SEARCH · PubMed Health

Results for “Making Difficult Health Care Decisions”

Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 703 records · Page 39Linked to original sources

PubMed2006

Health system in India: opportunities and challenges for improvements.

PURPOSE: The paper seeks to show that health and socio-economic developments are so closely intertwined that is impossible to achieve one without the other. DESIGN/METHODOLOGY/APPROACH: This paper sees that building health systems that are responsive to community needs, particularly for the poor, requires politically difficult and administratively demanding choices. Health is a priority goal in its own right, as well as a central input into economic development and poverty reduction. FINDINGS: The paper finds that, while the economic development in India has been gaining momentum over the last decade, the health system is at a crossroads today. Even though Government initiatives in public health have recorded some noteworthy successes over time, the Indian health system is ranked 118 among 191 WHO member countries on overall health performance. ORIGINALITY/VALUE: This working paper describes the status of the health system, discusses critical areas of management concerns, suggests a few health sector reform measures, and concludes by identifying the roles and responsibilities of various stakeholders for building health systems that are responsive to the community needs, particularly for the poor.

Community Health Planning↗

PubMed1983

The ethics of resource allocation: a case study.

The paper analyses the factors involved in a series of decisions by the Newcastle Area Health Authority concerning the future of one of its hospitals, as an illustration of the way in which choices about priorities in the health service are actually made. There is no easy way to resolve the various conflicts of interest, notably in this case the competing demands of acute and chronic medicine. Difficult decisions are made more difficult, however, by the over-rigid division of medicine into compartments, by mistrust between the medical profession and administrators, and by the inordinately long time-scale of the decision-making process. It is suggested that there might be value in acknowledging explicitly that occasional examples of 'heroic medicine' must not be allowed too much influence in shaping public expectations. The paper results from the deliberations of a working group on current medical-ethical problems, set up under the auspices of the Northern Regional Health Authority (I).

Decision Making↗

PubMedDate not supplied

[Interdisciplinary cooperation: experiences from the model project "Development of Counseling Criteria for Counseling Pregnant Patients Expecting a Handicapped Child"]].

The three-year model project "Development of consultation criteria in consulting pregnant women expecting a child with possible birth defects" aimed above all at constructing an interdisciplinary cooperation to offer the possibility of a psycho-social consultation to women and couples who are put under pressure of decision after prenatal examinations. The intended interdisciplinary cooperation between physicians and psycho-social consultation centres which are independent of the medical system resulted to be especially difficult due to the fact that various cooperation impediments stood against the construction of regular working relationships. Most of all, the differentiation of the various definitions of medical and psycho-social consultation and the relevant tasks seem to be evaluated differently by the individual profession groups. Moreover, it is not yet possible to make compatible the special working structures of the profession groups, i.e. in the medical public health system, hierarchical structures are prevailing while psycho-social consultation in free bodies bases on the voluntariness of its use. Thus, a cooperation between psycho-social consultation centres for pregnant women and clinics and established gynecologists was possible in a few cases only.

Congenital Abnormalities↗

PubMed1993

[Prioritizing in hospital departments].

A framework for decision-making is introduced in which two out of five patients will be denied treatment. Certain resource constraints are accepted in this hypothetical example. The authors' own ranking of five patients from a department of internal medicine are presented. It was not difficult to select the highest prioritized patients. However, ranking of the remaining patients revealed considerable controversy. Emphasis is therefore laid on the reasons given for each ranking. An interesting finding is that variations in awarding priority to some cases are clearly based on disagreement about facts, not values. The article concludes by suggesting a classification of selection criteria for priority setting based on a distinction between necessary, controversial and unacceptable criteria. The article is presented in an attempt to stimulate a debate about priority setting in everyday hospital work.

Decision Making↗

PubMed2005

Creating a new structure for research on health care effectiveness.

