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PubMed2003

Relationship of depression and anxiety to cancer patients' medical decision-making.

The purpose of this study was to examine the relation of depression and anxiety to cancer patients' medical decision-making. Participants were 79 rural and urban cancer patients undergoing chemotherapy. The four decisional styles of the Decisional Processing Model were the independent variables. Dependent variables were anxiety and depression, measured by Spielberger's State-Trait Anxiety and the Center for Disease Control Depression Scale, respectively. Consistent with the Decisional Processing Model, analysis suggested that patients make medical decisions by information seeking, information processing, advice following, or ruminating. Decisional style did not vary according to type or stage of cancer, prognosis, time elapsed since initial diagnosis, or whether cancer was initial or recurrent. Decisional style did not systematically vary with depression and anxiety suggesting how a person makes decisions is a stable personality trait. Thus, decision-making may follow a cognitive schema. It is likely that patients' decisional styles help to manage anxiety and depression when confronted with life-threatening illness. Implications for informed consent and patients' involvement in decision-making are discussed.

Adult↗
PubMed1998

Promoting patient decision making in life-and-death situations.

OBJECTIVES: To review factors in the health care culture that deny seriously ill patients' last wishes regarding care. DATA SOURCES: Review articles and research studies that pertain to decision making. CONCLUSIONS: Decision making in palliative care has been identified as an understudied area. Although there are significant benefits to being involved in treatment decision making, long-term follow-up of the consequences of active participation in the final stages of life is lacking. IMPLICATIONS FOR NURSING PRACTICE: Nurses have a role to play in assisting patients and their families in treatment decision making in both the curative and palliative phase of care. A nursing intervention to promote patient involvement in decision making is described.

Attitude to Death↗
PubMed2001

[The cost in calculating transport noise disturbances in public decision making].

The public decision-making methods in transport are based on cost-benefit analysis, by which the consequences of the decision (standards for vehicles, new infrastructures...) are converted in monetary amounts and compared to the cost of implementation of the decision. But some of these consequences, especially those related to environment, are not directly expressed in monetary terms. The article aims at offsetting this difficulty in the case of noise. The possible methods for getting money values of noise are presented; it is shown that the estimates to which they lead are coherent and consistent. Then a comparison is made between the present procedures and the procedures which could be implemented, and it is shown that large gains of efficiency could be obtained.

Cost-Benefit Analysis↗
PubMed2006

Hot and cool aspects of cognitive control in children with ADHD: decision-making and inhibition.

This study investigated hot and cool aspects of cognitive control in children with Attention Deficit Hyperactivity Disorder (ADHD). The study aimed to: (1) replicate the postulated response inhibition deficit of children with ADHD; (2) explore whether children with ADHD choose disadvantageously in a decision-making task and to explore the mechanisms underlying the expected response pattern; and (3) study whether performance on a combination of hot and cool executive control measures has predictive value for an ADHD diagnosis. The sample consisted of 20 children with ADHD and 22 normal developing children (NC, 8 to 12 years) matched on age, FSIQ, and gender. Two paradigms have been applied: (1) the stop signal paradigm, and (2) the adapted children's version of the IOWA Gambling task. There were no group differences for both paradigms. Both groups chose in a reward-oriented manner and seemed to develop the ability to take future consequences into account in making decisions. Moreover, feedback resulted in direct behavioral changes. Children with ADHD did not have a specific response inhibition deficit or a decision-making deficit.

Attention Deficit Disorder with Hyperactivity↗
PubMed1993

Decision making in case management of home healthcare clients.

Public health nurses face ethical decision-making dilemmas in their everyday practice, but how well are they prepared to make these decisions? This research study examined the decision-making capabilities of nurses in case management in regard to terminating and maintaining services in difficult client situations. The results showed that nurses varied in their decision-making capabilities and that their beliefs about case management were not always carried out in actual practice.

Adult↗
PubMedDate not supplied

Neural-network-based decision making in diagnostic applications.

