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PubMedDate not supplied

Informed consent: court viewpoints and medical decision making.

Twenty-five years of appellate court decisions about informed consent in three influential states were examined to address four issues: the criteria used to define adequate informed consent; trends in court decisions; parallels between court decision making and decision analysis; the contribution of decision analytic concepts to defining "reasonable" medical informed consent. Court standards have evolved in three phases: the "medical community" standard before 1972, the "reasonable person" standard since 1972, and recent inroads toward developing an "individual preference" standard. The latter two standards form the current basis for deciding whether a patient has been adequately informed. Decision analysis offers a framework for communication about medical outcomes and probabilities, and methods for assessing preferences. Jurists and physicians should consider whether the legal system should adopt a decision analytic perspective in the doctrine of informed consent. Researchers should address issues raised by use of decision analysis for communication between the physician and the patient.

California↗

PubMed1998

Interactive video assists in clinical decision making.

The Hawaii Quality and Cost Consortium began a project in 1993 to implement and evaluate interactive videodisk programs to assist in clinical decision-making for breast cancer. Communication problems between physicians and patients, limitations of available outcomes data and varying preferences of individual patients can result in treatment outcomes that are less than satisfactory. Shared Decision-making Programs (SDPs) were developed by the Foundation for Informed Medical Decision Making (FIMDM) in Hanover, New Hampshire, to assist in the treatment decision-making process. Utilizing interactive videodisks, the programs provide patients with clear, unbiased information about available treatment options. With this information, patients can become more active participants in making treatment decisions. The SDPs for breast cancer were implemented at two sites in Hawaii. Evaluation data from 103 patients overwhelmingly indicate that patients find the programs clear, balanced and very good or excellent in terms of the amount of information presented and overall rating.

Adult↗

PubMed2004

Parental decision-making in congenital heart disease.

OBJECTIVE: To explore whether prenatal diagnosis of congenital heart disease is associated with lower levels of parental distress and greater satisfaction with decisions about cardiothoracic surgery when compared to postnatal diagnosis. METHODOLOGY: A combined quantitative-qualitative design was used. Participants included the parents of 31 neonates (30 mothers and 22 fathers) admitted to the cardiac intensive care unit between 1 November 2001 and 1 May 2002 for repair of congenital cardiac malformations. Participants completed self-report measures of anxiety, optimism, and life events pre-operatively, and semi-structured qualitative interviews assessing satisfaction with decision-making within 1 week of the operation. RESULTS: At the time of surgery, mothers of neonates receiving the diagnosis prenatally did not differ from mothers of neonates receiving the diagnosis postnatally on measures of anxiety, optimism, and life events. Fathers of neonates receiving the diagnosis prenatally, however, reported more optimism, lower state and trait anxiety, and fewer negative life events than fathers of neonates receiving the diagnosis postnatally. When we analyzed the interviews, we found that, regardless of the timing of the diagnosis, parents felt as though they made a genuine choice for their baby to have surgery. CONCLUSIONS: In this pilot study, fathers who learned prenatally that their child had a congenital cardiac malformation were less distressed than those who discovered this fact only postnatally. From the parental perspective, nonetheless, distress and urgency do not impair their ability to make decisions about neonatal cardiac surgery.

Adult↗

PubMed2004

Applying decision analysis to facilitate informed decision making about prenatal diagnosis for Down syndrome: a randomised controlled trial.

OBJECTIVE: To evaluate decision analysis as a technique to facilitate women's decision-making about prenatal diagnosis for Down syndrome using measures of effective decision-making. DESIGN: Randomised controlled trial in a UK hospital's prenatal diagnosis clinic. INTERVENTION: Routine versus routine consultation structured by decision analysis. PARTICIPANTS: 117/132 women receiving a screen-positive maternal serum screening result participated (58 routine, 59 decision analysis). METHODS: Consultations were audio tape-recorded, transcribed and coded; questionnaires were completed after the consultation and one month later after receipt of a diagnostic test and/or the 19-week scan result. MAIN MEASURES: Test decision, subjective expected utilities, knowledge, informed decision-making, risk perception, decisional conflict, anxiety, perceived usefulness and directiveness of consultation information. RESULTS: 48/59 in the decision-aided group and 47/58 in the routine group underwent prenatal diagnosis. Informed decision-making was higher, perceived risk more realistic and decisional conflict over time lower in the decision analysis group. Decision analysis had no impact on knowledge or SEU scores, and was no more or no less directive, useful or anxiety provoking than the routine care. Consultations were six minutes longer. CONCLUSIONS: Decision analysis consultations enable women to make more informed prenatal diagnosis decisions. Professionals will need training to use this technique effectively.

