Substitute decision-making and the substitute decision-maker.
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Patient decision making: in search of good decisions.
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Decision Making↗
Ethical decision making for nurse administrators.
The authors' purpose is to offer a theoretical perspective to help the nurse administrator make ethical decisions congruent with social policies in allocating scarce resources. The goal is approached in two ways: by exploring the philosophical principle of morality on which decisions to distribute scarce resources can be made and by clarifying the principles of justice and distributive justice in two classic moral theories. Principles of distributive justice that serve as guidelines for social justice policy are delineated. A case study illustrates the dilemma.
Decision Making↗
An organizational ethics decision-making process.
The management team of Memorial Medical Center must make a decision regarding the continuation of one of its outpatient clinics. To provide better community service, MMC developed three outpatient clinics throughout a large metropolitan area. Over the past several years, one of the clinics has consistently been a financial loser. The losses have grown even as the costs of maintaining the clinic have increased. A primary reason for the negative financial performance is the high amount of nonreimbursed healthcare services-the clinic provides needed healthcare to a low-income part of the metropolitan area. Several members of the executive management team believe MMC has no alternative other than closing the clinic. One member of the management team, however, believes that the situation raises ethical concerns, and that executive seeks an ethics-grounded response to the problem.
Decision Making, Organizational↗
The right to refuse treatment: an application of the economic principles of decision-making under uncertainty.
When courts do not defer to professional medical judgement alternative ways must be found to make treatment decisions for persons who are deemed incompetent. Rather than impose the preferences of society upon the mentally ill individual, US courts favoured alternative procedures such as substituted judgement and the principle of the patient's best interest.
Antipsychotic Agents↗
Planning for medical decision making: living wills and durable powers of attorney.
The enactment of living will and durable power of attorney statutes in most states, including Maryland, provide individuals with a mechanism for setting forth their preferences for medical treatment in the event of their inability to make treatment decisions on their own behalf. Although still under used, these mechanisms are becoming more common, and physicians will be confronting them more frequently. The following overview of the Maryland Life Sustaining Procedures Act and the Durable Power of Attorney Act and discussion of their advantages and limitations is from the perspective of patients and their physicians.
Adolescent↗
Counseling the elderly on decision making for the end of life. Practical issues for physicians.
As the rapidly evolving trend to encourage seniors to express advance health care directives struggles to elaborate a science of the ethical premises, so physicians will be required to master the art of guiding patients to making autonomous decisions. This article focuses on the latter aspect of counseling the elderly, by providing practical tips based on the author's experience.
Advance Directives↗
Surrogate decision-making and ethics committees: the new role of the New York State nurse.
"When Others Must Choose: Deciding for Patients Without Capacity" is health care legislation proposed for New York state. Its intent is to remedy the absence of legal authority for families or other surrogates to make treatment decisions for their incapacitated loved ones who have neither completed an advance directive nor designated a health care agent. This paper provides a summary of this legislation and highlights nursing implications and the role of the nurse as a member of institutional ethics committees.
Adolescent↗
Five-year survival curves: how much data are enough for patient-physician decision making in general surgery?
OBJECTIVE: To find out whether patients' preferences for a particular type of treatment are changed by the way in which the information is presented (point estimates-year 0 and year 5 data points-or two five-year survival curves). DESIGN: Prospective study. SETTING: University-based Department of Veterans Affairs Medical Center, USA. SUBJECTS: 236 Consecutive patients seen in a general medical outpatient clinic. INTERVENTIONS: Patients were asked to choose between two treatments, one with a 10% immediate mortality and 37% five-year survival (treatment A) and one with no immediate mortality and 22% five-year survival (treatment B). They were randomised to be given the survival data either as point estimates or as two five-year survival curves. MAIN OUTCOME MEASURES: Number of patients who chose each treatment. RESULTS: The mean age was 67 years (range 40-84) and mean duration of education was 13 years (range 0-22). Significantly fewer patients chose the treatment with better immediate survival when they were given the data as survival curves (47/140, 34% compared with 93/140, 66% p < 0.0001) than when they were given data as point estimates (57/96, 59%, compared with 39/96, 41%). CONCLUSION: Patients are significantly more likely to make different decisions when given more data (in the form of five-year survival curves which show short, medium, and long term results) than when they are presented with only point estimates.
Adult↗
Changes in diagnostic decision-making after a computerized decision support consultation based on perceptions of need and helpfulness: a preliminary report.
