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Results for “Making Difficult Health Care Decisions”

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PubMed2000

Rethinking fundamental assumptions: SUPPORT's implications for future reform. Study to Understand Prognoses and Preferences and Risks of Treatment.

BACKGROUND: The intervention in SUPPORT, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments, was ineffective in changing communication, decision-making, and treatment patterns despite evidence that counseling and information were delivered as planned. The previous paper in this volume shows that modest alterations in the intervention design probably did not explain the lack of substantial effects. OBJECTIVE: To explore the possibility that improved individual, patient-level decision-making is not the most effective strategy for improving end-of-life care and that improving routine practices may be more effective. DESIGN: This paper reflects our efforts to synthesize findings from SUPPORT and other sources in order to explore our conceptual models, their consistency with the data, and their leverage for change. RESULTS: Many of the assumptions underlying the model of improved decision-making are problematic. Furthermore, the results of SUPPORT suggest that implementing an effective intervention based on a normative model of shared decision-making can be quite difficult. Practice patterns and social expectations may be strong influences in shaping patients' courses of care. Innovations in system function, such as quality improvement or changing the financing incentives, may offer more powerful avenues for reform. CONCLUSIONS: SUPPORT's intervention may have failed to have an impact because strong psychological and social forces underlie present practices. System-level innovation and quality improvement in routine care may offer more powerful opportunities for improvement.

Decision Making↗

PubMed1987

Application of meta-analysis using an electronic spread sheet to exercise testing in patients after myocardial infarction.

Decision analysis is being applied to medical practice in order to achieve cost efficacy in health care delivery. Critical to this process is establishing the diagnostic and prognostic accuracy of medical tests and the effectiveness of interventions. Meta-analysis is an approach that applies statistical methods to groups of studies in order to extract consensus results. Electronic spreadsheets facilitate meta-analysis with their ability to store, sort, graph, and mathematically manipulate both the methodologic approaches and clinical findings of seemingly disparate studies. As an example, this application is demonstrated with an analysis of studies that were performed to evaluate the prognostic value of exercise testing in patients recovering from a myocardial infarction. The following conclusions were reached: (1) patients excluded from exercise testing have the highest mortality; (2) only subsets of patients have been tested resulting in highly selected patient samples that make findings difficult to generalize; (3) of the five exercise test responses, only an abnormal systolic blood pressure response and a poor exercise capacity predicted risk more frequently than by chance; (4) submaximal or predischarge testing has greater predictive power than postdischarge or maximal testing; and (5) exercise-induced ST segment depression only appears to be predictive of increased risk in patients with inferior-posterior myocardial infarctions. This approach to combining studies is important since even careful analysis of a single study cannot elucidate all of the complex interactions and selective biases that have occurred. However, comparison of many heterogeneous studies is at best an arduous and time-consuming task. This approach to using electronic spreadsheets to collate and analyze multiple studies facilitates recognition of the population characteristics, clinical factors, and methodologic considerations that affect outcome and allows the quick inclusion of additional studies for re-analysis and interpretation.

Blood Pressure↗

PubMedDate not supplied

Gender and cancer support group participation.

PURPOSE: Although support groups are offered to many patients who have received a diagnosis of cancer, a majority of patients choose not to participate. This article reports the results of a study comparing the behavior of men diagnosed with prostate cancer and women diagnosed with breast cancer in their responses to invitations to participate in support groups. DESCRIPTION OF STUDY: One hundred thirty women with breast cancer and 87 men with prostate cancer completed a structured telephone interview. The interview included questions about the patients' choices about support group participation. RESULTS: Interview findings showed that men are less likely to join a support group, but those men who do join attend meetings for about 1 year, as do the women who join. Men and women cite essentially the same reasons for participation: to learn more about their diagnosis, to share their, concerns to compare their physical and emotional progress with other individuals. CLINICAL IMPLICATIONS: These results indicate the need for further exploration of effective interventions for men and women who have been diagnosed with prostate and breast cancer, respectively, in an effort to offer support for the difficult psychological and emotional issues associated with their diagnoses. Although more women than men join support groups, the majority of both populations (67% for women, 87% for men) do not attend any support group meetings. Innovative approaches are needed to encourage participation in existing support groups or to design alternative interventions.

Aged↗

PubMed2001

Health promotion and the First Amendment: government control of the informational environment.

