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PubMed2004

[The evaluation of decision making capacity in health care and its relationship to informed consent].

The decision making capacity of patients will acquire special relevance with the introduction of informed consent in clinical practice and the new normative that will appear in the future when the bills about health services are approved in the Congress. This paper reviews the concept of decision making capacity in the context of health care and its legal background in Chile. The main problems that arise from the comprehension, use and assessment of decision making capacity, are analyzed. The assessment of this capacity is, in most cases, subjective since there are no criteria, protocols or standards to be used. In courts of justice, the exercise capacity assessment is requested to experts. These specilized physicians will evaluate the mental health of the subject and its implications in the capacity to make decisions. In practice, it is difficult to integrate the concept of capacity from the law or health care perspective. It is concluded that the elaboration of criteria, standards and procedures to evaluate the decision capacity of patients, is mandatory.

Chile↗

PubMedDate not supplied

The relationship of resiliency to decision making and risk behaviors of cancer-surviving adolescents.

Adolescents with a history of cancer frequently engage in risk behaviors. The purpose of this correlational study was to explore factors that affect decision making and risk behaviors (smoking, alcohol use, and illicit drug use) of cancer-surviving adolescents. A sample of 52 teen survivors participated at two cancer centers. In addition to a medical record review and IQ testing, several psychosocial measures were administered in a semistructured interview with the teen survivor. Three antecedent factors (cognitive function, resiliency, and role modeling of risk behaviors by parents and peers) were examined in a hierarchical regression model to predict decision making. These same factors, with an additional mediating variable (decision making), were examined in a hierarchical logistic regression model to predict risk behaviors in teen survivors. In the decision-making model, adjusted for demographic covariates, resiliency was a marginally significant predictor of decision making. As non-resiliency increases, quality of decision making may decrease for teen survivors. In the model to predict risk behaviors, four factors (cognitive function, resiliency, role modeling, and decision making) were added to the basic model, controlling for the same covariates. Resiliency and decision making were highly significant predictors of one or more risk behaviors. Non-resilient teen survivors with poor-quality decision making are more likely to engage in risk behaviors of substance use and need intervention that is aimed at improving decision-making skills to reduce these behaviors.

Adolescent↗

PubMed2004

Women's satisfaction with decision-making related to augmentation of labour.

OBJECTIVE: to describe women's experiences of participating in decision-making related to augmentation of labour. DESIGN: a qualitative approach using modified grounded theory technique. Open-ended interviews were conducted 1-3 days after childbirth. SETTING: the interviews were performed in the postnatal wards in five hospitals (tertiary level) in Stockholm, Sweden. PARTICIPANTS: 20 newly delivered women who had received oxytocin infusion for augmentation of labour during childbirth. FINDINGS AND KEY CONCLUSIONS: support and guidance from midwives in combination with knowledge and expectations about the intervention seemed to be important for women's satisfaction with decision-making concerning augmentation of labour. Four patterns of decision-making were found. One group of women participated in the decision-making regarding augmentation of labour while a second group was invited, but refrained from participation. These women were satisfied with the decisions made. A third group of women did not participate, but wanted to and they were dissatisfied with the decisions made. The fourth group did not participate in the decision-making-and did not want to. These women accepted the decisions made. The desire for information exceeded the desire for involvement in decision-making and the majority of women had confidence in the midwives' assessment.

Adult↗

PubMedDate not supplied

Legal basis of decision-making in critical care.

The issue of legal responsibility around decision-making in critical care units is one that can lead to confusion and uncertainty. This paper aims to examine the nature of decision-making in critical care and the legal basis for decision-making. The roles and responsibilities of doctors and nurses in critical care are explored. Both legal responsibility and legal accountability for decision-making in critical care are considered.

Critical Care↗

PubMedDate not supplied

Collaborative interdisciplinary bioethical decision making in intensive care units.

