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Well-developed intuitive skills can open up a world of innovation and help leaders make difficult decisions that defy two-dimensional, logical analysis. An Intuition Fellowship program teaches health care leaders to hone those skills.
With the growth of scientific knowledge in the health care disciplines, it has become increasingly difficult for practicing health care professionals to store and manipulate the information required to make clinical decisions. Where the decision making process can be defined and validated, expert systems will be able to assist beginning professionals to learn appropriate patterns of decision making. This article discusses the rationale for utilization of expert systems in a nursing environment. A prototype expert system called CAREPLAN, developed for use in an obstetrical environment, was built using Personal Consultant Plus, a software tool based on the LISP language. The project demonstrates that it is feasible to develop and validate an expert system for a specialized clinical environment in a relatively short period of time in comparison to traditional development methods. Graphics were used to enhance textual information and to increase user appeal. Strategies for future implementation and evaluation are outlined.
In the preceding discussion we have attempted to set forth some realistic guidelines for the primary care physician in the critical care area. We feel that he is of utmost importance in setting the tone for his patient's care. He is the first physician to be called when his patient becomes critically ill. He decides whether or not consultation is needed immediately. He should choose appropriate consultants, trying to provide required expertise and compatible personalities to relate with his patient and the patient's family. His work does not end with establishing roles and delivering care. He is the single most important physician when difficult ethical and medicolegal decisions must be made. He is the physician who knows the patient and the patient's family best. They look to him for guidance and decision making about their health care. He is best able to discuss the wishes and desires of the patient if the patient becomes unable to decide for himself. The primary care physician can be extremely helpful when the appropriate medical decision is to withhold therapy. He can comfort and console the family and help them realize that the proper decisions have been made. His previous close relationship with the patient and family makes difficult decisions much easier to accept. He is also of primary importance when trying to provide care to a patient who ostensibly refuses such care. The trust he has earned in the past because of the care he was provided allows him to be much more forceful than the subspecialist who may have been on the case for 1 or 2 days. He can be the difference between survival and death merely by his presence and advice. Other difficult decisions are always made easier by a primary physician who can relate to the consultants as well as the patient and his family. In conclusion, we feel that the technologic advances of the past 30 years have tended to drive the primary care physician away from the critical care unit. This is mostly because of a need for particular expertise to run the machines of medicine. One cannot be expected to become or remain an expert in primary care and critical care medicine. The primary care physician should not feel or be excluded from the critical care area. His knowledge of general medicine and his expertise in interpersonal and family relationships allow him to provide the much needed "high touch" component of "high tech" critical care medicine.
The information retrieval systems currently available in general practice, such as Medline, and web search engines are passive and relatively difficult to access during consultations. Emergent technologies, including the National Electronic Library for Health, offer opportunities for more active decision support. We examine the extent to which information retrieval could support primary care consultations by examining the impact of the new technology at different stages of the consultation. We advocate a system whereby professional organisations concerned with quality of care, such as the Royal College of General Practitioners, might contribute the the process.
One essential component of AD that many mistakenly overlook is that health care wishes should not be kept secret. Copies of the document should not be locked up; several should be distributed among family, health care providers, and significant others. Resistance can be expected with discussion of AD and ultimate decision making. A difficult task in life is learning to let go of life. Despite the numerous barriers presented, persistence and encouragement in AD discussion will hopefully result in improved completion rates. After all, it is an immense opportunity for individuals to say what matters most to them.
BACKGROUND: Personnel working in neonatal intensive care units frequently face difficult ethical problems related to the initiation, maintenance or withdrawal of life support therapies. AIM: To assess the importance of ethical issues in the clinical decision making of health care providers in neonatal intensive care units. MATERIAL AND METHODS: A questionnaire based on five clinical vignettes that assessed judgments about quality of life, impact of parent's opinions and decision making in emergency situations and with different degrees of certainty, was designed. Eleven neonatologists and 20 nurses and midwives specialized in neonatology anonymously answered this questionnaire. RESULTS: There was a great inter individual variability in therapeutic approaches in cases with a bad vital and neurological prognosis. In cases of medical emergencies with uncertain diagnoses, bad vital prognosis but neurological indemnity, most professionals coincided in delivering all possible therapeutic options. Parent's opinions had a great impact in medical decisions, except when there was neurological indemnity. CONCLUSIONS: The specific responsibilities of the different agents in medical decision making must be delimited. Parents do not have absolute rights over their offspring and physicians must reject useless therapies.
