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 775 records · Page 43Linked to original sources

PubMed2006

Is it ethical to study what ought not to happen?

In the Democratic Republic of Congo, only an estimated 2% of all AIDS patients have access to treatment. As AIDS treatment access is scaled-up in the coming years, difficult rationing decisions will have to be made concerning who will come to gain access to this scarce medical resource. This article focuses on the position, expressed by representatives of Médecins sans Frontières (MSF), that the practice of AIDS treatment access rationing is fundamentally unethical because it conflicts with the ideal of universal treatment access and the human right to health. The conclusion is that MSF's position lacks coherence, has negative practical implications, and is unfair to governments struggling to increase patient's access to AIDS treatment in unfavorable circumstances.

Acquired Immunodeficiency Syndrome↗

PubMed1995

The stories of physicians, registered nurses and enrolled nurses about ethically difficult care episodes in surgical care.

Twenty physicians, 19 registered nurses (RN), and 20 enrolled nurses (EN) working in surgical care in Sweden narrated their experiences of being in ethically difficult care situations. All three professional groups disclosed a strong wish to help patients. The narrations of the physicians and the ENs indicated that they were very much involved in their patients, while most of the RNs' stories were narrated from a distanced onlooker's perspective and disclosed a lot of moral outrage, mainly directed towards physicians. The physicians were the only group that emphasized the importance of acting in accordance with science and proven experience. Like RNs they emphasized the importance and difficulty of telling the truth to the patients and their families and being open to one's own and others' harsh experiences. RNs and ENs emphasized the patient's right to a death with dignity and the difficulties connected with being with dying patients, and they also described feelings of powerlessness and neglect of patients related to a heavy work load. ENs narrated difficulties related to providing patients with individualized but fair care.

Adult↗

PubMed1996

What role do patients wish to play in treatment decision making?

BACKGROUND: Although current ideology suggests patients should be active participants in decision making about their care, the literature suggests that patients wish to be informed but not involved. OBJECTIVE: To test the hypothesis that most patients want their physicians to take the responsibility for problem solving (PS, identifying the one right answer), but that many want to be involved in decision-making (DM, selecting the most desired bundle of outcomes) tasks. METHODS: Survey responses from 300 patients undergoing angiogram at a Toronto, Ontario, hospital were analyzed (response rate, 72%). Survey items included scales to measure desire for information and participation, including Autonomy Preference Index, the Krantz Health Opinion Survey, and the Deber-Kraetschmer Problem-Solving Decision-Making Scale measured on a scale from, 1 (doctor only) to 5 (patient only). RESULTS: Patients had a relatively high desire for information. On the Problem-Solving Decision-Making Scale, they overwhelmingly wished the PS tasks to be performed by or shared with the physician (98.4% of the 12 PS scores are between 1 and 3), but wanted to be involved in DM (78% of the 6 DM scores are between 3 and 5). Preference for handing over control to the physician was significantly greater for the vignette involving potential mortality (chest pain) than for the vignettes involving mainly morbidity (urinary problems) or quality of life (fertility). CONCLUSIONS: Although patients do not wish to be involved in PS tasks, few wish to hand over DM control to their physician. These findings suggest 2 major roles for clinicians--assisting patients in PS to structure choices and supporting them in making often difficult decisions.

Attitude to Health↗

PubMedDate not supplied

Circumstances leading to placement: a difficult caregiving decision.

Due to advances made in medicine and healthcare, older adults are living longer but enduring problems with physical functioning and health over longer periods of time. In addition, the percentage of older adults with cognitive impairments is increasing. Caregiving duties, which decades ago lasted for months, now last for years. This long-term strain of caring for an older adult who is physically and/or cognitively impaired may lead many caregivers to feel frustrated, angry, overwhelmed, and isolated. As a result of this stress many caregivers resort to nursing home placement. The Caregiver Options Program and Evaluation research project was undertaken to provide service options to participating caregivers to alleviate some of the debilitating stress associated with caregiving and postpone institutionalization. Results of logistic regression indicate the predictors of nursing home placement were whether the caregiver felt she/he had provided good care, and whether the elder had a problem with household tasks and/or woke the caregiver or other family members up during the night. Findings suggest that elderly care receivers who are predominately low-to-middle income have a physical and/or cognitive impairment, along with their caregivers, need to be especially targeted for help by case managers early in the caregiving process before placement becomes the only alternative.

