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PubMed2006

Understanding cardiopulmonary resuscitation decision making: perspectives of seriously ill hospitalized patients and family members.

BACKGROUND: To improve communication and decision making related to cardiopulmonary resuscitation (CPR), a greater understanding of the perspectives of hospitalized patients with advanced diseases and their family members are needed. METHODS: In five Canadian hospitals, we administered a face-to-face questionnaire to older inpatients with end-stage cancer and advanced medical diseases and, where possible, to one of their family members, regarding information needs, the deliberation process, and their preferred decisional role. FINDINGS: A total of 440 of 569 patients (78%) and 160 of 176 available caregivers (91%) agreed to participate. Most patients (61%) had thought about what treatment they wanted if their heart stopped, few patients (11.3%) could describe more than two components of CPR, and only 2.7% of patients thought that the success rate of CPR was < 10%. A minority of patients (34%) had discussed CPR with their physician; 37% did not want to discuss their preferences with their doctor. Patients who felt that end-of-life issues were relevant to them were 5.5 times more likely to want a discussion with the physician regarding resuscitation (odds ratio, 5.5; 95% confidence interval, 2.5 to 12.0). The preferred role in decision making was variable, but most patients (59.7%) and family members (81.6%) preferred some degree of shared decision making that included the family member. There were no significant differences between cancer and medical patients in their preferred decisional role. INTERPRETATION: Seriously ill hospitalized patients have poor knowledge about CPR, and variable preferences for deliberation and their role in the decision-making process regarding their treatment. Strategies that improve understanding of CPR and foster discussions that involve patients, family members, and physicians in the decision-making process may improve the quantity and quality of communication and decision making about CPR.

Aged↗

PubMed2002

Medical tests: women's reported and preferred decision-making roles and preferences for information on benefits, side-effects and false results.

OBJECTIVE: To determine women's preferences for and reported experience with medical test decision-making. DESIGN: Computer-assisted telephone survey. SETTING AND PARTICIPANTS: Six hundred and fifty-two women resident in households randomly selected from the New South Wales electronic white pages. MAIN OUTCOME MEASURES: Reported and preferred test and treatment (for comparison) decision-making, satisfaction with and anxiety about information on false results and side-effects; and effect of anxiety on desire for such information. RESULTS: Overall most women preferred to share test (94.6%) and treatment (91.2%) decision-making equally with their doctor, or to take a more active role, with only 5.4-8.9% reporting they wanted the doctor to make these decisions on their behalf. This pattern was consistent across all age groups. In general, women reported experiencing a decision-making role that was consistent with their preference. Women who had a usual doctor were more likely to report experiencing an active role in decision-making. More women reported receiving as much information as they wanted about the benefits of tests and treatment than about the side-effects of tests and treatment. Most women wanted information about the possibility of false test results (91.5%) and test side-effects (95.6%), but many reported the doctor never provided this information (false results = 40.0% and side-effects = 31.3%). A substantial proportion said this information would make them anxious (false results = 56.6% and side-effects = 43.1%), but reported they wanted the information anyway (false results = 77.6% and side-effects = 88.1%). CONCLUSIONS: Women prefer an active role in test and treatment decision-making. Many women reported receiving inadequate information. If so, this may jeopardize informed decision-making.

Adult↗

PubMed2003

The seriously ill hospitalized patient: preferred role in end-of-life decision making?

PURPOSE: The objective of this study was to further our understanding of the decision-making process near the end of life. Specifically, we ascertained the seriously ill patients' preferred role in the decision-making process, what factors were associated with this role, and how this stated preference related to physicians' perception of preferred role. MATERIALS AND METHODS: Prospective cohort study of hospitalized patients with end-stage congestive heart disease, chronic pulmonary disease, cirrhosis, or metastatic cancer. Eligible patients were interviewed to ascertain their personal views on end-of-life decision making, desired role, and level of symptoms experienced. RESULTS: A total of 135 patients were enrolled in this study. The majority of patients (103, 76%) had thought about end-of-life issues although only 48 (36%) had discussed them with their doctor in the hospital. With respect to preferred role in decision making, in the scenario of a competent patient, 14 (10%) preferred to leave all decisions to the doctor, 12 (9%) preferred that the doctor make the final decision after considering their opinion, 43 (32%) preferred that the doctor shared responsibility with them to make the decision, 32 (24%) patients preferred to make the final decision after considering the doctor's opinion, 21 (16%) preferred to make the treatment decision alone, and 13 (10%) did not answer. Physicians were not able to accurately predict patient's preferred role nor could the variability in patient choice be accounted for by demographic or symptom covariates. CONCLUSION: Seriously ill hospitalized patients desire to discuss end-of-life issues with their physicians but their preferred role in decision making is variable and difficult to predict.