Effectiveness research (a term we use in preference to the more confining and difficult health services or outcomes research) evaluates the clinical setting and the health care system on which it depends. It uses a variety of health care assessment techniques and the practical clinical trial to inform clinical practice, quality interventions, and health policy decisions. Effectiveness research had not had sufficient public or private funding to produce the information needed to facilitate evidence-based health care improvement. However, recent trends, such as the likelihood for continued substantial increases in health care costs and concern regarding the quality and safety of the US health care system, are among the important arguments for increasing its funding and capacity. We propose a new entity, a public-private consortium to expand and offer new capability and resources in this area. The consortium would consist of all relevant public and private entities. It would be organized into an executive committee, which would identify research priorities and panels to design requests for proposals. Competitive peer-reviewed proposals, transparency and balance of forces in choice of topics, conduct of research, and interpretation of results would be important features. Metrics for success would be use of the data derived from consortium projects in medical decision making and benefit design. The consortium would provide balance and potential mediation of conflicting or competing interests in which all stakeholders will be present to establish the rules. Broad representation of all interests would serve to avoid the economic, policy, and political issues that have bedeviled past efforts. Models for the consortium include the Health Effectiveness Institute, the Centers for Education and Research on Therapeutics, and the Transportation Research Board.

Clinical Competence↗

PubMedDate not supplied

[Obstetrical care in Berlin: possibilities for delivery from the gynaecologists' point of view].

BACKGROUND: Berlin offers a variety of delivery facilities: maternity clinics, birth centres, obstetrical practices and ambulant working midwives for the various options and kinds of delivery. To select an individual service is a difficult task for most women. In this process of decision-making the gynaecologist plays an important part. This raised the question as to how established gynaecologists appraise the available services, which delivery sites they recommend, and what criteria are decisive for their recommendation. METHODS: A postal survey of all the 523 gynaecologists of Berlin was conducted anonymously, 273 (52.2 %) of whom completed the questionnaire. RESULTS: The results of the study demonstrated that the most important aspects for the recommendation of a delivery place are the technological equipment and qualification of the staff. However, characteristics of good care and support and an atmosphere of kindness and mutual trust are equally important. According to these goals, criticism has been expressed especially in the area of care and kindness, larger obstetrical divisions having more defaults in this regard. CONCLUSIONS: Future developments in delivery units of hospitals should take into consideration that both safety and optimal care are expected.

Attitude of Health Personnel↗

PubMed1996

Orthodontic care in Sweden. Outcome in three counties.

The purpose of this series of studies was to evaluate the outcome of orthodontic care in Sweden from the professional's and the patient's perspective. In addition, a model was devised for the priority-planning of orthodontic care and for evaluating the different factors influencing the decision for orthodontic treatment. The results may be summarized as follows: Treatment Decision. Treatment desire, followed by treatment need and treatment benefit were the most important factors to consider when deciding whether or not treatment should be carried out. Regardless of the differences in resources and the structure of the free public care, a substantial proportion of the untreated 19-year-olds had malocclusions with treatment need, but they had no desire for treatment. Most of the 27-year-old individuals were satisfied with their earlier treatment decision, regardless of whether they had undergone orthodontic treatment. Dental professionals were considered to have had the greatest influence on this decision, which means that desire for treatment may be guided by the orthodontist. Individuals with malocclusions and treatment need--but who had refused proposed orthodontic treatment--were in general more discontented with their dental arrangement than other respondents, and a majority of them regretted their decision. Greater information to these individuals would have been desirable. Resources and Treatments Provided by General Practitioners or by Specialists. The sparsity of specialist resources resulted in either a greater restriction on the number necessary treatments being initiated or a greater proportion of the treatment being provided by general practitioners. In the 3 counties analysed, the treatment standard correlated well with the available resources: the greater the number of orthodontic specialists and ability to supervise the work of general practitioners and taking care of patients in need of specialist treatment, the higher the standard of treatment. Individuals treated by specialists were more contented than individuals treated by general practitioners. The measures of treatment outcome in general yielded more favourable scores for specialist treatments than for treatments provided by general practitioners, despite the specialist treatments on the average being classified as more difficult than those provided by general practitioners. Perceived treatment difficulty. About one-fourth of all treatments were classified as easy, one-fourth as moderately difficult, and one-half as difficult. The perceived treatment difficulty was associated on a group basis with the pretreatment need. The treatment investment increased and the treatment outcome became less favourable with increasing perceived difficulty. The treatment outcome was least favourable in the group where no treatment was suggested. Almost every fourth treatment was successfully carried out by mere extraction therapy. Attitudes in 27-year-olds. Orthodontic treatment was considered important by three out of four individuals, even in cases where irregularities of the teeth were small. A majority of the individuals thought that they would have been able to wear visible braces if needed, even in adult age. Methodological aspects. Studies that have used different indices to evaluate treatment outcome can only be compared with great caution. Measures with wide bases for evaluation may be more valid than measures with narrow bases. To estimate treatment outcome in terms of decrease of treatment need, the Indication Index may be recommended.