Government efforts to protect public health often include controlling health information. The government may proscribe messages conveyed by commercial entities (e.g., false or misleading), recommend messages from commercial entities (e.g., warnings and safety instructions), and convey health messages (e.g., health communication campaigns). Through well-developed, albeit evolving, case law, government control of private speech has been constrained to avoid impinging on such values as free expression, truthfulness, and autonomous decision making. No simple legal framework has been developed for the government's own health messages to mediate between the legitimate goals of health protection and these other values. Nevertheless, government recommendations on matters of health raise difficult social and ethical questions and involve important societal trade-offs. Accordingly, this article proposes legal and ethical principles relating to government control of the health information environment.

Advertising↗

PubMed1985

Financing urban primary health services. Balancing community and government financial responsibilities, Pikine, Senegal, 1975-81.

It is difficult to prejudge a community's capacity to satisfy its basic human needs, because no satisfactory method has been developed to predict the potential resources of a poor community. To improve their health conditions, all people, even poor, have some resources available. When they can manage themselves and be involved in decision making, they can become very efficient and contribute many material and human resources needed to organize health facilities in situations where the government fails to provide for wide-ranging needs, especially in the new cities. This was demonstrated by our experiment in Senegal between 1975 and 1981. This paper discusses the respective roles and responsibilities of the communities and the government in terms of: the process of setting up and carrying out the project in Pikine and the stages of community participation; and the pre-conditions for successful co-management in a primary care organization financed in a large part by the community.

Community Health Services↗

PubMed2002

Supporting organizational learning: a comparative approach to evaluation in action research.

For well over a decade, the organizational context of nursing in the United Kingdom has been one of change and reform with a policy shift towards primary and community led health care. Such a major shift in policy provides nurses with an opportunity to re-think their approaches towards the individuals and communities they serve in order to promote self-care, recognize achievable health goals and provide family and community support. Although there is a growing appreciation of action research as an useful approach to this kind of development, it can be difficult to evaluate published studies because of the diverse nature of the literature. This paper will present and evaluate two case studies using a particular conceptual device (The Normative Information Model-based Systems Analysis and Design) in order to explore a possible alternative to the interpretative narrative or positivistic hypothesis-testing models used to report other kinds of nursing research and enlarge the debate about process evaluation.

Decision Making, Organizational↗

PubMed1999

Ethics in long-term care. Are the principles different?

It has become common in medical ethics to discuss difficult cases in terms of the principles of respect for autonomy, beneficence, nonmaleficence, and justice. These moral concepts or principles serve as maxims that are suggestive of appropriate clinical behavior. Because this language evolved primarily in the acute care setting, I consider whether it is in need of supplementation in order to be useful in the long-term care setting. Through analysis of two typical cases involving residents of long-term care facilities, I argue for the additional principles of candor and responsibility for narrative integrity.

Aged↗

PubMedDate not supplied

Strategic decision-making in healthcare organizations: it is time to get serious.

New and continuing environmental demands and competitive forces require healthcare organizations to be increasingly careful in thinking about their strategies. They must do so in a highly unusual (multi-actor) marketplace where a variety of system interdependencies complicate decision-making. A good strategy requires an attempt to understand the real, as distinct from the perceived, environment, and is characterized by explicit tradeoffs along three dimensions: service or program variety, patient needs, and patient access. The quality of these tradeoffs can be assessed in terms of whether the strategy is (a) attuned to critical success factors in the organization's environment, (b) highly focused, (c) linked to the organization's capabilities, and (d) accompanied by an activity set that is difficult for competitors to imitate. An organization also must be capable of adapting appropriately to changes in its environment. Thus, even the best strategy must be reviewed constantly if it is to remain viable. A strategy's sustainability can be adversely affected by increased buyer or supplier power, lowered barriers to entry, growing rivalry, the threat of substitutes, and increased slack in resource usage. By thinking more creatively in the future than they have in the past, healthcare organizations can make tradeoffs and choose a focused strategic position. They then can design an activity set that is appropriate for that position, and that will assist them to achieve both financial viability and superior programmatic performance. A well-designed activity set also will assist them to sustain their performance in the face of changing environmental demands and competitive forces.

Age Distribution↗

PubMed1993

Resolving the casualty evacuation conflict.

One of the most contentious issues surrounding the prehospital management of the injured is the decision to stabilize on site or to rapidly evacuate the patient. Although there are vociferous proponents for both views, there appears to be little thought given to the rationalization of these decisions, and the subject has only merited lip-service in previous texts. Treatment choices and decisions in the prehospital environment are notoriously difficult to make. The doctor, unlike ambulance paramedics, does not necessarily work to didactic protocols and, if suitably trained, is at liberty to commence advanced resuscitation procedures at the roadside. However, these may be time consuming and, to be of greatest benefit to the patient, a fine balance between resuscitation and evacuation must be drawn. This paper aims to discuss some of the key issues which need to be considered in the prehospital scenario, such as treatment triage, evacuation priorities, mode of transportation and hospital destination. The end result must be to eliminate the medical 'bottleneck' and to afford early and appropriate definitive care to those in most need.