Aged↗

PubMed2003

A perspective on the analysis of credible commitment and myopia in health sector decision making.

This paper examines the role of credible commitment in facilitating long-term decision making in health care. Commitments are defined as an undertaking by one party to perform a certain task in the future.Policy objectives and political imperatives within public sector organisations can often mean that decision making takes place on shifting institutional terrain. This creates incentives on decision making that favours those choices that yield short-term gains. Such myopia is not necessarily consistent with organisational objectives and the implementation of policies that promote such objectives. These incentive problems can be formally modelled in terms of prisoners' dilemma and co-ordination games. Measures that promote public sector organisations to credibly commit to various values or policy positions can assist in reconciling individual and organisational objectives by allowing decision makers, in good faith, to build long-term outcomes into their decision making. In effect they allow co-operation and co-ordination. Given these potential gains, credible commitment can occur spontaneously but when not, may need to be facilitated by a third party (notably the State). Such forms of commitment are usually apparent in various policy measures such as health service constitutions, long-term contracting, legislation and incentive payments. Measures that secure credible commitment allow the discount rate to be reduced on long-term decisions of not only public sector organisations but also those stakeholders who rely on stable public sector institutions. However, the importance of the notion of commitment needs to be recognised against the background of other institutional factors that may influence decision making.

Decision Making, Organizational↗

PubMed2004

Increased sensitivity to error during decision-making in bipolar disorder patients with acute mania.

BACKGROUND: Decision-making is a complex and important function for daily life that can be assessed quantitatively using a simple two-choice prediction task. Bipolar disorder (BD) patients are thought to show altered responsivity to positive and negative feedback. In this study we examined whether BD patients with psychotic mania show altered patterns of decision-making as a function of the frequency of incorrect predictions or error rate. METHODS: Fourteen adult DSM-IV-diagnosed BD patients with psychotic mania and 14 normal comparison subjects (NC) were tested with a two-choice prediction task using three error rate conditions (20%, 50%, or 80%). RESULTS: BD patients showed an increased sensitivity to error rate changes and switched more frequently at high error rates than NC subjects. In comparison, there were no differences between BD and NC subjects on the degree to which the response or stimulus during a previous trial predicts the current response. CONCLUSIONS: Decision-making in BD patients with psychotic mania appears to be highly sensitive to high error rates. Moreover, the patterns of responses appear distinct from what has been previously observed in acutely and chronically ill schizophrenia patients. The results of this study are informative as to the effects of errors on decision-making strategies in psychotic BD manic patients.

Adult↗

PubMed2005

Does 'peer coaching' increase GP capacity to promote informed decision making about PSA screening? A cluster randomised trial.

BACKGROUND: Very little effort has been directed to enable GPs to better informed decisions about PSA screening among their male patients. OBJECTIVES: To evaluate an innovative programme designed to enhance GPs' capacity to promote informed decision making by male patients about PSA screening. METHODS: The study design was a cluster randomised controlled trial set in New South Wales, Australia's most populous state. 277 GPs were recruited through a major pathology laboratory. The interventions were three telephone-administered 'peer coaching' sessions integrated with educational resources for GPs and patients and the main outcome measures were: GP knowledge; perceptions of patient involvement in informed decision making; GPs' own decisional conflict; and perceptions of medicolegal risk. RESULTS: Compared with GPs allocated to the control group, GPs allocated to our intervention gained significantly greater knowledge about PSA screening and related information [Mean 6.1 out of 7; 95% confidence interval (CI) = 5.9-6.3 versus 4.8; 95% CI = 4.6-5.0; P < 0.001]. They were less likely to agree that patients should remain passive when making decisions about PSA screening [Odds ratio (OR) = 0.11; 95% CI = 0.04-0.31; P < 0.001]. They perceived less medicolegal risk when not acceding to an 'uninformed' patient request for a PSA test (OR = 0.31; 95% CI 0.19-0.51). They also demonstrated lower levels of personal decisional conflict about the PSA screening (Mean 25.4; 95% CI 24.5-26.3 versus 27.8; 95% CI 26.6-29.0; P = 0.0002). CONCLUSION: A 'peer coaching' programme, supplemented by education materials, holds promise as a strategy to equip GPs to facilitate informed decision making amongst their patients.