There is strong support in the literature for involvement of nurses with patients and physicians in bioethical decision making about patient care. There are indications that nurses and physicians have different beliefs about decisions made and about the decision-making processes, such as who should be involved and what factors should influence such decisions. The literature also demonstrates that nurses often disagree with physicians or are not involved in ethical decision making or both. Interdisciplinary collaboration has been proposed to improve decision making and recommended for health care giving generally. There is research support for the benefit of collaboration in care giving. Ethical principles also support collaborative decision making, involving nurses, as well as physicians, patients, and family. With collaboration there is sharing of information and perspectives, respect for patient and family autonomy, and disclosure. More studies of interdisciplinary bioethical decision making are needed, measuring both professions' perceptions of their roles in ethical decision making, as well as examining the effects of collaboration on care outcomes.

Decision Making, Organizational↗

PubMed2006

The impact of regional culture on intensive care end of life decision making: an Israeli perspective from the ETHICUS study.

BACKGROUND: Decisions of patients, families, and health care providers about medical care at the end of life depend on many factors, including the societal culture. A pan-European study was conducted to determine the frequency and types of end of life practices in European intensive care units (ICUs), including those in Israel. Several results of the Israeli subsample were different to those of the overall sample. OBJECTIVE: The objective of this article was to explore these differences and provide a possible explanation based on the impact of culture on end of life decision making. METHOD: All adult patients admitted consecutively to three Israeli ICUs (n = 2778) who died or underwent any limitation of life saving interventions between 1 January 1999 and 30 June 2000 were studied prospectively (n = 363). These patients were compared with a similar sample taken from the larger study (ethics in European intensive care units: ETHICUS) carried out in 37 European ICUs. Patients were followed until discharge, death, or 2 months from the decision to limit therapy. End of life decisions were prospectively organised into one of five mutually exclusive categories: cardiopulmonary resuscitation (CPR), brain death, withholding treatment, withdrawing treatment, and active shortening of the dying process (SDP). The data also included patient characteristics (gender, age, ICU admission diagnosis, chronic disorders, date of hospital admission, date and time of decision to limit therapy, date of hospital discharge, date and time of death in hospital), specific therapies limited, and the method of SDP. RESULTS: The majority of patients (n = 252, 69%) had treatment withheld, none underwent SDP, 62 received CPR (17%), 31 had brain death (9%), and 18 underwent withdrawal of treatment (5%). The primary reason given for limiting treatment was that the patient was unresponsive to therapy (n = 187). End of life discussions were held with 132 families (36%), the vast majority of which revolved around withholding treatment (91% of the discussions) and the remainder concerned withdrawing treatment (n = 11, 9%). There was a statistically significant association (chi2 = 830.93, df = 12, p < 0.0001) between the type of end of life decision and region-that is, the northern region of Europe, the central region, the southern region, and Israel. CONCLUSIONS: Regional culture plays an important part in end of life decision making. Differences relating to end of life decision making exist between regions and these differences can often be attributed to cultural factors. Such cultures not only affect patients and their families but also the health care workers who make and carry out such decisions.

Adult↗

PubMed1994

The bioethics of human fetal tissue research and therapy: moral decision making of professionals.

OBJECTIVE: We investigated the decision making of professionals regarding the ethical acceptability of using human fetal tissue from elective abortion for research or therapy. STUDY DESIGN: We surveyed 390 professionals from 20 European countries on their ethical beliefs regarding the scientific and medical use of human fetal tissue from elective abortion. We assessed the importance of basic medical ethics and beliefs regarding the morality of abortion and fetal rights to their decision making. RESULTS: Sixty-six percent of 198 responding professionals believed that use of fetal tissue from elective abortion was ethically acceptable. Beliefs regarding the morality of elective abortion and fetal exploitation overwhelmingly influenced individual ethics regarding fetal tissue research or therapy. CONCLUSION: Ethical decision making is a dynamic process and individuals are not altogether consistent in their beliefs. The important public policy issues raised in this study concern the rights of the dead fetus, whether these rights are exploited through fetal tissue therapy, and whether women's right of authority over the disposition of aborted fetal tissue is abdicated.