We examined the degree to which attending physicians, residents, and medical students' stated desire for a consultation on difficult-to-diagnose patient cases is related to changes in their diagnostic judgments after a computer consultation, and whether, in fact, their perceptions of the usefulness of these consultations are related to these changes. The decision support system (DSS) used in this study was ILIAD (v4.2). Preliminary findings based on 16 subjects' (6 general internists, 4 second-year residents in internal medicine, and 6 fourth-year medical students) workup of 136 patient cases indicated no significant main effects for 1) level of experience, 2) whether or not subjects indicated they would seek a diagnostic consultation before using the DSS, or 3) whether or not they found the DSS consultation in fact to be helpful in arriving at a diagnosis (p > .49 in all instances). Nor were there any significant interactions. Findings were similar using subjects or cases as the unit of analysis. It is possible that what may appear to be counter-intuitive, and perhaps irrational, may not necessarily be so. We are currently examining potential explanatory hypotheses in our ongoing current, larger study.
Attitude to Computers↗
Transition decision-making and strategy.
With the advent of practice management companies and management service organizations, the already complicated area of practice transitions has become even more complex. This article discusses some of the key information a dentist will want to have in hand before making a decision on any transition, whether new or traditional. The key to all successful transitions is to enter into them with as much information as possible, rather than relying merely on feelings.
Consultants↗
Medical and nursing clinical decision making: a comparative epistemological analysis.
The aim of this article is to explore the complex forms of knowledge involved in diagnostic and interventional decision making by comparing the processes in medicine and nursing, including nurse practitioners. Many authors assert that the practice of clinical decision making involves the application of theoretical knowledge (acquired in the classroom and textbooks) as well as research evidence, upon concrete particular cases. This approach draws on various universal principles and algorithms to facilitate the task. On the other hand, others argue that this involves an intuitive form of judgement that is difficult to teach, one that is acquired principally through experience. In an exploration of these issues, this article consists of three sections. A clarification of terms commonly used when discussing decision making is provided in the first section. In the second section, an epistemological analysis of decision making is presented by examining several perspectives and comparing them for their use in the nursing and medical literature. Bunge's epistemological framework for decision making (based on scientific realism) is explored for its fit with the aims of medicine and nursing. The final section presents a discussion of knowledge utilization and decision making as it relates to the implications for the education and ongoing development of nurse practitioners. It is concluded that Donald Schön's conception of reflective practice best characterizes the skillful conduct of clinical decision making.
Decision Making↗
Models of governance in multihospital systems. Implications for hospital and system-level decision-making.
This study utilizes data from a national survey of 159 multihospital systems in order to describe the types of governance structures currently being utilized, and to compare the policy making process for various types of decisions in systems with different approaches to governance. Survey results indicate that multihospital systems most often use one of three governance models. Forty-one percent of the systems (including 33% of system hospitals) use a parent holding company model in which there is a system-wide corporate governing board and separate governing boards for each member hospital. Twenty-two percent of systems in the sample (but 47% of all system hospitals) utilize what we have termed a modified parent holding company model in which there is one system-wide governing board, but advisory boards are substituted for governing boards at the local hospital level. Twenty-three percent of the sampled systems (including 11% of system hospitals) use a corporate model in which there is one system-wide governing board but no other governing or advisory boards at either the divisional, regional or local hospital levels. A comparison of systems using these three governance approaches found significant variation in terms of system size, ownership and the geographic proximity of member hospitals. In order to examine the relationship between alternative approaches to governance and patterns of decision-making, the three model types were compared with respect to the percentages of systems reporting that local boards, corporate management and/or system-wide corporate boards have responsibility for decision-making in a number of specific issue areas. Study results indicate that, regardless of model type, corporate boards are most likely to have responsibility for decisions regarding the transfer, pledging and sale of assets; the formation of new companies; purchase of assets greater than $100,000; changes in hospital bylaws; and the appointment of local board members. In contrast corporate management is relatively uninvolved in these issues, again regardless of governance model type. There is substantial variation in the locus of decision-making responsibility by governance model type for a variety of other issues, however, including: hospital-level service additions and deletions; operating and capital budgets; medical staff privileges, hospital-level long-range planning; hospital CEO performance evaluation and the appointment of hospital CEOs.(ABSTRACT TRUNCATED AT 400 WORDS)
Decision Making, Organizational↗
Decision story strategy: a practical approach for teaching decision making.