Adult↗

PubMed2006

Social processes used by African American women in making decisions about mammography screening.

PURPOSE: To describe the social processes used by African American (AA) women ages > or = 50 years in making decisions about mammography screening. DESIGN: Grounded theory methodology. METHODS: Tape-recorded interviews with a researcher-designed, semi-structured interview guide with an initial and theoretical sample of 30 AA women ages 52 to 71 of diverse socioeconomic status. Interviews occurred in various settings such as the church rectory, women's homes, and work settings. Extensive written field notes and tapes were transcribed verbatim immediately after the interviews by an experienced transcriptionist. FINDINGS: The women's decisions about mammography screening were associated with five social processes: (a) acknowledging prior experiences with healthcare providers and systems; (b) reporting fears and fatalistic beliefs of breast cancer and related treatment; (c) valuing the opinions of significant others; (d) relying on religious beliefs and supports; and (e) caregiving responsibilities of significant others. The processes were further differentiated by three distinct decision-making styles: taking charge, enduring, and protesting. CONCLUSIONS: Each of the social processes was reported equally and emphasized by the diverse sample of AA women in decisions related to mammography screening. Mammography screening decisions were heavily influenced by caregiving responsibilities. Further research is needed to explain and understand this social process on the health and well-being of AA women over time.

Adaptation, Psychological↗

PubMed2005

Exploring the decision-making preferences of people with colorectal cancer.

OBJECTIVES: To explore patient views on participation in treatment, physical care and psychological care decisions and factors that facilitate and hinder patients from making decisions. DESIGN: Qualitative study using semi-structured interviews with patients. SETTING AND PARTICIPANTS: Three NHS Trusts in the north-west of England. Theoretical sampling including 41 patients who had been treated for colorectal cancer. RESULTS: For patients, participation in the decision-making process was about being informed and feeling involved in the consultation process, whether patients actually made decisions or not. The perceived availability of treatment choices (surgery, radiotherapy, chemotherapy) was related to type of treatment. Factors that impacted on whether patients wanted to make decisions included a lack of information, a lack of medical knowledge and trust in medical expertise. Patients perceived that they could have a more participatory role in decisions related to physical and psychological care. CONCLUSION: This study has implications for health professionals aiming to implement policy guidelines that promote patient participation and shared partnerships. Patients in this study wanted to be well informed and involved in the consultation process but did not necessarily want to use the information they received to make decisions. The presentation of choices and preferences for participation may be context specific and it cannot be assumed that patients who do not want to make decisions about one aspect of their care and treatment do not want to make decisions about other aspects of their care and treatment.

Adult↗

PubMed2002

Medical students, clinical preventive services, and shared decision-making.

OBJECTIVE: Improving access to preventive care requires addressing patient, provider, and systems barriers. Patients often lack knowledge or are skeptical about the importance of prevention. Physicians feel that they have too little time, are not trained to deliver preventive services, and are concerned about the effectiveness of prevention. We have implemented an educational module in the required family practice clerkship (1) to enhance medical student learning about common clinical preventive services and (2) to teach students how to inform and involve patients in shared decision making about those services. DESCRIPTION: Students are asked to examine available evidence-based information for preventive screening services. They are encouraged to look at the recommendations of various organizations and use such resources as reports from the U.S. Preventive Services Task Force to determine recommendations they want to be knowledgeable about in talking with their patients. For learning shared decision making, students are trained to use a model adapted from Braddock and colleagues(1) to discuss specific screening services and to engage patients in the process of making informed decisions about what is best for their own health. The shared decision making is presented and modeled by faculty, discussed in small groups, and students practice using Web-based cases and simulations. The students are evaluated using formative and summative performance-based assessments as they interact with simulated patients about (1) screening for high blood cholesterol and other lipid abnormalities, (2) screening for colorectal cancer, (3) screening for prostate cancer, and (4) screening for breast cancer. The final student evaluation is a ten-minute, videotaped discussion with a simulated patient about screening for colorectal cancer that is graded against a checklist that focuses primarily on the elements of shared decision making. DISCUSSION: Our medical students appear quite willing to accept shared decision making as a skill that they should have in working with patients, and this was the primary focus of the newly implemented module. However, we have learned that students need to deepen their understanding of screening services in order to help patients understand the associated benefits and risks. The final videotaped interaction with a simulated patient about colorectal cancer screening has been very helpful in making it more obvious to faculty what students believe and know about screening for colorectal cancer. As the students are asked to discuss clinical issues with patients and discuss the pros and cons of screening tests as part of the shared decision-making process, their thinking becomes transparent and it is evident where curricular changes and enhancements are required. We have found that an explicit model that allows students to demonstrate a process for shared decision making is a good introductory tool. We think it would be helpful to provide students with more formative feedback. We would like to develop faculty development programs around shared decision making so that more of our clinical faculty would model such a process with patients. Performance-based assessments are resource-intensive, but they appear to be worth the added effort in terms of enhanced skills development and a more comprehensive appraisal of student learning.