Adolescent↗

PubMed2002

Pro/con clinical debate: are steroids useful in the management of patients with septic shock?

Decision-making in the intensive care unit is often very difficult. Although we are encouraged to make evidence-based decisions, this may be difficult for a number of reasons. To begin with, evidence may not exist to answer the clinical question. Second, when there is evidence it may not be applicable to the patient in question or the clinician may be reluctant to apply it to the patient based on a number of secondary issues such as costs, premorbid condition or possible complications. Finally, emotions are often highly charged when caring for patients that have a significant chance of death, and care-givers as well as families are frequently prepared to take chances on a therapy whose benefit is not entirely clear. Steroid use in septic shock is an example of a therapy that makes some sense but has conflicting support in the literature. In this issue of Critical Care Forum, the two sides of this often heated debate are brought to the forefront in an interesting format.

Adrenal Cortex Hormones↗

PubMed1999

Health care delivery and change: thoughts on Lema's "... of dinosaurs, dodos and anesthesia personnel".

Problems in health care delivery relative to access, costs, and quality have been debated for more than a quarter of a century. Health care costs have significantly increased since the implementation of the Medicare/Medicaid legislation. Cost containment has been high on the agendas of government officials, legislators, health policy decision makers, business leaders, and economists since the 1980s. There has been a shift toward market medicine and managed care as a means for cost containment. Although some costs were contained for a short period, they are once again rising significantly, and there is growing dissatisfaction with this shift. The United States is not alone in this dilemma. Mark Lema, MD, PHD, editor of the ASA Newsletter, wrote a thought-provoking editorial in the July 1999 issue, raising concerns about change, relationships, reimbursement, and demise relative to anesthesia personnel. In response, this article primarily raises the issue of health manpower mix as a major factor in the cost of health care delivery regarding these systems. Whereas change is inevitable, it is difficult for state and federal governments in the United States to force change because of the number of special interests involved in campaign financing involving elected government officials. It is nevertheless important for health professionals to be involved in the changes that come about, or change will be made for them. It is essential to renew society, institutions, and individuals in order to prevent decay and obsolescence. If we don't make the future, the future will make us.

Anesthesiology↗

PubMed1999

Community-dwelling cognitively impaired frail elders: an analysis of social workers' decisions concerning support for autonomy.

Home health care practice with cognitively impaired elders and their families often raises difficult clinical and ethical issues for social workers. This descriptive study examined the influence of safety, caregiver burden, and diagnostic labels on social workers' support for autonomy. All three factors were found to be significantly related to support for autonomy. There were also interactive effects between safety, caregiver burden and diagnosis. Especially important was the identification of the influence of diagnostic labels on social workers' support for autonomy. Respondents supported less autonomy for elders depicted as diagnosed with Alzheimer's disease than those diagnosed with stroke.

Adult↗

PubMed2001

[Ethical considerations in mass casualty situation].

Mass casualty is a situation, in which, the physician is compelled to make critical decisions under heavy pressure load, due to severe shortage in time, personnel and information. This task is extremely difficult to fulfill, as the physician has to consider not only professional tools, but needs also to utilize ethical principles, in order to provide the best possible care to most of the casualties who might benefit from it. By definition, in the mass casualty situation the medical facility lacks temporarily the ability to deliver effective therapy to all, as the injured outnumber the medical capacity for a given time. The ethical conflicts and dilemmas that arise during such an event are enormous. Amazingly, only a few articles have addressed the issue of ethical considerations during mass casualty situation. Ethical decision making is based on four principles: beneficence, nonmaleficence, autonomy and justice. Compassion, trustworthiness, discernment and integrity are the four qualities required from those practicing medicine. These virtues should be manifested in mass casualty situations, one of the most demanding situations a physician may face.