Aircraft↗

PubMedDate not supplied

Using a quality improvement team to reduce patient falls.

Preventing falls among hospitalized patients continues to be a major concern of nurses, as evidenced by the volume of literature on this subject during the past 10 years. Yet, preventing falls, like preventing medication errors, has been a difficult and chronic issue for most nursing departments. Carolyn Corbett and Barbara Pennypacker describe how the nursing staff at Robert Packer Hospital in Sayre, PA, finally has experienced success by applying the systematic methods and principles of continuous quality improvement and establishing a fall prevention process.

Accidental Falls↗

PubMed2006

Endodontic or dental implant therapy: the factors affecting treatment planning.

BACKGROUND: Clinicians are confronted with difficult choices regarding whether a tooth with pulpal and/or periapical disease should be saved through endodontic treatment or be extracted and replaced with an implant. METHODS: The authors examined publications (research, literature reviews and systematic reviews) related to the factors affecting decision making for patients who have oral diseases or traumatic injuries. RESULTS: The factors to be considered included patient-related issues (systemic and oral health, as well as comfort and treatment perceptions), tooth- and periodontium-related factors (pulpal and periodontal conditions, color characteristics of the teeth, quantity and quality of bone, and soft-tissue anatomy) and treatment-related factors (the potential for procedural complications, required adjunctive procedures and treatment outcomes). CONCLUSIONS: On the basis of survival rates, it appears that more than 95 percent of dental implants and teeth that have undergone endodontic treatment remain functional over time. CLINICAL IMPLICATIONS: Clinicians need to consider carefully several factors before choosing whether to perform endodontic therapy or extract a tooth and place an implant. The result should be high levels of comfort, function, longevity and esthetics for patients.

Bone Density↗

PubMed1988

Multidisciplinary teams in health care: lessons from oncology and renal teams.

An indepth study conducted on units treating renal disease and cancer clinics determined that multidisciplinary teams are relatively commonplace in these areas. Developing four team organizational structures--sequential, primary, nucleus and dynamic--the authors hypothesize that each varies on a continuum in terms of how highly structured they are. The framework suggests that the ideology of equal participation on the team is the most difficult to sustain, and that difficulties typically arise as organization requirements become more complex. More research seems to be indicated to develop a comprehensive organizational framework, and the probable effect of organizational form on team performance. One of the key issues addressed is team leadership.

Canada↗

PubMed2001

Parent-requested treatment.

The decision about EPO was referred to and made by the Drug Committee, a committee of physicians, nurses and pharmacists. This committee has perforce to make decisions about drugs and vaccines, decisions which sometimes have a significant ethical component due to concerns about cost, safety and efficacy. Our hospital is considering developing a Clinical Ethics Advisory Committee, to assist with difficult ethical decisions such as this one. Should such a committee be asked to make acute ethical judgements on patient management? Larcher describes his ideal Hospital Ethics Committee as nonprescriptive, and suggests a more appropriate role is retrospective analysis and reflective discussion of clinical ethical problems. Such discussion may help with future rather than current management issues, and can help support clinicians in their decisions and hospital staff in their management of patients.

Anemia↗

PubMed1987

Ethical and legal issues in the care of the impaired newborn.

The subject is approached from the standpoint of the debates and events of the "Baby Doe era," from 1982 to 1985. Historic episodes of mass infanticide and practices in other cultures, while often cited as warnings of moral peril, are difficult to apply to the problem of infant euthanasia. Key cases in American courts are reviewed, although no standard pattern of analysis is found to have emerged. The two streams of policy making at the national level, from the Department of Health and Human Services and the Congress, have effectively led back to underlying ethical dilemmas about the proper interpretation of the infant patient's best interests. The conclusion alludes to several issues that neonatal ethics has yet to confront.

Beneficence↗

PubMed1996

[High technology in a family perspective].

High technology medicine poses high demands for knowledge and technical competence. In addition, the hospital is expected to represent a model for total care where the "customers" also include family members, eg. parents and children. Both economic and human resources are needed in order to avoid negative after-effects and complications for both patient and family. High technology medicine also raises difficult ethical questions: How much decision-making should be left to parents? These problems are illustrated by clinical examples, and hospital-based ethical committees are suggested as a structure for the further efforts to improve ethical competency at the hospital and to find appropriate solutions for patients and their families in both the long and the short term.