Activities of Daily Living↗

PubMedDate not supplied

Improving knowledge of the prostate cancer screening dilemma among African American men: an academic-community partnership in Washington, DC.

OBJECTIVE: Studies have shown that African American men are at greater risk than other men for prostate cancer in terms of both incidence and mortality. At the same time, the utility of screening asymptomatic men for prostate cancer remains controversial. The combination of high incidence and high mortality with the uncertain benefits of screening poses a difficult problem for African American men. This study was part of an ongoing project that sought to develop and evaluate health education materials designed to help African American men make an informed decision about prostate cancer screening. The project represented a collaboration between the Most Worshipful Prince Hall Grand Lodge of the District of Columbia and the Lombardi Cancer Center of Georgetown University. METHODS: The authors conducted eight focus groups with 44 members of the Prince Hall Masons. The focus groups covered men's understanding of prostate cancer screening and their preferences for methods of health education. RESULTS: Participants demonstrated a high level of awareness of the availability of prostate cancer screening, a low awareness of the screening controversy, and a desire for detailed epidemiologic information and information about the benefits and limitations of screening. The preferred forms of educational materials were video and print-based materials, which the research team has recently developed. CONCLUSIONS: These findings demonstrate the feasibility of developing an academic-community collaboration with the goal of improving a health-related problem in the African American community. A randomized trial is underway to evaluate the impact of the video and print education materials.

Academic Medical Centers↗

PubMed1999

A taxonomy of health networks and systems: bringing order out of chaos.

OBJECTIVE: To use existing theory and data for empirical development of a taxonomy that identifies clusters of organizations sharing common strategic/structural features. DATA SOURCES: Data from the 1994 and 1995 American Hospital Association Annual Surveys, which provide extensive data on hospital involvement in hospital-led health networks and systems. STUDY DESIGN: Theories of organization behavior and industrial organization economics were used to identify three strategic/structural dimensions: differentiation, which refers to the number of different products/services along a healthcare continuum; integration, which refers to mechanisms used to achieve unity of effort across organizational components; and centralization, which relates to the extent to which activities take place at centralized versus dispersed locations. These dimensions were applied to three components of the health service/product continuum: hospital services, physician arrangements, and provider-based insurance activities. DATA EXTRACTION METHODS: We identified 295 health systems and 274 health networks across the United States in 1994, and 297 health systems and 306 health networks in 1995 using AHA data. Empirical measures aggregated individual hospital data to the health network and system level. PRINCIPAL FINDINGS: We identified a reliable, internally valid, and stable four-cluster solution for health networks and a five-cluster solution for health systems. We found that differentiation and centralization were particularly important in distinguishing unique clusters of organizations. High differentiation typically occurred with low centralization, which suggests that a broader scope of activity is more difficult to centrally coordinate. Integration was also important, but we found that health networks and systems typically engaged in both ownership-based and contractual-based integration or they were not integrated at all. CONCLUSIONS: Overall, we were able to classify approximately 70 percent of hospital-led health networks and 90 percent of hospital-led health systems into well-defined organizational clusters. Given the widespread perception that organizational change in healthcare has been chaotic, our research suggests that important and meaningful similarities exist across many evolving organizations. The resulting taxonomy provides a new lexicon for researchers, policymakers, and healthcare executives for characterizing key strategic and structural features of evolving organizations. The taxonomy also provides a framework for future inquiry about the relationships between organizational strategy, structure, and performance, and for assessing policy issues, such as Medicare Provider Sponsored Organizations, antitrust, and insurance regulation.

