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PubMed2005

[Should health care information be provided in more than words? Experiences of plastic surgery in patients at looking at clinical photos].

INTRODUCTION: This article deals with an empirical study on the use of clinical photos as part of the information/communication between health professionals and patients. Normally the verbal method is used to provide information to patients. The hypothesis is that figurative and illustrative material can be a useful supplement to the spoken word. The study focused on patients' experience of looking at clinical photos. MATERIALS AND METHODS: The research was conducted in the Department of Plastic Surgery and Burn Care, Rigshospitalet, Copenhagen, Denmark. The study was a quality, explorative and descriptive interview research including 10 patients. RESULTS: This study shows that patients find it positive to look at clinical photos, because it gives them knowledge and understanding, as well as realistic expectations and a sense of security in having made the right decision. The photographs help confirm or invalidate their expectations. The combination of listening to verbal information and looking at pictures makes sense to the patient. DISCUSSION: This study shows that looking at clinical photos is one way to improve the information/communication between patient and health professionals. Clinical photos contribute to the emotional and bodily part of gaining knowledge and thereby complement the verbal information, which is primarily cognitive. The study shows that patients experience photos as a positive element in their treatment and demonstrates that photos give them an answer to how they will appear after surgery, which is difficult to describe in words. In this study age, sex and diagnosis did not seem to matter for the experiences of the patients.

Adult↗

PubMed1998

Priorities and priority-setting in health care in the Netherlands.

Since 1990, the priority-setting has become one of the key issues in making choices in health care. In 1991, the now famous Dunning Report was presented to the Dutch Cabinet. One of its main conclusions was that health services should satisfy four criteria: necessary care, effectiveness, efficiency, and individual responsibility. Priority-setting can be done either by excluding medical treatments from compulsory health insurance coverage and/or by the use of both protocols and guidelines, and the individual selection of patients by health professionals. The discussion on the introduction of in vitro fertilization into the basic health insurance package and the exclusion of dental care for adults have shown that, on the basis of the Dunning criteria, it is not easy to leave complete or parts of services out of the basic health insurance package. The second strategy - the application of the Committee's criteria by the use of protocols, guidelines, and budget restrictions - is even more difficult to realize. More patients assert their right to health care benefits before courts. The courts' decisions have shown that it is difficult for the patient's counsellor to prove that government is responsible for non-delivery due to force majeur. Courts attach much importance to the Dunning criteria; in particular the criterion of necessity.

Adult↗

PubMed2006

Communication about euthanasia in general practice: opinions and experiences of patients and their general practitioners.

OBJECTIVE: Public opinion and professional organisations dominate the euthanasia debate, and there is a need to understand the opinions of people confronted with euthanasia. The aim of this study was to investigate whether patients and their GPs talk about euthanasia, and if so, how they communicate about this. METHODS: Qualitative, semi-structured interviews were held with 20 GPs and 30 of their patients in primary care in the Netherlands, where euthanasia is legalised. The patients had a life expectancy of less than 6 months, and cancer, heart failure or chronic obstructive pulmonary disease as underlying disease. RESULTS: Many patients did not communicate about euthanasia with their GP. Neither the patient nor the GP were clear in formulating their expectations concerning future decision making. CONCLUSION: The initial patient-GP communication consisted of an exchange of opinions about situations in which euthanasia would be desirable. GPs had different opinions about who should initiate communication, and found it difficult to judge the right moment to talk. PRACTICE IMPLICATIONS: It is essential to pay attention to education in communication about dying and euthanasia and to train the GPs to gain insight in the patient's end-of-life preferences, and to direct care at the best possible quality of life.

Advance Care Planning↗

PubMed1993

Linking ethical principles with community practice.

Nurses must frequently make arduous decisions when faced with ethical dilemmas that occur in clinical practice. Utilizing ethical principles for analyzing and reflecting on the issues may ease this difficult task. In addition, the nurse involved may experience less anxiety and uncertainty over whether or not the correct decision was made. The purpose of this article is to present a case study that involves the allocation of a scarce resource that posed an ethical dilemma for a nursing instructor and her students in a community health setting. Toulmin's framework is utilized for analyzing this dilemma.

Beneficence↗

PubMed1995

[Methodologic decisions in evaluation of psychotherapy].

Psychotherapy research makes demands on evaluation studies in regard to content and methodology. These demands, however, are difficult to realize. The expense of a study results in a multidimensional matrix consisting of: the different sources of data, number and extent of the measures on theoretically derived assessment levels, the number of times measures are repeated, and the sample size. Decisions for research methods should be deduced explicitly from the goal of the evaluation study as well as from the goals of the evaluated therapy. Alternatives for the choice of operationalization, test designs, data evaluation and presentation will be reviewed and discussed.