Breast Neoplasms↗

PubMedDate not supplied

[Decision-making style among hemodialysis patients].

UNLABELLED: The purpose of this descriptive study was to identify the decision-making style among the dialysis patients. Subjects were a Convenience sample of hemodialysis patients who agreed to participate this study. The data was collected through semi-structured interviews. The interviews were recorded on the tape and transcribed. Decision-making episodes were picked and interpreted by searchers. Data was analyzed based on the Inductive Theory Approach. RESULT: Subject were 21 patients from 4 hospitals. The mean age was 51.1 and the mean duration after they started the hemodialysis was 9.1 years. The 16 decision-making styles were identified: accept, unvacillate, resignation, compromise, perseverance, challenge, self-activation, groupie, crisis-avoidance, withdrawal, prudent, reserve, escape, refusal, dogmatic, and entrust. These 16 decision-making styles were characterized by the reality oriented perception, the constructive regimes, the higher quality of social support. On the other hand, the passive decision-making styles were characterized by the distorted perception, the passive regimes, and the poor social support. DISCUSSION: The reality orientation, energy, openness, values system were discussed as key factors which determined the decision-making style among hemodialysis patients. The nursing approach supporting the patients to make their decision were discussed.

Adolescent↗

PubMed2005

Shared decision-making in primary care: tailoring the Charles et al. model to fit the context of general practice.

OBJECTIVE: To explore the application of the original Charles et al. model of shared treatment decision-making [Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med 1997;44:681-92; Charles C, Gafni A, Whelan T. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med 1999;49:651-61] in the context of general practice, and to determine whether the model needs tailoring for use in this clinical context. METHODS: Conceptual paper, presenting the defining characteristics of general practice compared to the original clinical context for which the model was developed (i.e. life threatening disease with different treatment options), and exploring how the model can be tailored for use in the context of general practice. RESULTS: We identify two areas where the original model requires tailoring: sharing the decision-making around agreeing on an agenda for each consultation; and adapting the information transfer component of the model to acknowledge that doctors may not be the only, or even the main, source of technical information for patients. Finally, we explore the importance of shared decision-making in the context of chronic disease. CONCLUSION: The Charles et al. model can be tailored for use in general practice. PRACTICE IMPLICATIONS: Tailoring the model for use in general practice has implications for research, in terms of identifying the additional physician competencies needed for implementation. Policy makers who wish to promote shared decision-making need to ensure that incentives which prioritize access and health outcomes do not militate against shared decision-making in general practice.

Acute Disease↗

PubMed1998

Quality parental decision making and distress.

The purpose of this study was to test three hypotheses in the context of parenting an adolescent: (1) socioeconomic status (SES), parental gender, marital status, and age of parent will be predictors of quality decision-making for parents of adolescents; (2) as predispositional and situational distress increase, quality decision making among these parents will decrease; and (3) predispositional distress will be as strong a predictor for quality decision making as situational distress. The sample included 123 parents of adolescents ages 13 to 19 years. SES was the only significant predictor (11%) for parental decision making; the higher the SES, the more quality in decision making reported. Moderate negative correlations were obtained between predispositional distress and quality decision making and situational distress and quality decision making. Both predispositional distress and situational distress contributed equally as predictors of quality decision making.

Adolescent↗

PubMed1986

Career preferences and decision-making habits of first-year medical students.

Few studies that examine the career decisions of medical students have been based upon theories of decision-making. Several theories were used by the present authors to study differences among first-year medical students in North Carolina who preferred family medicine and those who preferred other specialties. Responses by 358 first-year students to a career preferences questionnaire administered in the fall of their freshman year revealed that students who preferred family medicine were more interested than other students in using medicine as a tool to help people. They were equally persistent and thorough in their career decision-making, were at an earlier stage of decision-making, and had less concern with themselves compared with other students. Decision-making theory helps to explain the relationships found in earlier studies between students' characteristics and their specialty preferences. The results of the present study also may explain the reason for the decrease during medical school in the number of students who prefer family medicine as a career. Those results show that first-year medical students who prefer family medicine are at an earlier stage of the decision-making process than other first-year medical students.