American Hospital Association↗

PubMedDate not supplied

Clinical diagnosis and management of suspicious pigmented skin lesions--a survey of GPs.

BACKGROUND: The ability of general practitioners to make important clinical decisions about the diagnosis and management of skin lesions is poorly understood. METHODS: A questionnaire on the diagnosis and management of eight photographed skin lesions was sent to 150 GPs in southeast Queensland. RESULTS: The questionnaire was completed by 114 GPs (response rate 77%). General practitioners' provisional diagnoses and management of photographed skin lesions were mostly or always correct, and there was general high consistency between diagnosis and intended management. Pigmented seborrhoeic keratoses were the most difficult lesions for GPs to diagnose correctly. Whether a lesion was different to usual moles appears to have the strongest association with clinical diagnosis. DISCUSSION: The high ability of GPs as measured in this artificial study is encouraging. The strong association between identifying moles that appear different to usual and correct clinical diagnoses suggest that unless GPs can increase the number of skin lesions they see as part of their typical workload, their clinical ability may not increase further.

Clinical Competence↗

PubMed2002

[Euthenasia: attitudes, wishes and behavior of the public, patients and physicians].

The lack of compatibility in conventional medical treatment for patients suffering from terminal diseases or severe disabilities has become one of the more difficult problems of developed countries. Different types of passive and active euthanasia have been adopted as solutions to these new problems. These solutions, however, raise ethical and professional dilemmas, as well as controversies regarding economic and policy-making issues. This situation of social confusion and the publics anxiety regarding end-of-life care are reflected in the literature review, which shows significant discrepancies between physicians and the public in attitudes, preferences and behavior regarding the preferred and existent medical treatment at the end of life. The publics preferences regarding end-of-life care are relatively stable over time. However, the readiness of the public and physicians to accept these solutions increases over time. Considering these controversial solutions and the publics wishes to participate in the decision making process regarding end-of-life care, an increase in open communication and the degree of cooperation among physicians and their patients and family members is suggested. Advancing the treatment methods for severely ill patients, and improving the education of professional caregivers is another essential need. The development of satisfactory treatment alternatives for patients at the end of life may prevent the Israeli society from debating active euthanasia and lead to clear social agreements on passive euthanasia, including the developing of legal options which will enable people, who are interested, to gain control over their end-of-life care.

Attitude of Health Personnel↗

PubMed2003

Evaluation of patients with suspected acute coronary syndromes in the emergency department.

Patients complaining of chest pain (CP) who visit the emergency department (ED) represent the second cause of consultation in this department, and 20-30% of hospital admissions for medical reasons. These patients form a somewhat heterogeneous group with many different aetiologies and degrees of severity. In this setting, the clinical objectives include the prompt identification of patients with acute coronary syndromes (ACSs), the prompt evaluation of the immediate risk (i.e., initial risk stratification) of cardiovascular complications in order to tailor the treatment for each individual patient and to make the best use of hospital resources, and the prompt identification of patients with other potentially severe diseases. The diagnosis of ACS in patients coming to the ED for CP or any equivalent angina is one of the most difficult diagnostic challenges facing physicians in the ED. The correct diagnosis and risk stratification of these patients has clinical consequences, as well as very important legal and economic implications. The only methodology with a clear clinical impact on diagnosis, risk stratification and initial management is clinical evaluation based on data obtained by questioning the patient, carrying out a physical examination, and interpreting the results of a standard 12-lead electrocardiogram (ECG). Nevertheless, its combined diagnostic efficiency for ACS is imperfect and additional strategies are emerging which include serial ECG, the detection of serum biochemical markers of myocardial necrosis, exercise testing, and radionuclide myocardial perfusion imaging.

Acute Disease↗

PubMed2004

How research-conscious GPs make decisions about anticoagulation in patients with atrial fibrillation: a qualitative study.