Goals↗

PubMedDate not supplied

Do notions of risk inform patient choice? Lessons from a study of prenatal genetic counseling.

Risk modeling is an increasingly important part of clinical medicine; however, "risk status" is a complex notion, understood differently by patients and clinicians. Patients' ability to make informed choices about clinical procedures often requires that they interpret risk statistics, which may be difficult to understand and apply. In this article, which is based on a study of prenatal care in South Texas, we consider how notions of risk affect patient decisions about prenatal genetic testing. The term "risk" carries multiple meanings for clinicians and patients. These meanings may conflate concepts of danger and probability as well as muddle population risk and individual risk. We propose that failure to articulate the varied and contrasting meanings of risk held by clinicians and patients can undermine clinical communication and, thereby, hamper patients' ability to make autonomous, informed choices. Attending to these differences may prove useful in empowering patients to make truly informed decisions.

Adult↗

PubMed1982

Physical therapy manpower planning. Projection models and scenarios of 1985.

Faced with the difficult task of coordinating statewide health education, the Kentucky Council on Higher Education is using several manpower projection statistics as one component of their decision-making process. These manpower data are essential when considering the establishment, expansion, continuation, or termination of health-related academic programs. Three models were used to project manpower requirements for licensed physical therapists in Kentucky. The models were 1) manpower:population ratio, 2) trend analysis based on time series, and 3) the American Physical Therapy Association's health-needs method. Four variants of the manpower:population ratio model are discussed and presented: population ratio based ona 1) national ratio, 2) Kentucky ratio, 3) weighted national ratio, and 4) weighted Kentucky radio. The trend analysis model is presented and discussed. The health-needs approach, based on expert opinion and health-related variables, identifies the quantity and quality of services required to provide the Kentucky population with the best possible care. The paper concludes with three brief scenarios describing the possible effects of the three models and physical therapy in Kentucky. The scenarios unfold from differing assumption about the effects of manpower production on health care. Scenario A is a "current arrangement" scenario. Scenario B considers the effects of predicting future manpower requirements and resources based on the past. Scenario C projects the effects of a comprehensive plan on the goal of producing the best possible care for all Kentuckians.

Forecasting↗

PubMed2006

Ethics review: position papers and policies--are they really helpful to front-line ICU teams?

During the past few years the ethics sections of critical care societies have proposed a number of policies describing the goals of intensive care unit (ICU) care and providing broad guidance on the diagnoses and physiological criteria that would mandate using the specialized skill and technologies of an ICU environment. Discussions on what constitutes appropriate use of such scarce resources, incorporating cultural and religious beliefs and exploring how they interact with these medical criteria, remain vague. To date, these policies do not provide any definitive guidance in the difficult decision making faced by clinicians. Some argue that they were never meant to do so and yet they have served to guide the development of local hospital policies. Many have explored how critical care services are allocated without achieving consensus on the best way to achieve fair and equitable access to life-sustaining interventions. A consensus is needed though, one that is reflective of both individual and societal values and goals. Otherwise, increasing pressure to provide treatments with marginal benefits at best will threaten the ability of others to access treatments that may offer them very real benefits.

Critical Care↗

PubMed1992

Clinician activism and ethical restraints in providing treatment: preventive as opposed to reconstructive approaches.

There is seldom controversy when faced with treatment decisions for a child born with a birth defect. Occasionally, the situation arises in which a decision to withhold treatment must be made. Under most circumstances the responsibility for making such decisions rests with the child's parents or guardians, since it is generally felt that these individuals are the best advocates for the child's best interests. In order to make such difficult decisions, the parents are dependent upon the guidance and counseling of health professionals, especially the physicians most closely involved in each case. The ultimate decisions made by parents are dependent upon open and unambiguous communication with their children's clinicians as well as open communications among the caregivers themselves. The role of the clinician as an advocate for treatment and nontreatment of children is dependent upon clear unbiased communication and the desire to do what is in the best interest for each patient.

Congenital Abnormalities↗

PubMed1990

[Christian social ethics and medicine].