Teachers are usually very enthusiastic in their evaluations of decision stories. Decision Story Strategies offer a change of pace, promote student involvement and stimulate creative thinking, problem solving and everpresent creative teaching-learning opportunities. The real-life problems presented within the structure of a decision story provide meaningful learning opportunities for students. Students begin to think in a broader perspective when considering other points of view and information sources. The Decision Story Strategy used with the Decision-Making Model provides a powerful tool for health educators to develop skills for making and evaluating decisions in an interesting and meaningful context. It may not be a panacea for all health educators, but is an effective strategy for the teacher concerned with developing independent decision makers. Most importantly, students are provided opportunities to solve their present problems as well as develop decision-making skills for the future.
Adolescent↗
Linking decision-making research and cancer prevention and control: important themes.
This article describes 6 themes underlying the multiple presentations from the Basic and Applied Decision Making in Cancer Control meeting, held February 19-20, 2004. The following themes have important implications for research and practice linking basic decision-making research to cancer prevention and control: (a) Traditional decision-making theories fail to capture real-world decision making, (b) decision makers are often unable to predict future preferences, (c) preferences are often constructed on the spot and thus are influenced by situational cues, (d) decision makers often rely on feelings rather than beliefs when making a decision, (e) the perspective of the decision maker is critical in determining preferences, and (f) informed decision making may--or may not--yield the best decisions.
Congresses as Topic↗
End-of-life decision making in the seriously ill hospitalized patient: an organizing framework and results of a preliminary study.
Recent studies of patient/family satisfaction with end-of-life care suggest that improvements in communication and decision making are likely to have the greatest impact on improving the quality of end-of-life care. The apparent failure of recent studies specifically designed to improve decision making strongly suggest that there are powerful determinants of the decision making process that are not completely understood. In this paper, we present an organizing framework that describes the decision making process and breaks it into three analytic steps: information exchange, deliberation, and making the decision. In addition, we report the results of a preliminary study of end-of-life decision making that incorporates aspects of this organizing framework. Thirty-seven seriously ill hospitalized patients were interviewed. The majority wanted to share decisional responsibility with physicians. We demonstrated the feasibility of measuring certain aspects of the decision making process in such patients. By providing and using a framework related to end-of-life decision making, we hope to better understand the complex interaction and processes between dying patients, caregivers, and physicians.
Aged↗
Group decision making: teaching the process--an introductory Guided Design project.
The Guided Design experience gives students excellent grounding in the decision-making process and knowledge of a decision-making language that will serve them well in all group decision-making contexts. The detailed component analysis, constraint identifications and the who, what, when, where, why and how questions applied to information gathering and analysis are simple terms, easily understood. The steps are applicable to problems needing a cause identification, solve process, and for anticipating potential problems. The process can be taught early in the curriculum and utilized throughout with special re-emphasis in leadership and management classes. The strength of the described unit lies in the provision of an introductory, nonthreatening classroom opportunity for practice in the use of decision-making language and an experience with the process using familiar content. The students experience the complexity of group decision making and the interesting variety of solutions possible for each complex problem. Like the Guided Design process, the projects used are improved with each successive experience. Student and colleague feedback provides the challenge.
Decision Making↗
Patient preferences for autonomy in decision making in asthma management.
BACKGROUND: Lower patient preferences for autonomy in management decision making during asthma exacerbations have been associated with an increased risk for future hospital admissions. We sought to examine patient preferences for asthma self-management autonomy, and the clinical and psychosocial factors associated with autonomy preferences. METHODS: A cross sectional observational study was performed with data collected between June 1995 and December 1997 of 212 adult patients with moderate to severe asthma managed, at least in part, at two teaching hospitals. Subjects completed a survey of autonomy preferences, quality of life, clinical morbidity and health service use, asthma knowledge, self-efficacy, coping styles, and psychosocial measures. RESULTS: Patients preferred clinicians to assume the major role in most decision making about their management. However, patients wished to remain in control in choosing when to seek care and wanted to share decisions regarding initiating changes in medications during a moderate exacerbation. Multiple regression analysis showed that concerns about adverse effects of medications, education level, an active coping style, perceptions of the propensity of physicians to involve them in treatment decision making, and concerns about costs causing delays in seeking medical care were associated with preferences for autonomy in decision making. Autonomy preferences were not related to measures of concurrent clinical asthma control or health related quality of life. CONCLUSIONS: In a group of patients with moderate to severe asthma, a high proportion of whom were from socioeconomically disadvantaged backgrounds, education level, perceived physician behaviour, cost barriers to care, and psychosocial factors (but not clinical asthma control or management) were related to patient preferences for autonomy in management decision making during asthma exacerbations. This has implications for asthma action plans and design of self-management programmes.
Adaptation, Psychological↗