Anxiety↗

PubMed2002

Treatment decisions about lumbar herniated disk in a shared decision-making program.

BACKGROUND: An explicit process of collaborative (shared) decision making involving the patient and physician has been recommended for discretionary surgical procedures in which small-area analysis demonstrates high variation not attributable to differences in the patient population in the area. One such example is laminectomy for lumbar herniated disk (HD). An observational study was undertaken to evaluate the impact of an HD videodisk program on patient satisfaction, decision making, and treatment preferences. METHODS: Enrollment occurred in the outpatient offices of surgeons treating Kaiser Permanente (Colorado Region) patients with HD who had indications for surgery. Enrollment took place from May 1993 to December 1995, and follow-up surveys of patients were completed by January 1997. RESULTS: A 6.0% decrease in the undecided group and a 1.3% decrease in the group preferring nonsurgical treatment drove a shift of patients toward laminectomy, from 26.7% to 35.8% (Wilcoxon signed rank test = 349.5, p = .017). Postviewing preference (74.0%) was a better aggregate predictor of the ultimate treatment than previewing preference (70.0%) for laminectomy. DISCUSSION: Viewing the videodisk increased the preference for laminectomy. However, limitations in the data prevented us from determining whether this change in preference was actually reflected in patients' ultimate decisions. The fact that the strongest predictor of choosing surgery was the patient's valuation of his or her condition supports shared decision making, with its emphasis on patient's values. Participation in other videodisk programs has been low; perhaps physicians should ask patients to view these videodisks before their visits.

Adult↗

PubMed2001

Benefits and outcomes of staff nurses' participation in decision making.

OBJECTIVES: To investigate the relations among staff nurses' participation in phases of the decision-making process related to decisions in nursing practice, competencies of nurse manager leadership, and nurse-physician collaboration. METHODS: This study is a secondary analysis of the Variations in Nursing Practice Model study. The data were derived from the responses of staff nurses to a questionnaire asking about their participation in decision making, their perception of the competency of nurse manager leadership, and their collaboration with physicians. RESULTS: Nurse-physician collaboration contributed to greater participation in all phases of both caregiving and condition-of-work decisions. The competency of nurse manager leadership had a small but significant positive correlation with participation in decision making, but it did not have a significant effect on phases of participation in both types of decisions. CONCLUSIONS: The study findings provide evidence to support the relations among an organizational structure, an organizational process, and a provider process of healthcare. Further research is needed to clarify the relation among structure, process, and specific outcomes.

Adult↗

PubMed1998

Patient participation in decision-making.

We review the research both for and against patient participation in decision-making and conclude that (a) patients want to be informed of treatment alternatives, (b) they, in general, want to be involved in treatment decisions when more than one treatment alternative exists, and (c) the benefits of participation have not yet been clearly demonstrated in research studies. However, studies that have addressed the latter issue suffer from methodological problems such as small sample sizes and lack of control for potential confounding variables. We conclude that patient participation in decision-making is justified on humane grounds alone and that physicians should endeavor to engage patients in decision-making, albeit at varying degrees, when more than one effective treatment option exists. We propose that methods be developed to evaluate a patient's level of "readiness" to participate in decision-making and that interventions that match the patient's level of readiness be applied to increase participation.

Decision Making↗

PubMed1991

An integrative model of clinical-ethical decision making.

The purpose of this paper is to propose a model of clinical-ethical decision making which will assist the health care professional to arrive at an ethically defensible judgment. The model highlights the integration between ethics and decision making, whereby ethics as a systematic analytic tool bring to bear the positive aspects of the decision making process. The model is composed of three major elements. The ethical component, the decision making component and the contextual component. The latter incorporates the relational aspects between the provider and the patient and the organizational structure. The model suggests that in order to arrive at an ethically, justifiable sound decision one make reference to those three elements.