BACKGROUND: Delays in the implementation of research findings have been of particular concern during the last decade. New findings, such as the use of warfarin to prevent stroke in patients with atrial fibrillation, have been found to be implemented patchily in clinical practice, in both primary and secondary care. OBJECTIVE: The purpose [corrected] of the study was to explore how GPs with an active interest in research or evidence-based medicine (EBM) make decisions about anticoagulation in patients with atrial fibrillation. METHODS: Semi-structured interviews with GPs about their experiences in managing patients with atrial fibrillation were recorded on audio-tape, transcribed and analysed using the 'Framework' method. A constructivist approach was taken to analysis and interpretation. RESULTS: Eleven interviews were included in the analysis. Two key themes, 'evidence' and 'professional role', were identified. No two respondents had the same perception of the evidence, which was influenced by experience, attitudes and a variable knowledge of the literature. Recent publications about the effectiveness of aspirin compared with warfarin, and the publication Clinical Evidence were the most frequently mentioned sources of evidence. GPs with confidence in EBM skills described giving highly detailed explanations to patients and having a great commitment to shared decision making, even if this resulted in patients declining treatment. For this reason, they also expressed antagonism towards prescriptive clinical guidelines. Hospital doctors were seen as exerting a powerful influence on decisions, as being 'disease-centred', difficult to challenge and poor at communicating. CONCLUSIONS: Decision making about anticoagulation is complex and is determined by a socially constructed view of the evidence strongly influenced by the GP's professional role.

Adult↗

PubMed2005

Organ transplantation in Malaysia: a need for a comprehensive legal regime.

Organ transplantation has become increasingly routine as a means of saving and improving the quality of lives of thousands of people each year. However, transplant activity is increasingly constrained by the shortage of organs. The major impediment in procuring organs for transplant in Malaysia is the lack of cadaveric donors. The lack of cadaveric donors has encouraged patients to go to countries like India and China to purchase organs especially kidneys for transplantation. The inadequacies of the existing Malaysian Human Tissues Act 1974 has also contributed to this problem. For instance, the word 'tissue" is not defined under the Act. This raises complex and ethical questions as to the scope of the definition for "tissue". There is also no definition of "the person lawfully in possession of the body." This is significant as he is the person who is empowered by the Act to authorise removal of tissue. Further, there is also no articulation of a hierarchy of relatives who are deemed the next of kin. In a situation involving a large number of relatives, asserting different opinions, this may pose a problem. The articulation of a priority list is particularly difficult in Malaysia as it is a multi-cultural society where the hierarchy of relatives with the right to claim decision-making powers may vary in different cultures. Furthermore, there is also a pressing need for a legislation to ensure that the rights of potential live donors are protected. At the moment, the Human Tissues Act 1974 only relates to cadaveric donors whereas live donors fall within the purview of the common law. The system of "opting out" should be considered in Malaysia whereby every individual is presumed to be a donor unless he or she registers an objection. But this system can only be fair if every person in the community is given notice of the law and understands its implications. For the system to work, there must also exist a simple and effective way of registering objections. There is a need for continuous intensive public education and counselling. A nationally co-ordinated mechanism must be in place to ensure effectiveness of identifying potential donors and recipients.

Humans↗

PubMedDate not supplied

Prosthodontics and the patient: what is oral rehabilitation need? Conceptual analysis of need and demand for prosthodontic treatment. Part 1: a conceptual analysis.

PURPOSE: The concepts of need and demand are central in studies on dental care. In the literature, a normative definition is often used, but it pays little attention to the individual's personal comfort and quality of life. Need and demand for prosthodontic services are difficult to measure, as prosthodontic treatment is highly individual and not closely related to edentulousness. Need, however defined, does not always lead to demand for treatment, depending on a variety of factors. MATERIALS AND METHODS: The present article is part of a larger study in which the intention is to evaluate need and demand for prosthodontic treatment among the participants in a 1989 and 1999 longitudinal study of a population sample. As the first step, this article reports a conceptual analysis of the need concept from the literature. RESULTS: Need is stated as socially established in the interaction between patient and clinician. It makes demand dependent on available treatment options from the care provider and society. In the prosthetic treatment decision-making process, the emancipatory perspective with the patient-clinician dialogue is of utmost importance to achieve an optimal treatment result. CONCLUSION: The professional attitude toward need must be that there is no true objective or subjective need. Need is established only in a communicative dialogue with mutual respect between the professional and the patient.