In bygone centuries, the maxim of doing no harm was enough to define intervention by a doctor; now, in contrast, dealing with the possibilities opened up by modern medical technology demands increasingly careful observance of the moral virtue of the correct degree of moderation. The present ethical challenge when medical decisions have to be made is not simply to be allowed to do everything possible. The art of medical intervention has to be exercised with due respect for the concept of temperantia medici, which, however, has to have significance not only in the concrete individual case, but also in the wider context of social ethics, that is to say for health services as a whole. The anonymity resulting from increasing specialization, the tendency to think impersonally in terms of probabilities following the introduction of screening programmes with routine examinations and the connected legalization of medicine are addressed as particularly important problems in this respect; all these trends beset the personal doctor-patient relationship with difficulties and suggest the procedure with the greatest technological input as the safest and most convenient solution, thus making it difficult to find the correct degree of moderation. As a result of all this, modern medicine is evidently being regarded with increasing scepticism by wide sections of the population, a situation demanding an ethically appropriate return to the old medical virtue of moderation.

Christianity↗

PubMedDate not supplied

Understanding the feasibility of integrated care: a rival viewpoint on the influence of actions and the institutional context.

There is in Europe growing awareness that the delivery of integrated care is required to meet the demands of an increasing number of patients with multiple problems. It is also clear that the provision of integrated care is difficult to achieve. As yet, the debate about the circumstances enabling or hindering provision is not settled. The objective of this article is to generate more knowledge on this issue. It is often assumed that the feasibility of integrated care provision is caused by characteristics of the legislation, the financing system and other aspects of the institutional context. Here it is argued that these characteristics are relevant but not decisive. Based on empirical evidence from the Dutch case a rival viewpoint is presented, suggesting that it is the commitment of the actors involved, their support, and the way developments are being managed, that make the difference. Following presentation of the evidence, the implications of the findings for integrated care policy are discussed.

Delivery of Health Care, Integrated↗

PubMed1996

Ethical decision-making near the end of life.

For ethical decision-making near the end of life, autonomy is the moral North Star. At the same time, for some treatments, the burdens so clearly outweigh benefits that physicians may make a judgment not to offer the treatment. This is often clearer in surgery. A person with colon cancer and metastases may not insist on resection of the metastases. For some reason, some treatments have escaped these logical constraints. Attempted resuscitation of a dying patient is a good example. The circumstances in which a physician may make choices on behalf of a competent, terminally-ill patient without consent, and even without notification, are hotly debated, but data suggest that physicians do so frequently. Patients who lack capacity present even more difficult challenges. Advance directives, when available, can be extremely helpful, but even with them difficult problems can remain. If advance directives have not been established, family and close friends are an obvious source of guidance. Their legal role varies in different jurisdictions; in practice, they are crucial in bedside decision-making. Guardianship and alternatives to it remain a poor last resort. Euthanasia is a very difficult problem. We believe it is semantically misleading to lump under the term "passive euthanasia" those circumstances where potentially life-sustaining treatment is withheld or withdrawn. The tension between patient autonomy and medical common sense remains unresolved within the "futility" controversy. The authors believe it serves no purpose to discuss carefully with dying patients propositions that are nonsense. At the same time, physicians must not confuse decisions about quality of life with judgements about treatment effectiveness. We believe that what many, although not all, dying patients want are physicians with intelligent compassion who can take care of them through the dying process.

Advance Directives↗

PubMed1988

Cost-effectiveness in healthcare: complexity of the equation.

Integrating scientific changes, citizens' needs and economic constraints has become a challenge. New types of cost-effective services, technologies and products must be found. Manufacturers, hospital administrators and health professionals must be capable of effectively documenting the benefits, risks and costs of their services to society and the quality of care to patients. Choices must be made to decide upon appropriate actions in allocating and using resources. The concepts of cost-benefit analysis and cost-effectiveness analysis should be understood. Identifying and valuing costs and benefits, measuring effectiveness, and assessing quality of life are complex and difficult issues. They are discussed in reference to Canadian studies on the cost-effectiveness of nutrition support. The need for further research to improve cost-effectiveness of nutrition support is stressed.

Canada↗

PubMedDate not supplied

Empowered employees--a good personnel investment.

Health care has entered a new competitive era in the 1990s, and, combined with the other pressures association with health care, clinical laboratory managers are facing the challenge of having to do more with less. This "pressure-cooker" environment requires clinical laboratory managers to find new ways to motivate their teams to perform at peak levels at all times; the key to doing this is empowerment. By empowering employees, managers create a nurturing environment in which their staffs can learn, grow, improve, and function effectively. This type of environment is created when managers are honestly concerned about their employees and exhibit a true "partner" attitude. This article describes five specific actions that clinical laboratory managers can take to empower their employees to work together to do better jobs. These actions include sharing expectations; providing new employees with helpers, guides, and buddies; giving feedback; involving employees in decision making; and paying attention to customer service and what other laboratories are doing. These actions will help clinical laboratory managers empower their employees to face the difficult challenges of the 1990s.