Beneficence↗

PubMed1998

Decision making by emergency nurses in triage assessments.

Triage assessment of patients on arrival at emergency departments involves complex decision making, resulting in categories being assigned to prioritize patients' needs for attention. The actual process of triage decision making has received limited attention. The aims of this study were to describe aspects of the triage decision-making process used by both more and less experienced nurses (n = 20) and to test the effect of uncertainty in the triage situation on the use of probability judgements (heuristics). Six triage cases based on actual triage situations were simulated to subjects, and their verbal protocols were collected. Protocols were transcribed and analysed. Main findings were: in conditions of higher uncertainty in triage situations all nurses used more probability in their judgements (t-test -2.37, df = 17, P = 0.03) with the heuristic of representativeness being relied on the most. The triage categories finally assigned for each triage situation showed no agreement on a specific triage category for each triage case and past triage experiences were used in decision making. The more experienced group reported higher estimations of correctness regarding the final category assigned, used more single previously experienced cases from memory, collected less data and made more judgements than the less experienced group. Further examination of the decision-making process of triage assessment should occur with attention to the variable use of triage categories, the role of past triage experiences in making judgements and development of triage decision rules for skilling nurses for triage.

Clinical Competence↗

PubMed1999

Testing the effects of a decision-making and risk-reduction program for cancer-surviving adolescents.

PURPOSE/OBJECTIVES: To test the effects of a decision-making and risk-reduction program for cancer-surviving adolescents. DESIGN: Prospective clinical trial using a quasi-experimental pretest/post-test design with repeated measures. SETTING: Two survivor follow-up clinics and a camp for children and adolescents with cancer located in upstate New York. SAMPLE: A convenience sample of 64 survivors (13-21 years of age). The intervention group consisted of 21 survivors who attended a workshop, and the comparison group consisted of 43 survivors who did not attend the workshop. METHODS: Intervention-integrated information specific to survivorship, decision-making skills, risk behaviors, and social support from peers and healthcare professionals. The educational component of the program lasted one day (five one-hour units), and the social component lasted overnight. A single, semistructured interview at the time of the previous yearly evaluation visit was used for baseline data. Testing was conducted during home visits at 1, 6, and 12 months. MAIN RESEARCH VARIABLES: Decision making, risk motivation, and risk behaviors (i.e., smoking, alcohol use, and illicit drug use). FINDINGS: The effect of the intervention for improving decision making was significant at 1-month postintervention, marginally significant at 6-months postintervention, and highly significant at 12-months postintervention. The effect of the intervention for motivation toward alcohol use was significant at 1-month postintervention and marginally significant at 6-months postintervention; however, the intervention had no effect on smoking motivation at any of the three time intervals. The effect of the intervention for improving smoking behavior was marginally significant at 6-months postintervention and was marginally significant at 12-months postintervention for alcohol use. CONCLUSIONS: The intervention had a dampening effect on the upward trajectory of substance use, a path that is well-known to increase with age for both genders in the general population. This short, five-hour program for improving decision making and affecting substance use of teen survivors shows promise; however, a larger sample is needed to enhance findings. IMPLICATIONS FOR NURSING PRACTICE: Besides tailoring risk-behavior information based on actual or potential late effects of treatment to each teen survivor during follow-up visits, oncology professionals need to provide booster programs to refine decision-making skills within meaningful decision context for teen survivors as a means of reducing risk behaviors.

Adolescent↗

PubMed2006

Caregiving decision making by older mothers and adult children: process and expected outcome.

Dyadic caregiving decision making was studied in 30 mother-son and 29 mother-daughter pairs (mother's age=65-94 years) who responded to a vignette depicting a caregiving decision situation. The observed decision-making process of mother-child pairs was largely naturalistic, with few alternatives proposed and quick convergence to a decision followed by a postdecision justification; a degree of more rational decision making was seen in some pairs. Among significant findings, adult children, especially sons, dominated the decision process, doing more talking and introducing more alternatives than did their mothers, who played a more subordinate role. Mother-son pairs expected more negative outcomes and greater regrets regarding their decisions than mother-daughter pairs. Closeness of the parent-child relationship influenced the decision-making process, expected outcomes, and regrets.