Health care decision making in modern society can pose a variety of complex issues for consideration by individuals, families, and providers. The Health Decisions Community Council (HDCC), a community-based bioethics committee, was established to offer a noninstitutional forum for discussion of difficult health care dilemmas. Social work skills and values for autonomy and self-determination are essential to the formation of the HDCC as a model for community bioethics discussions.
Regional health information organizations (RHIOs) form the core building blocks of any approach to creating the National Health Information Infrastructure. RHIOs are computer-supported information sharing alliances composed of health care institutions that need to exchange clinical, financial or administrative data. Many uncertainties, including institution conversion costs, price-to-participate, and RHIO governance decisions make estimating the cost consequences difficult to establish. Current approaches to health information technology investment rely on a net-present-value analysis, which is inadequate to capture the dynamic, uncertain course likely to occur in the RHIO environment. Methods from operations research provide decision makers robust tools for exploring the cost and consequences of RHIO structures. We present here an initial modeling approach that allows explicit examination of RHIO structure and pricing options. Once refined, these models will provide the core of a suite of decision support tools for evaluation of RHIO pricing options, discount rates, and optimal organizational structures.
Medical care is becoming more technically challenging and community-based. The majority of patients and family health gatekeepers (the family member who regulates health care services for the family unit) are female, while the majority of physicians are male. Therefore, differences in female versus male methods of decision making add to the difficulty in making health choices. The female patient and family health gatekeeper may need new knowledge, skills and time to help them deal with difficult medical choices. They may benefit from a multidisciplinary, unbiased group of experts in the form of a Community Healthcare Committee. Trained to be responsible for the general health of the community, the primary care practitioner is ideal to take a leadership role in developing such a committee. A Community Healthcare Committee that understands different methods of health decision making could serve as a resource by providing community health education and private case reviews intended to help individuals with health care decisions.
Academic health centers (AHCs) face numerous challenges as they prepare students, housestaff, and faculty for the rapidly changing health care environment. An already overburdened curriculum makes it difficult to provide medical students with skills in outcomes assessment, health economics, clinical decision making, epidemiology, and basic statistics. Practicing physicians may find it difficult to expend the time and resources needed for degree programs in public health or the evaluative clinical sciences. AHCs may need to tap into existing resources in the health evaluation sciences, as Emory University (Atlanta, Georgia) has done by establishing the Emory University Center for Clinical Evaluation Sciences. Although the Center's primary missions are to be an analytical resource for Emory's health care delivery system and to promote health services research across the university, the authors illustrate its potential as a resource for training medical students, housestaff, and faculty in the evaluative clinical sciences.
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Cost-conscious health care organizations are demanding that their investments in information technology generate a measurable return. For some applications, predicting a quick payoff is relatively easy. But for complex clinical systems, proving a tangible return can be difficult.
In the literature three mechanisms are commonly distinguished to make decisions about the care of incompetent patients: A living will, a substituted judgment by a surrogate (who may or may not hold the "power of attorney"), and a best interest judgment. Almost universally, the third mechanism is deemed the worst possible of the three, to be invoked only when the former two are unavailable. In this article, I argue in favor of best interest judgments. The ever more common aversion of best interest judgments entails a risk that health care providers withdraw from the decision-making process, abandoning patients (or their family members) to these most difficult of decisions about life and death. My approach in this article is primarily negative, that is, I criticize the alleged superiority of the living will and substituted judgment. The latter two mechanisms gain their alleged superiority because they are supposedly morally neutral, whereas the best interest judgment entails a value judgment on behalf of the patient. I argue that on closer inspection living wills and substituted judgments are not morally neutral; indeed, they generally rely on best interest judgments, even if those are not made explicit.
Health care providers and payers are being asked to weigh data on the economic impact of new interventions along with clinical evidence when making decisions about the care of patients. The notion of incorporating formal health economic assessments into clinical and resource decisions is a difficult concept for many in the health care sector. However, it is the reality in today's environment. To effectively participate in these ongoing discussions, clinicians and other decision makers must be able to understand and critically assess the evidence on economic impact of medical interventions. This second of 2 articles describes the elements of comparative economic evaluations, reviewing the published literature on asthma and rhinitis in an attempt to critically appraise the studies from the perspective of one who might use data for decision making. Unfortunately, the quality of the economic evidence in these two disease states is not extensive. Until better economic analyses are conducted and made available, the allocation of resources for asthma and allergic rhinitis will continue to primarily rely on expert opinion rather than evidence-based literature.