Aborted Fetus↗

PubMed1996

Designing an emergency medicine physician workstation to support risk management in decision making.

The practice of emergency medicine requires rapid decision making. The speed of decision making in the face of limited information contributes to the high risk of medical malpractice suits. We explore design approaches to an emergency physician electronic medical record product, EMstation, that may reduce the risk of adverse medical events by providing cues and tools while the patient may still be in the emergency department. EMstation is an Emergency Medicine Physician Workstation base on a Microsoft Windows 3.1 user interface. Because adaptation and adaptability to physician needs are critical to user acceptance, design to workflow, multisite end user customization, and integrated database support are used to support risk management documentation in EMstation. This article describes techniques that can be incorporated into electronic medical products which may prevent adverse medical events.

Decision Making, Computer-Assisted↗

PubMed2002

Decision-making in a risk-taking task: a PET study.

As decision-making is central to motivated behavior, understanding its neural substrates can help elucidate the deficits that characterize various maladaptive behaviors. Twenty healthy adults performed a risk-taking task during positron emission tomography with (15)O-labeled water. The task, a computerized card game, tests the ability to weigh short-term rewards against long-term losses. A control task matched all components of the risk-taking task except for decision-making and the difference between responses to contingent and non-contingent reward and punishment. Decision-making (2 runs of the active task minus 2 runs of the control task) activated orbital and dorsolateral prefrontal cortex, anterior cingulate, insula, inferior parietal cortex and thalamus predominantly on the right side, and cerebellum predominantly on the left side. In an exploratory analysis, guessing (run 1 minus run 2 of the active task) accompanied activation of sensory-motor associative areas, and amygdala on the left side, whereas informed decision-making (run 2 minus run 1) activated areas that subserve memory (hippocampus, posterior cingulate) and motor control (striatum, cerebellum). The findings provide a framework for future investigations of decision-making in maladaptive behaviors.

Adult↗

PubMed2000

Implementing shared decision-making in routine practice: barriers and opportunities.

OBJECTIVE: Determine feasibility of shared decision-making programmes in fee-for-service hospital systems including physicians' offices and in-patient facilities. DESIGN: Survey and participant observation. Data obtained during Phase 1 of a patient outcome study. SETTINGS AND PARTICIPANTS: Three hospitals in Michigan: one 299-bed rural regional hospital, one 650-bed urban community hospital, one 459-bed urban and suburban teaching hospital. All nurses and physicians who agreed to use the programmes participated in the evaluation (n = 34). INTERVENTION: Two shared decision-making(R) (SDP) multimedia programmes: surgical treatment choice for breast cancer and ischaemic heart disease treatment choice. MAIN OUTCOME MEASURES: (1) clinicians' evaluations of programme quality; (2) challenges in hospital settings; and (3) patient referral rates. RESULTS: SDP programmes were judged to be clear, accurate and about the right length and amount of information. Programmes were judged to be informative and appropriate for patients to see before making a decision. Clinicians were neutral about patients' desire to participate in treatment decision-making. Referral volume to SDPs was lower than expected: 24 patients in 7 months across three hospitals. Implementation challenges centred on time pressures in patient care. CONCLUSIONS: Productivity and time pressure in US health care severely constrain shared decision-making programme implementation. Physician referral may not be a reliable mechanism for patient access. Possible innovations include: (1) incorporation into the informed consent process; (2) provider or payer negotiated requirement in the routine hospital procedure to use the SDP as a quality indicator; and (3) payer reimbursement to professional providers who make SDP programmes available to patients.

Journal Article↗

PubMed1999

Health policy directions for evidence-based decision making in Canada.