Adult↗

PubMed1991

Adolescent women's contraceptive decision making.

A modified rational decision model incorporating salient events and social influences (particularly from sexual partners) is used to analyze adolescent women's consistent use of oral contraceptives (OCs) over a six-month period. Data are taken from a panel study of 308 clients of an inner-city family planning clinic. Expected OC use was computed for each subject on the basis of subjective expected utility (SEU) theory, and is found in multivariate analyses to be a significant predictor of actual OC use. In addition, variables representing baseline and follow-up partner influences, the salience of pregnancy for the subject, and positive side effects of OCs during the first months of use are found to predict OC use. Partner's support of OC use during follow-up and positive side effects of OCs are found to predict OC use among subjects for whom OC use was not the expected decision according to baseline SEU. Implications of the findings for models of adolescents' contraceptive behavior and for clinicians are discussed.

Adolescent↗

PubMed2001

Understanding the role of contextual influences on local health-care decision making: case study results from Ontario, Canada.

Approaches to involving the public in local health care decision making processes (and analyses of these approaches) have tended to treat participation and publics uniformly in search of the ideal method of involving the public or providing the same opportunities for public participation regardless of differing socio-economic, cultural, insitutional or political contexts within which decisions are made. Less attention has been given to the potential for various contextual factors to influence both the methods employed and the outcomes of such community decision-making processes. The paper explores the role that context (three sets of contextual influences more specifically) plays in shaping community decision-making processes. Results from case studies of public participation in local health-care decision making in four geographic communities in Ontario are presented. During the study period, two of these communities were actively involved in health services restructuring processes while one had recently completed its process and the fourth had not yet engaged in one. Several themes emerge from the case studies regarding the identification and role of contextual influences in differentially shaping participation in local health care decision-making. These include the propensity for communities with different social and structural attributes to engage in different "styles" of participation; the importance attached to "community values" in shaping both the qualitative and quantitative aspects of participation: the role of health councils, local government and inter-organizational collaboration as participation "enablers"; and the politicization of participation that occurs around contentious issues such as hospital closures.

Community Health Planning↗

PubMed2003

Development and testing of the theory of collaborative decision-making in nursing practice for triads.

BACKGROUND: Although nurses depend heavily on informal family caregivers to provide care to clients and to be involved in care planning and decision-making, no nursing theories that include the client, the caregiver, and the nurse were available to guide collaborative care planning and decision-making. AIM: The purpose of this paper is to describe the construction and initial testing of the theory of collaborative decision-making in nursing practice for a triad. The theory represents an extension of Kim's theory of collaborative decision-making in nursing practice. Kim's theory was developed to describe and explain collaborative decision-making in a dyad (client and nurse). The inclusion of a third person (family caregiver) in the theory required the addition of concepts about the caregiver, coalition formation, and nurse and caregiver outcomes. The expansion of Kim's dyadic theory to a triadic theory was achieved by means of a modified version of the theory derivation process described by Walker and Avant. CONCLUSIONS: The theory of collaborative decision-making in nursing practice for a triad can be used to guide further research and clinical practice. The theory provides a framework for researchers who are interested in studying the effects of collaboration regarding decision-making among nurses, family caregivers, and clients. The initial testing of the new theory in home health care nursing revealed variety in the nature of the client-caregiver-nurse relationships, the many processes used by the nurses in proceeding with the home visits, a multitude of decisions considered and different collaborative, noncollaborative, and coalition-forming interactions. The limited evidence of the empirical adequacy of the theory precludes development of definitive guidelines for clinical practice at this time. More studies are required before clinical practice guidelines can be developed.

Caregivers↗

PubMed2006

Productivity and turnover in PCPs: the role of staff participation in decision-making.