Decision Making↗

PubMed2004

Jehovah's witnesses, blood transfusions and transplantations.

The firm refusal of blood transfusion treatment by Jehovah's Witnesses has always caused some discomfort to physicians. Two fundamental principles contained in the constitution of our own and other democratic countries specifically dictate that human rights are to be respected. No one may be forced to undergo any particular health treatment, save under the provisions of the law. These principles have led doctors and lawyers to address this difficult patient-doctor issue decisively. On the one hand, a vast jurisprudence has been accumulated, which, although not resolving all the questions regarding the issue, has provided valuable guidelines, elaborated to support physicians in their treatment of patients who refuse homologous blood. On the other hand, wide-ranging research has been undertaken to find therapeutic and surgical methods that make it possible to treat patients without recourse to blood transfusions. Paradoxically, the dilemma presented to doctors by Jehovah's Witnesses has led to new knowledge regarding "the good use of blood," the advantages of which have been experienced also by non-Witnesses. In this article, we briefly consider the roots of Jehovah's Witness beliefs and the principles that lie behind their refusal of blood. Furthermore, we consider which treatments may be accepted, and which are invariably refused. Last, we examine the progress of current scientific research into alternative methodologies and the position of Jehovah's Witnesses when a transfusion is not an option, but a necessity.

Blood Transfusion↗

PubMed1992

Avoiding "Cloudcuckooland" in ethics committee case review: matching models to issues and concerns.

... The special concerns of families, patients, and caregivers are inevitably interwoven among the difficult ethical issues that ethics committees confront when they review individual cases. Certain of these ethical issues and special concerns can be addressed more effectively by the use of one particular case review model. This means that no one model for case review is suited to address every ethically difficult patient care situation. When one case review model is used exclusively by an ethics committee, some issues and concerns will not be resolved effectively. This difficulty cannot be ameliorated by switching to another exclusive model. To do so would be to trade an Athens for a "Cloudcuckooland." The case review model selected by ethics committees must vary from case to case. The model that is chosen should be geared to resolve the ethical issues central to that situation and the special concerns of patient, family, and caregivers. An examination of the three received models [the committee as a whole, teams, and individual members or consultants] will show that each is particularly suited to resolve certain kinds of ethical issues and special concerns. Because of this, ethics committees should develop a method for choosing the most appropriate model for reviewing specific cases.

Bioethical Issues↗

PubMed2004

[Geriatric assessment. Is it significantly helpful in selection of elderly tumour patients for a difficult therapy?].

With increasing life expectancy, a therapeutic decision raises the question of the primary goals to be aimed for. Is an absolute gain in age a goal equal to the preservation of an active life? While in younger patients the strategy followed by the patient and the doctor will usually be that of long-term survival, the decision making process for older patients with functional deficits is more challenging. Though functional deficits show a positive correlation with age, a causal relationship does not exist, which implies considerable inter-individual heterogeneity in the group of older patients. In particular, patients who have reached older ages "successfully" without any major limitations in their health should be considered for more intensive treatment strategies. At the same time, younger patients with relevant functional limitations and without any chance of improvement may not benefit from these interventions. The comprehensive geriatric assessment (CGA) offers the opportunity to describe and classify these deficits systematically. It therefore has a key role in the individual decision making process.

Activities of Daily Living↗

PubMed2005

[Learning from the experiences of an arbitration unit for medical liability questions].