Career Choice↗

PubMed1997

Public health nurses' decision making in Canada, Finland, Norway, and the United States.

The purpose of this study was to describe the decision-making processes of 369 public health nurses in Canada, Finland, Norway, and the United States, and to discuss any differences observed among these countries. The results indicate that public health nurses used different decision-making models on the job and that these models varied considerably. Five different decision-making models were identified, each exhibiting features of different decision-making theories. The differences between decision making of public health nurses in different countries were statistically significant. The differences in decision making appear to be due to differences in health care systems in the 4 countries and the nature of the nursing task and context.

Canada↗

PubMedDate not supplied

Physician leadership in hospital strategic decision making.

In this article, three models of hospital strategic decision making are presented. These models focus on the role of physician leaders, particularly chiefs of clinical services, in decision making regarding major changes in the nature and scope of hospital services. The recommended model of decision making for any individual hospital is contingent on the competitive environment which the hospital faces, the complexity of decisions which must be made, and the characteristics of the physician leadership.

Decision Making, Organizational↗

PubMed2004

Think different: the merits of unconscious thought in preference development and decision making.

The role of unconscious and conscious thought in decision making was investigated in 5 experiments. Because of the low processing capacity of consciousness, conscious thought was hypothesized to be maladaptive when making complex decisions. Conversely, unconscious thought was expected to be highly effective. In Experiments 1-3, participants were presented with a complex decision problem in which they had to choose between various alternatives, each with multiple attributes. Some participants had to make a decision immediately after being presented with the options. In the conscious thought condition, participants could think about the decision for a few minutes. In the unconscious thought condition, participants were distracted for a few minutes and then indicated their decision. Throughout the experiments, unconscious thinkers made the best decisions. Additional evidence obtained in Experiments 4 and 5 suggests that unconscious thought leads to clearer, more polarized, and more integrated representations in memory.

Adult↗

PubMed2000

The medical visit context of treatment decision-making and the therapeutic relationship.

The ascendance of the autonomy paradigm in treatment decision-making has evolved over the past several decades to the point where few bioethicists would question that it is the guiding value driving health-care provider behaviour. In achieving quasi-legal status, decision-making has come to be regarded as a formality largely removed from the broader context of medical communication and the therapeutic relationship within which care is delivered. Moreover, disregard for individual patient preference, resistance, reluctance, or incompetence has at times produced pro forma and useless autonomy rituals. Failures of this kind, have been largely attributed to the psychological dynamics of the patients, physicians, illnesses, and contexts that characterize the medical decision. There has been little attempt to provide a framework for accommodating or understanding the larger social context and social influences that contribute to this variation. Applying Paulo Freire's participatory social orientation model to the context of the medical visit suggests a framework for viewing the impact of physicians' communication behaviours on patients' capacity for treatment decision-making. Physicians' use of communication strategies can act to reinforce an experience of patient dependence or self-reliance in regard to the patient-physician relationship generally and treatment decision-making, in particular. Certain communications enhance patient participation in the medical visit's dialogue, contribute to patient engagement in problem posing and problem-solving, and finally, facilitate patient confidence and competence to undertake autonomous action. The purpose of this essay is to place treatment decision-making within the broader context of the therapeutic relationship, and to describe ways in which routine medical visit communication can accommodate individual patient preferences and help develop and further patient capacity for autonomous decision-making.

Journal Article↗

PubMed2005

Multi-ontology sense making: a new simplicity in decision making.

Imagine organising a birthday party for a group of young children. Would you agree a set of learning objectives with their parents in advance of the party? Would those objectives be aligned with the mission statement for education in the society to which you belong? Would you create a project plan for the party with clear milestones associated with empirical measures of achievement? Would you start the party with a motivational video so that the children did not waste time in play not aligned with the learning objectives? Would you use PowerPoint to demonstrate to the children that their pocket money is linked to achievement of the empirical measures at each milestone? Would you conduct an after-action review at the end of the party, update your best practice database and revise standard operating procedures for party management? No! Instead, like most parents, you would create barriers to prevent certain types of behaviour, you would use attractors (party games, a football, a videotape) to encourage the formation of beneficial largely self-organising identities; you would disrupt negative patterns early, to prevent the party becoming chaotic, or necessitating the draconian imposition of authority. At the end of the party you would know whether it had been a success, but you could not have defined (in other than the most general terms) what that success would look like in advance.

Decision Making, Organizational↗