The topic, evidence-based decision making, may be seen from many perspectives and levels of policy consideration. Canada has been actively pursuing policy macro-level directions for health information and evidence-based decision making through the National Forum on Health and the Advisory Council on Health Infostructure, together with changes in the federal health ministry, Health Canada, and other important national health organizations such as the Canadian Institute for Health Information. It remains to be determined how these initiatives will fundamentally influence a culture of evidence-based decision making and health information availability and quality for the average Canadian. Canada has, nonetheless, recognized that our health care delivery system has fallen behind in terms of using information management and technology to enable and facilitate the ever-growing information needs of the system. Policy direction provided by the National Forum on Health and the Advisory Council on Health Information offer an agenda for action and strategic direction drawn from two broadly based, highly iterative processes.

Canada↗

PubMedDate not supplied

Parental decision-making for the varicella vaccine.

INTRODUCTION: With the advent of new vaccines, improvements in established vaccines, and the availability of new combination vaccines, parents' decisions about vaccinating their children have become more complicated. This study examined parents' decision-making processes pertaining to whether to have their children vaccinated for varicella to gain a better understanding about how parents make vaccination decisions for their children. The "Awareness-to-Action Model" was used to examine parents' decision-making process before the action to vaccinate or refuse vaccination occurs. METHOD: This study used a cross-sectional design and logistic regression to test the explanatory power of several factors related to the parental decision-making process. A stratified random sample of 262 members of Kaiser Permanente Hawaii participated in the study. Data were collected through telephone interviews. RESULTS: In the "Awareness-to-Action Model," the decision construct was statistically significant in explaining parents' decisions to have their child vaccinated. The overall model correctly classified 80% of the sample as accepters or nonaccepters of the vaccination for their child. This study provides a model that enables health care providers to understand parental decisions about vaccines. This knowledge can help target interventions to increase vaccine compliance, thus minimizing the risk of diseases preventable by vaccine.

Adult↗

PubMedDate not supplied

Ethical problems in neonatal intensive care unit--medical decision making on the neonate with poor prognosis.

In current NICU (neonatal intensive care units), it is inevitable that ethical decisions on neonates with a poor prognosis will have to be made. At Tokyo Women's Medical College, we have been applying our own policy of medical decision making, which is somewhat different to those of most western countries. Most families are not asked to make final decisions, and the ethical committee is not actively involved. Staff in the NICU make the decision after plenary discussions. The position after decision making is not to discontinue the life supporting system but to observe, with no additional treatments and with routine care (class C). From October 1984 to September 1989, 58 out of 1589 neonates admitted to the NICU at Tokyo Women's Medical College died and 32 (55%) of them were classified as class C. The main causes of medical decision making were; non-viable (4/4, 100%), lethal malformations (13/20, 65%) and birth asphyxia (15/19, 79%).

Decision Making↗

PubMed1993

Clinical decision making: a primer for preceptors.

The ability to apply the critical care nurses' knowledge, skills and attitudes to patient care requires clinical decision making at all phases of the patient-nurse interaction. As a novice critical care nurse, the patient care environment is often so complex as to overwhelm the orientee and prevent effective clinical decision making. This article includes a review of current strategies for teaching clinical decision making with special reference to critical care nursing. Relevant theoretical concepts in clinical decision making are applied to the clinical setting, particularly the orientation of novice critical care nurses. The approach is practical, with suggestions for the preceptor involved in the orientation process. As critical care nurses, we spend a major portion of our professional lives making decisions which will, to a greater or lesser extent, influence the hearts, the minds, and often the very survival of others. The process by which we make these decisions is sometimes mysterious even to the person making them. In order to improve our own decision making ability, and to enable us to teach new critical care nurses the skills needed in the critical care setting, we must explore and "demystify" this process.

Clinical Competence↗

PubMed2003

Neural substrates of decision making in adults with attention deficit hyperactivity disorder.

