial methods of delivering hydration and nutrition are often very difficult for patients, families, and health care providers. Once private and personal matters, these decisions now frequently involve the judicial system. Five years ago, Hospice of Washington recognized the need for a written policy and wrote the one published here. Its goal is to respect individual preferences and family concerns while addressing the nutrition and hydration needs of dying patients. The policy sets parameters on the issue, provides basic information, and encourages crafting the most fitting resolution to each situation.

Adult↗

PubMed2003

[Actual situation of medical checkups carried out by Industrial Health Organizations in Japan--manpower and service].

Japanese Industrial Health Organizations (IHOs) have been taking part in medical checkups for employees in accordance with the law of industrial safety and health in Japan. We carried out a questionnaire survey for each IHO in order to learn the actual number of full-time doctors and their proportion of work time. We sent a questionnaire to 112 IHOs (members of International Federation of Industrial Health Organizations) by mail, of which 77 replied (68.8%). In addition, we carried out an interview survey in 3 IHOs. The actual number of full-time doctors was 0 to 51, about half of IHOs have less than 5 doctors/each. Regarding the proportion of work time, among full-time doctors, half of them take part in general health checkups. About 70% of nurses' work time is taken up doing health checkups. The results revealed that the number and the proportion of work time of full-time doctors depends on the characteristics of the area and the background of the organization, for instance, what kind of hygiene services they provide. Depending on the doctors' work style (e.g. full-time or part-time) and their specialities and experience, their work may be shared. Japanese employers are required to report the number of workers with abnormal findings found by medical checkups to the Labor Standards Office. Many IHOs provide service to employers in filling out their reports. Thus, we also asked each IHO about this service. Forty out of the 77 IHOs (51.9%) answered that they are providing statistical analysis and the filling-out service. They count the number of workers with abnormal findings in each company and helped the employer to fill out the report form. Twenty-nine of those 40 IHOs responded that they decided which findings were "abnormal" by using only items that are set by law. However, 7 IHOs reported the fact that they also add some optional items when making the decision. The prevalence of workers with abnormal findings in annual medical checkups, which is one of the msot important indices of the state of occupational health, should be measured by using an objective definition and by being compatible with future systems of medical checkups for all Japanese workers. Although IHOs are endeavoring to improve their level, it will be difficult, and because of diversities in the way of periodical medical checkups among IHOs, there are still many problems to be solved.

Data Collection↗

PubMed1997

De facto gatekeeping and informed consent in intensive care.

Medical decision-making is based on the doctrine of informed consent which is, in turn, based on autonomy, which represents one of four pillars of medical ethics, the others being beneficence, non-malfeasance and social justice. Decision-making in intensive care with respect to the withdrawal of treatment, in particular ventilator therapy, is often extremely difficult for patients or their relatives and they would rather not make any decision other than to insist on the maintenance of therapy in spite of sound, reasonable medical advice that such therapy is of no value to the patient. Aside from issues of a dignified death, this is likely to be to the detriment of other patients who might be refused admission to intensive care and thus is counter to the dictates of social justice. Under these circumstances, there would appear to be a need to give authority to the reasonable medical decision to discontinue resuscitation.

Critical Care↗

PubMed1991

Representation of preferences in decision-support systems.

The recommendations of computer-based decision-support systems depend on the preferences of an expert on which the model is based. Often, these preferences are represented only implicitly, rather than explicitly, in the system. Decision-theoretic preference models that explicitly represent the preferences of the decision maker provide numerous advantages for decision-support systems. In this paper, we describe these advantages. The creation and refinement of decision-theoretic preference models, however, remains a difficult task. We describe an accurate and efficient method for determining the preferences of domain experts and for refining the model that captures those preferences. In this preference-assessment method, we simulate decisions common in the expert's area. We then infer the preferences of the expert from the choices that she makes on the simulated decisions, and use the preference information to refine the model automatically.

Decision Making, Computer-Assisted↗

PubMed2001

Head injury in athletes.

HEAD INJURIES INCURRED during athletic endeavors have been recorded since games were first held. During the last century, our level of understanding of the types of cerebral insults, their causes, and their treatment has advanced significantly. Because of the extreme popularity of sports in the United States and worldwide, the implications of athletic head injury are enormous. This is especially true considering the current realization that mild traumatic brain injury (MTBI) or concussion represents a major health consideration with more long-ranging effects than previously thought. When considering athletic injuries, people who engage in organized sports, as well as the large number of people who engage in recreational activities, should be considered. There are 200 million international soccer players, a group increasingly recognized to be at risk for MTBI. The participation in contact sports of a large number of the population, especially youth, requires a careful and detailed analysis of injury trends and recommended treatment. There are numerous characteristics of this patient population that make management difficult, especially their implicit request to once again be subjected to potential MTBI by participating in contact sports. Recent research has better defined the epidemiological issues related to sports injuries involving the central nervous system and has also led to classification and management paradigms that help guide decisions regarding athletes' return to play. We currently have methods at our disposal that greatly assist us in managing this group of patients, including improved recognition of the clinical syndromes of MTBI, new testing such as neuropsychological assessment, radiographic evaluations, and a greater appreciation of the pathophysiology of concussive brain injury. The potential for long-term consequences of repetitive MTBI has been recognized, and we no longer consider the "dinged" states of athletic concussions to have the benign connotations they had in the past. We review the historical developments in the recognition and care of athletes with head injuries, the current theory of the pathophysiology and biomechanics of these insults, and the recommended management strategy, including return-to-play criteria.

Athletic Injuries↗

PubMed1996

Elective neck irradiation versus observation of the clinically negative neck of patients with oral cancer.

PURPOSES: A retrospective study was conducted to determine the efficacy of elective neck irradiation (ENI) versus observation of patients with oral tumors of varying T stages and clinically negative necks, and to statistically evaluate outcome in the two groups with regard to the subsequent development of neck disease. PATIENTS AND METHODS: Seventy-three patients were treated with surgery of their primary site; 31 received ENI, and 42 of the necks were observed. Of the ENI patients, 3.2% developed neck disease compared with 31% of those observed. When the two groups were evaluated by the T stage of the primary tumor, the results for ENI versus observation were as follows: T1 (0% vs 31%), T2 (5.9% vs 26.7%), T3 + 4 (0% vs 31%), respectively (P < .0000, adjusted odds ratio = 13.73, 95% confidence interval). The difference between the two groups was highly statistically significant. One hundred fourteen patients were treated with only radiation therapy alone at the primary site. In this group, 88 received ENI, and 16 necks were observed. Eight percent of the ENI group developed neck disease, compared with 3.8% of the observational group. Further evaluation by T stage of ENI versus observation showed T1 (3% vs 0%); T2 (9.3% vs 7.7%); T3 + 4 (5.6% vs 0%), respectively. The difference between these groups was not found to be statistically significant. RESULTS: The 5-year disease-free survival rate for the surgical group was 90% for patients who received ENI and 40% for those observed. This difference was statistically significant (P = .0007). No statistical difference was found in 5-year disease-free survival for the radiation group between ENI and observation. CONCLUSIONS: When comparing the above data for ENI versus observation, the survival advantages of elective neck irradiation in patients whose primary tumor was treated surgically is striking for all T stages. These results make the decision to observe the neck in such patients difficult to justify. Lack of statistical difference between ENI and observation in the radiation cohort likely reflects selection bias. If radiation therapy is being used to treat the primary disease, only low-risk sites or histologically favorable tumors would not, on a routine basis, have the neck fields treated as well.

Adult↗