In this article the NN approach for medical decision making was applied for three specific examples. The first example was decision making with single-valued data for IUGR detection. The second example was decision making with double-valued data in prediction of ovulation. The third example was the use of independent NN modules and consensus theory for prediction of ovulation time. The NN approach has superiority over classical statistical approaches for decision making with medical data for the following reasons: 1. It is distribution-free. 2. It captures correlative features and does not need any specific consideration for mutual test dependence. 3. It provides weighted reliability of various tests. 4. It produces fast, accurate results. The statistical decision approach will probably outperform the NN approach in making decisions when an accurate distribution model is provided. However, the NN is proposed as a useful tool to help physicians in decision making and diagnosis of certain symptoms. The capability and performance of this tool has generally been proven in combining mutually dependent medical tests.

Algorithms↗
PubMed2003

Attitudes and preferences of intensivists regarding the role of family interests in medical decision making for incompetent patients.

OBJECTIVE: The role of family interests in medical decision making is controversial. Physicians who routinely treat incompetent patients may have preferred strategies for addressing family interests as they are encountered in surrogate medical decision making. We sought to determine how physicians view the role of family interests in surrogate medical decision making. DESIGN: Cross-sectional mail survey. SETTING: Remote study. PATIENTS: Surveyed were neonatologists, pediatric intensivists, and medical intensivists affiliated with American medical schools. MEASUREMENTS AND MAIN RESULTS: A total of 327 (55%) of 596 surveys were returned; 35% of respondents were pediatric intensivists, 39% were neonatologists, and 26% were medical intensivists. The majority of respondents believed that family interests should be considered in decisions for incompetent patients, even if those interests are not necessarily important interests of the patient. Less than 10% preferred the traditional model in which the physician-patient relationship is exclusive and family interests are excluded. Medical intensivists, and those who described themselves as more religious, more opposed to healthcare rationing, and more protective of patients, tended to prefer patient-centered surrogate decision-making models. Physicians who treat children, especially neonatologists, were more accepting of family-centered surrogate decision-making models than were physicians who exclusively treat adults. CONCLUSIONS: A majority of the academic intensivists in our study believed that family interests should play an important role in medical decision making for incompetent patients. Our findings suggest that the traditional view of the physician-patient relationship may represent an overly simplistic model for medical decision making.

Adult↗
PubMed1998

The physician-patient encounter: the physician as a perfect agent for the patient versus the informed treatment decision-making model.

Assuming a goal of arriving at a treatment decision which is based on the physician's knowledge and the patient's preferences, we discuss the feasibility of implementing two treatment decision-making models: (1) the physician as a perfect agent for the patient, and (2) the informed treatment decision-making models. Both models fall under the rubric of agency models, however, the requirements from the physician and the patient are different. An important distinction between the two models is that in the former the patient delegates authority to her doctor to make medical decisions and thus the challenge is to encourage the physician to find out the patient's preferences. In the latter, the patient retains the authority to make medical decisions and the physician role is that of information transfer. The challenge here is to encourage the physician to transfer the knowledge in a clear and nonbiased way. We argue that the choice of model depends among other things on the ease of implementation (e.g., is it simpler to transfer patient's preferences to doctors or to transfer technical knowledge to patients?). Also the choice of treatment decision-making model is likely to have an impact on the type of incentives or regulations (i.e., contracts) needed to promote the chosen model. We show that in theory both models result in the same outcome. We argue that the approach of transferring information to the patient is easier (but not easy) and, hence, more feasible than transferring each patient's preferences to the physician in each medical encounter. We also argue that because better "technology" exists to transfer medical information to patients and time costs are involved in both tasks (i.e. transferring preferences or information), it is more feasible to design contracts to motivate physicians to transfer information to patients than to design contracts to motivate physicians to find out their patients' utility functions. We illustrate our arguments using a clinical example of the choice of adjuvant chemotherapy versus no adjuvant chemotherapy for women with early stage breast cancer. We also discuss issues relating to the current realities of clinical practice and their potential implications for the way that economists model physician-patient clinical encounters.

Breast Neoplasms↗
PubMed2006

Characteristics of decision-making process during prescribing in general practice.