Disaster Planning↗

PubMed1989

The well-year of life as a basis for patient decision-making.

Medical decision-making requires the integration on costs, risks, and benefits of treatment. Clinical side effects and benefits are typically expressed in terms of symptoms and clinical states of diseases. Integrating probabilistic information about different categories is often difficult from both the patient's and the clinician's perspectives. We offer a General Health Policy Model that expresses the benefits and side effects of treatment within a common unit. The model takes into consideration mortality, function (morbidity), and preference for health states. In addition, the model uses probability information to describe the prognosis or likelihood of transition among states over the course of time. The output of the model is a well-year which is defined as the equivalent of a completely well-year of life. The well-year is a comprehensive expression of benefits minus side effects that may be useful for individual patient decision-making.

Activities of Daily Living↗

PubMed2004

Nursing attrition and the work environment in South African health facilities.

A number of media reports appeared on the shortages of professional health workers in the public health sector. Unsatisfactory working conditions in health facilities were mentioned as one of the key aspects responsible for the shortages. Literature indicates that stress caused by unsatisfactory work environments may play a major role in employees' decision to resign their jobs, in spite of enjoying the nature of their work. The aim of this article is to explore the current human resource situation in nursing i.e. to determine if a shortage of nursing skills exists, to establish the challenges that nurses have to face in performing their duties and to establish the potential effect of the work environment on attrition. Currently 155 484 nurses are practicing in South Africa at a rate of 343 nurses per 100 000 of the population, which compares favourably with the World Health Organisation minimum of 200:100 000. The lack of reliable data on the supply of and demand for nurses makes it difficult to determine whether real shortages exist. However the supply of nursing services is influenced by the uneven distribution of skills across regions and the outflow of professional skills. It seems that the existing situation will deteriorate because fewer people are interested in taking up or pursuing nursing as a career in South Africa. At the same time a need for more nurses was identified because of the growth in the population as well as a change in health care needs. Workplace conditions for health workers employed at hospitals and clinics in South Africa were explored as part of a recent national study on the impact of HIV/AIDS on the health sector. Health workers' opinions on aspects such as workload, staff morale and working hours were obtained during personal interviews, which were conducted at 222 health facilities. Nine hundred and twenty four professional nurses, enrolled nurses and nursing assistants, who were mostly employed in the public health sector, participated. A stressful work environment was identified in public hospitals and clinics. An increase in the number of patients visiting these facilities, accompanied by a lack of equipment, unsatisfactory work environment and a shortage of nurses were pointed out. Many patients cannot be accommodated elsewhere because of a lack of finance and alternative health care options. Nurses also indicated that they do not get much support from their employers. The effect of all these factors culminates in a stressed workforce who may be forced to consider alternative career options. This will be to the detriment of health care in the country.

Burnout, Professional↗

PubMed1986

Hospice care.

"Birth and death are the most singular events we experience and therefore the contemplation of death as of birth should be a thing of beauty." The hospice movement emerged out of an awareness that the needs of the dying patient were not being adequately met by the modern medical establishment. It has brought about a positive change in attitudes toward the dying. Hospice has given the patient and family back the responsibility of making decisions regarding life and death. It has called to our awareness difficult moral and ethical issues to which no clear right or wrong answers exist but about which only informed judgments may be made. However, the hospice program has a long way to go. The public needs to be educated about existing financial, social, and medical provisions available to them in preparation for death. The education of medical, nursing, and paramedical professionals must emphasize technical and philosophical principles about death and dying. Teachers must address moral and ethical issues, and physicians must demonstrate kind and compassionate care in the management of their dying patients. Finally, society has the moral obligation to ensure that its dying members have access to care directed specifically to their needs. Hospice does not offer simple solutions to all the problems raised in this article, but it does embody a philosophy of care that acknowledges these issues, and it provides support for those with the courage to address them. Hospice care in the United States is now at a crossroads; whereas such care is appealing and acceptable to the public, this care has yet to find its place as an integral part of the health care system and be accepted as another facet of health delivery.