Assuming that rationing health care is unavoidable, and that it requires moral reasoning, how should we allocate limited health care resources? This question is difficult because our pluralistic, liberal society has no consensus on a conception of distributive justice. In this article I focus on an alternative: Who shall decide how to ration health care, and how shall this be done to respect autonomy, pluralism, liberalism, and fairness? I explore three processes for making rationing decisions: cost-utility analysis, informed democratic decision making, and applications of the veil of ignorance. I evaluate these processes as examples of procedural justice, assuming that there is no outcome considered the most just. I use consent as a criterion to judge competing processes so that rationing decisions are, to some extent, self-imposed. I also examine the processes' feasibility in our current health care system. Cost-utility analysis does not meet criteria for actual or presumed consent, even if costs and health-related utility could be measured perfectly. Existing structures of government cannot creditably assimilate the information required for sound rationing decisions, and grassroots efforts are not representative. Applications of the veil of ignorance are more useful for identifying principles relevant to health care rationing than for making concrete rationing decisions. I outline a process of decision making, specifically for health care, that relies on substantive, selected representation, respects pluralism, liberalism, and deliberative democracy, and could be implemented at the community or organizational level.
Pharmacoeconomics is starting to be employed in strategic therapeutic decision making. Costs associated with antimicrobials included: (i) acquisition costs; (ii) preparation, administration and consumables costs; (iii) monitoring costs; (iv) costs of unwanted drug effects; (v) costs of resistance and therapeutic failures and (vi) costs of duration of stay. Most hospitals have a Drug and Therapeutics Committee but acquisition costs are still the most important economic criterion for acceptance for use, even though medicines only consume between 3 and 5% of total revenue costs, of which antibiotics account for around 15%. In any sequential programme acquisition costs and consumables are immediately realizable. Staff time and monitoring tests are less realizable but require changes in the way budgets are handled. Microbial resistance and risk management are difficult to quantify but are increasingly becoming important in strategic decision-making. The educational needs of health care decision makers in economic need addressing and mechanisms need to be put in place to enable the putative savings reported in the pharmacoeconomic literature to be realized.
Coma, vegetative state, lock-in syndrome and akinetic mutism are defined. Vegetative state is a state with no evidence of awareness of self or environment and showing cycles of sleep and wakefulness. PVS is an operational definition including time as a variable. PVS is a vegetative state that has endured or continued for at least one month. PVS can be diagnosed with a reasonable amount of medical certainty; however, the diagnosis of PVS must be kept separate from the outcome. The patient outcome can be predicted based on etiology and age. Using outcome probabilities and etiology as criteria, patients can be subdivided in 5 groups and reasonable management guidelines can be suggested. Three levels of care can be provided to PVS patients: high technology, supportive and compassionate care. Pragmatic options for the various subgroups of patients are suggested. Management decisions will remain difficult for both the family and the health-care team. The role of the physician in these difficult cases is to share the decision-making with the family.
BACKGROUND: To determine the availability of information concerning medical care available onboard the ships of the major cruise lines operating in the North American market. METHODS: The Web pages of the 16 members of the International Council of Cruise Lines were explored for the following types of information: ease of access of medical information, qualifications of medical personnel, description of medical facilities on board, maximum distance from nearest port, telemedicine capabilities, maximum gestational age and minimum infant age allowed, medical insurance information, and links to recognized guidelines for medical care on cruise ships. RESULTS: Seven cruise lines had minimal or no medical information at all. No cruise line presented information about medical evacuation or telemedicine services. Ten cruise lines had no information on maximal gestational age and 11 did not specify minimum infant age. No site offered a link to guidelines concerning medical facilities on board. CONCLUSION: The advanced age of the average cruise ship passenger and the isolation of the cruise environment create a need for high quality medical facilities and staff onboard cruise ships. The lack of detailed information concerning medical care available onboard makes it difficult for the average prospective passenger, who has health concerns, to make an informed decision as to choice of cruise line and itinerary. Cruise lines should correct this by including more information regarding medical services as well as links to other cruise health Web sites.