BACKGROUND/AIM: The process of precribing decision-making by general practitioners requires numerous consultations in order to obtain maximal effects, minimal risks, and cost-effectiveness with the full appreciation of a patient's right to choose. The aim of our study was to describe the process of decision-making by general practitioners who decide on the treatment for an individual patient, and to relate the scope and nature of this process to the quality of the outcome of the decision. METHODS: The study involved 53 general practitioners who worked in the Health Center, Kragujevac at the time of investigation (September-December 2002.). General practitioners made prescribing decisions, thinking aloud, for five patients with urinary tract infections (n = 2), or stomach complaints (n = 3). The resulting 265 transcripts were analyzed to determine the scope and nature of the decision-making processes. Differences in prescribing were related to the case or the practitioners' working experience, and to their educational background. RESULTS: Our results showed that the more years of practice the practitioners had the less treatments they prescribed, and the less additional aspects before prescribing they considered. The doctors with less experience, in most of the cases, considered the core aspects, while those with more experience more often considered the contextual and habitual aspects. Educational background of the general practitioners, and the type of a considered disease, had an influence on the decision-making process. The most optimal method for decision-making (marked as type F) was mostly used by the practitioners with the least experience, while the those with more experience mainly made their decisions in the ways considered the least acceptable. The optimal method for decision-making process does not necessarily provide the optimal therapy, so the least acceptable decision-making might not result in an inappropriate treatment. CONCLUSIONS: The observed prescribing decisions were mostly in disagreement with the Good Clinical Practice. Our study pointed out the need for the obligatory continuation of medical education of general practitioners in decision-making process during prescribing.

Adult↗
PubMed2000

The effects of clinical decision making on nurse practitioners' clinical productivity.

The degree of clinical decision making and clinical productivity among nurse practitioners (NPs) is of great interest to policy makers and planners involved in providing appropriate outpatient primary care services. The authors performed a statewide mailed survey of all NPs practicing either full-time or part-time in Wisconsin (response rate of 72.1%) to address the following research questions: Do the demographic characteristics, practice attributes, and primary practice settings of NPs impact their level of clinical decision making (e.g., the autonomy to order laboratory and radiological tests or to refer a patient to a physician specialist other than their collaborating physician)? Do NPs' levels of clinical decision making correlate with their outpatient clinical productivity, adjusting for demographic characteristics, practice attributes, and primary practice settings? The multiple linear regression results indicated that having more years in practice as an NP, practicing in the family specialty area (vs. a combined other category, which included pediatrics, acute care, geriatrics, neonatal, and school), treating patients according to clinical guidelines, practicing in settings with a fewer number of physicians, and practicing in a multispecialty group practice versus a single-specialty group practice were associated with greater levels of clinical decision making. However, NPs who primarily practiced in a hospital/facility-based practice, as compared with a single-specialty group practice, had lower levels of clinical decision making. After adjusting for demographic characteristics, practice attributes, and primary practice settings, NPs with greater clinical decision-making authority had greater outpatient clinical productivity. The conclusions discuss the policy implications of the findings.

Decision Making↗
PubMed1999

Faulty judgment, expert opinion, and decision-making capacity.

An assessment of decision-making capacity is the accepted procedure for determining when a person is not competent. An inferential gap exists between the criteria for capacity specific abilities and the legal requirements to understand relevant information and appreciate the consequences of a decision. This gap extends to causal influences on a person's capacity to decide. Using a published case of depression, we illustrate that assessors' uses of diagnostic information is frequently not up to the task of bridging this inferential gap in a justifiable way. We then describe cases of faulty judgement which challenge the understanding of diagnostic causal influences. These cases help to clarify the nature of the expertise required for capacity assessments. In practice, the requirements of decision-making capacity are often abandoned to other considerations due to a lack of requisite expertise. The legal policy supporting decision-making capacity as a means to protective intervention is justified only if the requisite expertise is developed. We propose the requisite expertise to be developed in the long term as a distinct multidisciplinary endeavour.

Beneficence↗
PubMed2001

The effects of routine strength on adaptation and information search in recurrent decision making.

The strength of decision routines was manipulated within a computer-controlled micro world simulation involving recurrent decision making. During a learning phase, participants were led to prefer a certain brand of an industrial good either about 15 times in a weak routine or about 30 times in a strong routine condition. In the test phase of Experiment 1, participants were confronted with changes in the microworld that rendered the routine obsolete. Routine maintenance over a series of repeated acquisition decisions was assessed as the major dependent variable. Although new information clearly suggested that a deviation from the routine would be beneficial, strong routine participants were more likely to maintain the routine compared to weak routine participants and a control group in which a comparable option (same outcome probabilities as the routine) carried an unfamiliar brand label. Experiment 2 investigated the effects of routine strength on information search. After having learned the routine, participants were asked to make one final decision involving the routine. The task was either framed as being similar to the learning task or as being novel. Before making the final decision, participants were asked to consider new information about the alternatives. Strong routine participants in the familiar task condition preferred information that favored the routine and avoided unfavorable information. If the task was framed as being novel, such confirmation biases disappeared completely. In contrast, weak routine participants exhibited a moderate confirmation bias in their searches independent from task framing.