Communication↗

PubMed2002

Clinical effectiveness and evidence-based practice.

An essential component of clinical governance is clinical effectiveness, which is achieved through evidence-based practice. This has enormous implications for the way nurses work, and the qualitative approach often taken by nurse researchers can be difficult to incorporate into the new systems. Clinical governance should have benefits for patients and NHS staff alike. If the goals are to be achieved, a multidisciplinary approach will be needed, with greater encouragement being given to creative research methods. In addition, nurses will have to become more powerful inside healthcare organisations.

Attitude of Health Personnel↗

PubMed2005

[Criteria for the development and evaluation of decision aids].

Decision aids (DA) are interventions designed to support individuals in making specific and deliberate health- or illness-related choices. The assessment of the quality of DAs is presently under discussion. On the basis of a systematic literature review, this article provides a survey of methods and open questions in quality assessment of DAs. Quality assessment of DAs is presently limited to the evidence of efficacy through controlled trials based on single-outcome measures. However, since DAs are multicomponent interventions, single-outcome trials are insufficient for complete quality assessment; also, it is difficult to identify the causes for the adequacy or inadequacy of a particular DA. The present analysis identified an elaborated and systematic guide to evaluate DAs. On the basis of this instrument, we propose a novel instrument which is aimed at disclosing the complex relation between background theory, methods, and aims of a DA. The proposed instrument is still under development and has to be evaluated in validation studies.

Decision Making↗

PubMed1984

Management of the unanticipated neural tube defect in late pregnancy.

The physician who encounters a patient in late pregnancy with a neural tube defect is presented with a difficult task of management and treatment. A thorough examination of the defect(s) is mandatory. This can be accomplished best with ultrasound examination. It is then imperative to assess the severity and survivability of the fetus, and to counsel properly the patient as to diagnosis, severity, and options available. After discussion with the proper consultants, patients should have considerable input into the management, and should be informed adequately to make an intelligent and proper decision. After careful assessment and thorough consultation and counseling with the patient and her support person, therapy can be initiated, followed by some type of grief counseling with appropriate follow-up. Patients also should be informed as to subsequent risks and what, if anything, could possibly be done to prevent recurrences. By this careful and thorough approach it is hoped that physicians who encounter neural tube defects late in pregnancy will make a considerable difference in the physical as well as the emotional health of the patient.

Counseling↗

PubMed2000

[Graft safety and need satisfaction: searching for a crucial balance].

In 1998, 3,033 organs were transplanted and 3,186 stem cell and 4,053 cornea grafts were performed in France. Organ shortage varies for each organ but is particularly critical for kidneys. Given the physiological and therapeutic efficacy of grafting, an increase in organ procurement is likely to raise safety problems. This paper concerns donor-transmitted infections, mainly viral infections. Regulations on health risks express a social and cultural refusal to accept any hazard. This collective concern is however in opposition with the interests of individual patients who are likely to accept a greater risk for an obvious benefit. Although the assessment of the risk/benefit ratio is clearly different between organ and tissue transplantation, further thought needs to be given to the problem of acceptance of infectious risk in organ transplantation. In France, special exceptions are now legally authorized for specific situations. Infectious agents transmitted by grafting have not been largely reported, mainly because screening tests were not available. The number of transmitted infections is increasing with the expansion of transport facilities and with the various geographical origins of the population. In some cases, search for histocompatibility between relatives living in endemic areas introduces new risks, for example tropical diseases. Diagnosis is often made by serological or molecular biological tests which may be difficult to analyze depending on their specificity. Organ transplantation is often an emergency requiring rapid decision making, for the donor or the recipient. However, with a quality assurance process based on accepted guidelines, the appropriate answers to operational problems can be given rapidly. Patient satisfaction can be achieved only if the public health challenge is met. Increasing organ procurement can clearly be expected to be beneficial, but at the cost of higher risks. Nevertheless, benefit and risk are quite different, benefit is for the time being while risk is delayed and may be uncertain depending on individual survival. Because of the variability of human disease, especially in situations where an ultimate therapy is involved, automatic application of a standard procedure must be avoided as it would inevitable lead to a cut-back in organ procurement in an attempt to achieve a theoretically safe situation which would be contrary to individual patient's self-interest. Health care workers should have good knowledge of the epidemiology of these diseases in order to assess risk. The patient must be able to express informed consent.

France↗