Adult↗

PubMedDate not supplied

Forgoing artificial nutrition and hydration in nursing home patients with dementia: patients, decision making, and participants.

OBJECTIVE: The purpose of this study is to investigate the characteristics of patients for whom it is decided to forgo artificial nutrition and hydration (ANH) and characteristics of the ANH decision-making process. We conducted an observational study with the use of written questionnaires. For 178 nursing home patients with dementia, the treating nursing home physician (NHP), a family member, and a nurse filled out a questionnaire directly after the decision was made to forgo ANH. RESULTS: We found that most patients had severe dementia and two thirds had an acute illness. Advance care planning had taken place in 68% of the cases. In two thirds of the cases, the primary aim in forgoing ANH was to avoid unnecessary prolongation of life; and nurses seemed to have less influence on the decision-making process than NHPs and family members. Almost all respondents evaluated the decision-making process as "good" or "adequate." Dissatisfaction was felt when the decision had to be made under the pressure of time constraint. CONCLUSIONS: On the basis of these results, we recommend that discussions that include NHPs, family members, and nurses concerning decisions about possible future situations be held on a regular basis. This will form the basis for the difficult ANH decision and will probably reduce the pressure of time constraint.

Advance Directives↗

PubMed2006

Values-based practice in primary care: easing the tensions between individual values, ethical principles and best evidence.

BACKGROUND: The provision of health care is inseparable from universal values such as caring, helping and compassion. Consideration for individual values, particularly those of the patient, has also been increasing. However, such consideration is difficult within the context of modern health care, where complex and conflicting values are often in play. This is particularly so when a patient's values seem to be at odds with evidence-based practice or widely shared ethical principles, or when a health professional's personal values may compromise the care provided. SUGGESTED NEW FRAMEWORK: Values-based practice, a framework developed originally in the domain of mental health, maintains that values are pervasive and powerful parameters influencing decisions about health, clinical practice and research, and that their impact is often underestimated. Although it shares starting points with other approaches to values, it suggests that our current approaches lead us to ignore some important manifestations of values at both the general level, as relevant in legal, policy and research contexts, as well as at the individual level, as relevant in clinical practice. Drawing on ideas from philosophy, values-based practice significantly extends the range of phenomena that may be regarded as value-laden. It suggests that one of the reasons for overlooking values is that they are presumed to be shared when not apparently conflicting. Values-based practice is an approach to supporting clinical decision-making, which provides practical skills and tools for eliciting individual values and negotiating these with respect to best available evidence.

Delivery of Health Care↗

PubMed1986

Consultation-liaison psychiatry and the teaching of ethics.

Medicine has undergone a technological explosion which presents physicians with an increased need to make difficult ethical decisions. This has been met by an equivalent development in American medical schools of efforts to teach the ethics of medical practice. The courses vary widely from school to school. It is recommended that a core curriculum of basic theory be taught in preclinical years, followed by case-centered teaching in clinical years and residency. Only with real cases can the influence of the doctor-patient relationship be appreciated. Teaching of ethics cannot be divorced from the clinical reality of the doctor-patient relationship. The emotional needs of both enter into all decisions. It is offered that consultation-liaison psychiatry, which addresses the needs of both, is an ideal focus for such teaching.

Adult↗

PubMed1999

Recommendations for endodontic referral among practitioners in a dental HMO.

This study assessed the effect of patients' presenting conditions on general practitioners' (GPs') self-reported endodontic referral patterns, and compared GPs' perceived indications for referral with those of endodontists. The study was based on a self-administered, confidential survey distributed to 79 GPs and 7 endodontists who provide care to members of one Dental HMO in the Pacific Northwest. GPs were most likely to recommend referral for teeth they felt needed surgical retreatment, but GPs and endodontists did not always agree on indications for referral. Compared with GPs, endodontists were more likely to recommend referral for patients with complex problems, but not necessarily technically difficult teeth. Compared with those with less experience, GPs with more than 10 yr both in dentistry and at this HMO were more likely to recommend (a) referring difficult cases rather than performing endodontic therapy themselves and (b) extracting perforated or root-fractured teeth prior to obturation rather than continuing treatment. Indications for referral that maximize favorable dental outcomes need to be identified.

Attitude of Health Personnel↗