Journal Article↗
PubMed2005

Analysis of clinical decision-making in multi-disciplinary cancer teams.

Management decisions for patients with cancer are frequently taken within the context of a multi-disciplinary team (MDT). There is little known, however, about decision-making at team meetings and whether MDT decisions are all implemented. This study evaluated team decision-making in upper gastrointestinal cancer. Consecutive MDT treatment decisions were recorded for patients with oesophageal, gastric, pancreatic and peri-ampullary tumours. Implementation of MDT decisions was investigated by examining hospital records. Where decisions were implemented it was recorded as concordant and discordant if the decision changed. Reasons for changes in MDT decisions were identified. 273 decisions were studied and 41 (15.1%) were discordant (not implemented), (95% confidence interval 11.1-20.0%). Looking at the reasons for discordance, 18 (43.9%) were due to co-morbid health issues, 14 (34.2%) related to patient choice and 8 (19.5%) decisions changed when more clinical information was available. For one discordant decision, the reason was not apparent. Discordant decisions were more frequent for patients with pancreatic or gastric carcinoma as compared to oesophageal cancer (P = 0.001). Results show that monitoring concordance between MDT decisions and final treatment implementation is useful to inform team decision-making. For upper gastrointestinal cancer, MDTs require more information about co morbid disease and patient choice to truly optimize the implementation of multi-disciplinary expertise.

Adult↗
PubMed1993

Coping patterns in adolescent decision making: an Israeli-Australian comparison.

The decision coping patterns of Israeli and Australian adolescents were compared in a cross-national study using two samples of 1028 Israeli and 428 Australian high-school students (age range 13.5-14.4 years). Both samples were administered a scale which measured self-reported level of confidence in decision making and tendencies to use various decision-coping patterns. Israeli adolescents scored higher than Australian adolescents on Self confidence as decision makers and Vigilance, and lower on evasive behavior in decision making (Cop out). In both samples, boys outscored girls on Self confidence as decision makers and on Complacency, and scored lower on Panicky behavior. For both samples, it was found that decision coping patterns reduce to two distinct clusters--a vigilant strategy and maladaptive strategies (panic, evasion, and complacency), evidence that decision-coping patterns have cross-cultural validity.

Adaptation, Psychological↗
PubMed1991

Participatory decision making: issues and guidelines.

The concept of shared responsibility in decision making through the use of participatory decision making has received considerable support in nursing education. There are important omissions in the discussions and applications of this concept. Problems in the use of participatory decision making as related to information transmission; conflict, consensus, and coalitions; and faculty/administrator role differences are analyzed. Criteria and guidelines for the appropriate use of participatory decision making are provided.

Conflict, Psychological↗
PubMed1989

[Ethical dilemmas in pediatrics: on competencies and qualifications in decision making].

In medicine medical decisions prove to be ethical issues. Whether treatment apart from being medically possible can also be meaningful, or can continue to be meaningful, is an ethical question, where interests, in nature different and sometimes contradictory, must be balanced against each other. In the department of paediatrics the doctor does not have to deal only with the patient himself, but he has also to deal with the parents, who have an interest of their own apart from the child's interest that they want to defend. A personal interpretation of standards and values can lead doctors and parents to different ways of considering the interest of the child. This can interfere with an ethically justified decision. What is essential in this discussion are the limits of everyone's proficiency, competence and responsibility. Starting from a case these notions and their implications for decisions-making will be worked out.

Cardiac Surgical Procedures↗
PubMed1995

Clinical decision making--an art or a science? Part I: An introduction.

In order to make the most appropriate decision in a given set of circumstances, an understanding is needed of how people formulate decisions on the basis of their surroundings. Using a case history, this article introduces the factors involved in clinical decision making and highlights the relevance of those factors in the decision making process. These will be discussed in depth in later sections of this series.

Adult↗