OBJECTIVE: The characteristics of attention deficit hyperactivity disorder (ADHD) include abnormalities in reward responsivity that may interfere with decision making. The study examined reward responsivity in ADHD by comparing the neural correlates of decision making in adults with childhood-onset ADHD and in healthy adults. METHOD: The neural correlates of performance on a decision-making task and a control task were compared in 10 adults with ADHD and 12 age-matched healthy volunteers by using [(15)O]H(2)O positron emission tomography. The decision-making task tested the ability to weigh short-term rewards against long-term losses. The control task matched all components of the decision-making task except for the decision-making process and related contingency. RESULTS: The ventral and dorsolateral prefrontal cortex and the insula were activated during performance of the decision-making task in both the ADHD and healthy groups; however, activation in the ADHD group was less extended and did not involve other regions, such as anterior cingulate and hippocampus, that subserve emotion/memory processes. Direct comparison of data from the ADHD subjects and the healthy volunteers suggested that the healthy subjects engaged the hippocampal and insular regions more than did the ADHD subjects and that the ADHD subjects recruited the caudal part of the right anterior cingulate more than did the healthy subjects. CONCLUSIONS: The findings suggest that the neural circuits engaged during decision making differ in subjects with ADHD and healthy comparison subjects. This difference may explain observed deficits in motivated behaviors in ADHD. A better understanding of the nature of these deficits could ultimately be applied to refine treatment strategies for ADHD.

Adult↗

PubMed2001

Improving the quality of surgeons' treatment decisions: a comparison of clinical decision making with a computerised evidence based decision analytical model.

OBJECTIVES: The purpose of this study is to demonstrate to what extent an evidence based decision model can improve physicians' decisions and whether a selective use of the decision model is feasible. METHODS: Four experienced vascular surgeons were asked to make a treatment decision for 137 "paper patient" cases with asymptomatic abdominal aneurysms. Their decisions were compared with the optimal treatment as calculated by a computerised evidence based decision analytical model. RESULTS: Surgeons agreed with the model's advice based on life expectancy in 81% of the cases, and decided to operate in only 12% of the cases for which there was no agreement. Surgeons' decisions differed from the decision model's calculated optimal treatment, in particular, for older patients with aneurysms of intermediate size and with many risk factors, and for younger patients with small aneurysms and few risk factors. Not all these decisions, however, were reported to be more difficult. CONCLUSION: Use of a decision analytical model might lead to more appropriate decisions and a better quality of care. Selective use of the decision tool for difficult decisions only would be more efficient but is not yet feasible because reported decision difficulty is not strongly related to disagreement with the decision tool.

Aged↗

PubMed1993

Risk assessment and clinical aeromedical decision-making.

This article presents a format of aeromedical decision-making used in neurology cases referred to a U.S. Navy Special Board of Flight Surgeons (SBFS) from 1988 to 1990. The format consists of a series of questions addressing aeromedical concerns, an aeromedical disposition flowchart, and a decision analysis tree. Decision Analysis is a tool used in clinical medicine to assist decision-making under conditions of uncertainty. The Decision Analysis approach may be applied to complex aeromedical disposition questions that face flight surgeons. The concept of risk assessment as it applies to decision-making and aeromedical disposition is discussed. The outcome of 24 neurology cases referred for aeromedical disposition are presented.

Aerospace Medicine↗

PubMed1997

Adolescent parents and medical decision-making.

The growing phenomenon of teenage pregnancy introduces the problem of who should serve as surrogate decision makers for the children of adolescent parents. The justifications which sanction society's grant of presumptive decision making authority for adult parents, and the rationales and empirical evidence supporting a central role for adolescents who wish to make medical decisions regarding their own care, together suggest that older adolescent parents should be viewed as the presumptive decision makers for their children. There is, however, empirical evidence that adolescent parents lack the cognitive abilities of childless adolescents of the same age and that many exhibit lower levels of emotional stability, sensitivity to infant needs, and social adjustment. These deficiencies, where present, undermine the very justifications for allowing adolescents to make medical decisions for their children. These findings are strong enough to justify a greater level of watchfulness over the competency and decisions of those adolescents who wish to make decisions for their children, but not definitive enough to conclude that, as a group, they be presumed incapable of making those decisions.

Adolescent↗