While other countries', e.g. the United States', experience with alternative dispute resolution (ADR) in medical malpractice has been disappointing, German physicians have instituted extrajudicial claims resolution as an alternative to civil litigation: Established by the Arztekammern (corporate bodies of professional self-governance) in the mid-1970s, the Schlichtungsstellen (SchlSt--claims resolution panels) offer patients and doctors, on a voluntary basis, proceedings directed toward achieving a settlement. The number of cases submitted to these panels has been constantly growing since. In 90% of cases decided upon by the panel, civil litigation was avoided. Doctors can, as exemplified by the operation of the SchlSt, tackle difficult and complex problems and solve them--without being funded or directed by outside agencies. What can be learnt from being, as a physician member, associated with a SchlSt for several years? (1) Physicians--as Eddy has pointed out--must make decisions about complex problems under difficult conditions on the basis of inadequate information. Expert testimony suffers from similar uncertainties. Decisions on individual cases cannot be improved by external and necessarily generalized ruling (disease management programs, other directives). (2) Errors and adverse events in medical care have to be accepted as principally unavoidable. Most claims heard by the panel have to do with operations and--in the non-surgical specialties--with invasive procedures. Medical tasks of high complexity, as many operative and invasive procedures indeed are, seem to have an inherent accident-proneness. Therefore decisions as to operations and invasive procedures should be weighed with utmost care. More is not always better (3) 25% of the patients filing claims with the SchlSt complain of deficient doctor-patient-communication. Failure of doctors and staff to communicate adequately with the patients and with their professional contacts plays an important role as risk factor for negligence and injury and even as cause of disputes and claims. (4) The GP, the generalist in a profession characterized by specialization, has to treat a wide spectrum of diseases, wider than any specialist. As far as can be seen, he does his job well. He needs adequate--if possible personal--contact with and support by his colleagues involved in the treatment of the same patient.

Germany↗

PubMed2006

A comparison of multivariable regression models to analyse cost data.

RATIONALE, AIMS AND OBJECTIVES: Analysis of cost data is important in providing reliable information to aid budgeting decisions. Certain features of cost data, such as its typically highly skewed distribution and the need to estimate arithmetic mean costs in order to allow inferences to be made on total costs, make it difficult to analyse. Multivariable regression analysis is useful for estimating the influence of explanatory variables on cost in order to predict costs of future patients and allows for the control of variables which influence cost but whose distributions differ between comparison groups. This is especially important in the case of observational studies, where there may be no control over the balance of characteristics between the comparison groups. METHOD: This paper compares the appropriateness of various multivariable models of cost data by examining regression diagnostics, using as an example data collected on costs incurred in the treatment of inflammatory bowel disease. The models compared are normal and bootstrapped multiple linear regression, median regression, gamma model with the log link and normal linear regression (NLR) of log costs. RESULTS: Gamma modelling with the log link was found to be the most suitable model. CONCLUSIONS: Bootstrapping was found to make very little difference to conclusions from the NLR model.

Health Care Costs↗

PubMed2001

Predicting treatment costs after acute ischemic stroke on the basis of patient characteristics at presentation and early dysfunction.

BACKGROUND: Given the pressure on healthcare budgets, assessing the cost of managing a disease has become a major research focus; yet collection of these data are labor intensive and difficult. Understanding the predictors of cost provides an efficient means of incorporating such information in decision-making concerning new therapies. METHODS: Data from two 12-week multinational trials that collected information on a variety of neurological, functional, and cost parameters for 1341 ischemic stroke patients were examined by means of multiple linear regression. Because the intent is for the model to be predictive, only patient characteristics that can be known at the time of patient presentation or shortly thereafter were evaluated for inclusion in the model. RESULTS: The Barthel Index was the strongest predictor of cost in all models evaluated. Other major predictors, either directly or through their impact on survival, were stroke subtype, neurological impairment, congestive heart failure, and country. A good model fit was obtained, judging by the model statistics (model F:=84, 3 df, P:<0.0001) and the accuracy of the predictions (<3% difference between mean actual and predicted cost). CONCLUSIONS: Through the use of key patient characteristics, this regression model allows for prediction of the cost of stroke care, which may be helpful in the context of therapeutic decisions and budgetary planning purposes. It also provides insight into how specific treatments, through their impact on clinical characteristics, can modify the cost of stroke treatment.

Age Factors↗