BACKGROUND: Efforts to redesign primary care practices are beginning to address how decisions are made in the practice setting. This study contributes to these efforts by examining associations between staff participation in decision-making, productivity, and turnover in primary care practices. The study is informed by organizational theories of participation that emphasize cognitive and affective influences on employee output and behavior. METHODS: This research used data collected from primary care practices involved in a national initiative sponsored by the Robert Wood Johnson Foundation. Cross-sectional survey data on organizational structures and attributes among 49 practices were analyzed. Regression analysis was used to examine associations among practice productivity, staff participation in decision-making, and formal structures such as staff meetings. Associations between staff turnover and participative decision-making were also examined. RESULTS: Staff participation in decisions regarding quality improvement, practice change, and clinical operations was positively associated with practice productivity, whereas formal structures such as staff meetings were not. In addition, higher levels of participation in decision-making were associated with reduced turnover among nonclinicians and administrative staff. CONCLUSION: Examination of organizational features is increasingly recognized as a key to improving primary care performance. Study findings suggest that one important strategy may be implementation of a participative model emphasizing greater staff involvement in practice decisions. This may enhance information-sharing, work satisfaction, and commitment to organizational decisions, all of which can lead to beneficial outcomes such as increased productivity and stability in primary care practices.

Cross-Sectional Studies↗

PubMed1999

Decision-making within the social course of dementia: accounts by Chinese-American caregivers.

The goal of this retrospective pilot study was to provide a naturalistic description of the decision-making process regarding dementia, a chronic illness. The hypothesis was that in-depth descriptions by caregivers in a community setting would provide a more comprehensive and realistic representation of decision-making in the case of chronic illness than has been provided by most models. Data were gathered from in-depth, qualitative interviews with seven Chinese-American families living in the Boston area and caring for an elderly family member with dementia. These were supplemented with interviews with medical professionals and ethnography done in the community regarding the care of elders with dementia. Based on the findings, this paper proposes a dynamic, more comprehensive model for the social process of decision-making which is particularly applicable to clinical and life situations of decision-making in the case of chronic illness. The model describes: 1) the decision-maker constellation, including multiple family members, professionals and service systems; 2) relationships between decision-makers as "allies" or "competitors"; 3) variations in the nature of the decision-making process; and 4) the interaction of decision-making with larger social, economic and cultural forces. Decision-making in the case of dementia is placed within the conceptual framework of the "social course" of chronic illness.

Asian↗

PubMed2005

Using cognitive models to map relations between neuropsychological disorders and human decision-making deficits.

Findings from a complex decision-making task (the Iowa gambling task) show that individuals with neuropsychological disorders are characterized by decision-making deficits that lead to maladaptive risk-taking behavior. This article describes a cognitive model that distills performance in this task into three different underlying psychological components: the relative impact of rewards and punishments on evaluations of options, the rate that the contingent payoffs are learned, and the consistency between learning and responding. Findings from 10 studies are organized by distilling the observed decision deficits into the three basic components and locating the neuropsychological disorders in this component space. The results reveal a cluster of populations characterized by making risky choices despite high attention to losses, perhaps because of difficulties in creating emotive representations. These findings demonstrate the potential contribution of cognitive models in building bridges between neuroscience and behavior.

Cognition Disorders↗

PubMed2002

Children's participation in the decision-making process during hospitalization: an observational study.

Twenty-four children (aged 5 months to 18 years) who were admitted to a university hospital were observed for a total of 135 hours with the aim of describing their degree of participation in decisions concerning their own care. Grading of their participation was made by using a 5-point scale. An assessment was also made of what was considered as optimal participation in each situation. The results indicate that children are not always allowed to participate in decision making to the extent that is considered optimal. In no case was it judged that a child participated in or was forced to make a decision that was too difficult for the child. The interactions between children, parents and staff were also described in connection with discussions and decision-making processes. This showed that parents do not always support their children in difficult situations and that health care staff often inform children about what is going to happen without presenting alternatives or asking for their views. Staff may, however, find themselves facing an ethical conflict in deciding between supporting a child's view or following hospital routine. It is of great importance that children are looked upon as potentially autonomous individuals and that staff members realize that one of their core duties is to facilitate children's participation in decision making concerning their health care.

Adolescent↗