Caregivers↗

PubMed2004

The effectiveness of public health nursing: the problems and solutions in carrying out a review of systematic reviews.

BACKGROUND: In 1999 the Scottish Office, United Kingdom, intimated that the Chief Nursing Officer would undertake a policy review of nurses' contribution to improving the public's health. The importance of reviewing the scientific literature on the effectiveness of public health nursing was recognized as a crucial part of the policy review. A final report was expected within a 6-month period. The reason for the short time period was to fit the policy-making schedule. This paper discusses our literature review for this work. AIMS: The aim was to conduct a review of the international scientific literature that gave the greatest coverage of the role and potential role of nurses in improving the public's health in relation to 14 major health topics. This paper describes the methods used, outlines the rationale underpinning the methods, discusses the problems encountered and offers solutions to some of these problems. METHODS: The initial search for relevant scientific literature revealed 709 suitable primary papers. Reviewing this number was beyond the time limit set by the funding organization. Therefore, a decision was made to concentrate on the evidence contained in systematic reviews. Reviewing systematic reviews raises a number of methodological problems to which there are often no predetermined solutions, such as ensuring that important interventions are included, assessing the relevance and quality of the reviews, and grading the strength of the evidence. DISCUSSION: Reviewing systematic reviews provides the scope to increase the number of topics that might be covered. However, it is possible that a number of interventions may be missed, particularly those that are not subject to review or those assessed using qualitative techniques. The definition of public health nursing used in the present study was also restrictive, and could be widened to include community interventions. Finally, assessing the quality of reviews and grading the evidence proved difficult and there is lack of consensus on how these tasks should be achieved. Nevertheless, the review presented policy makers with accessible information on a large number of relevant international studies.

Delivery of Health Care↗

PubMed1997

Diagnostic tools and measurements--impact on appropriate care.

The diagnosis of primary coronal caries should be seen as a complex process, comprising both detection and measurement phases, which enables clinicians, researchers and epidemiologists to make informed decisions about the management and prognosis of the disease process. The different diagnostic thresholds employed for measurements of caries experience can be viewed as an iceberg, a metaphor which demonstrates the ambiguity of the term "caries free" and which can also represent the differing management options appropriate for the care of different types of active and inactive lesions: NAC (No Active Care). PCA (Preventive Care Advised) and OCA (Operative Care Advised). There are considerable methodological difficulties in drawing valid comparisons between studies using incompatible criteria and simulations. However, it is apparent that no caries diagnostic tool in current clinical use fulfils all of the ideal criteria for measurements needed to plan and monitor appropriate care. Systems providing reliable serial measurements with which to assess future caries risk and present caries activity are urgently required as diagnostic tasks are becoming both more difficult and more important from the standpoint of long-term oral health. Existing diagnostic tools frequently rely on subjective judgements and provide only semi-quantitative measures insensitive to smaller lesions. In the future tools are needed which are objective, quantitative and which can provide acceptable compromises between sensitivity and specificity for a wide range of applications for individual patient care as well as for research and survey use. Key problem areas with existing tools include confusion in terminology and between caries assessments made by clinicians and epidemiologists as well as the lack of valid measurements relating to the activity of primary root caries and secondary caries. Deficiencies with current tools impact on the care of individuals by allowing false negative diagnoses of hidden occlusal dentine lesions and approximal cavities on the one hand, whilst generating some false positive diagnoses on sound surfaces leading to inappropriate decisions to restore on the other. At the population level, current conventional tools significantly underestimate overall caries experience. In future the adoption of more accurate and reliable methods would facilitate more effective preventive care and promote more appropriate restorative treatment decisions. Research in this area should focus for the next five years on diagnostic technologies which: 1) inform valid prospective caries risk assessments for different age groups, 2) can help to determine present caries activity and monitor lesion behaviour over time and 3) help identify methods which can implement existing and new research knowledge about diagnostic tools into clinical and research practice.

Age Factors↗

PubMed2004

The transformational model for professional practice: a system integration focus.

Healthcare organizations face the increasingly difficult challenge of providing services that are of high quality, reasonable cost, and easy accessibility for their constituents. Mergers and acquisitions are one strategy for accomplishing this, but in doing so it is critical to have a "road map" to create an integrated system, rather than merely a consortium of hospitals. The University of Pittsburgh Medical Center has successfully created an integrated healthcare system of 19 hospitals. The authors describe the professional practice model used as a framework for success in integrating patient care.

Decision Making↗