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Results for “Making Difficult Health Care Decisions”

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PubMed1997

Ethical dilemmas faced by mental health nurses.

This paper considers the dilemmas faced by mental health nurses when they encounter difficult ethical decisions. Using a case study, the author analyses the patient's right to autonomy and the nurse's duty of care. Theories of decision-making are assessed for their relevance to the work of mental health nurses. The author proposes that Hare's (1981) theory of universal prescriptivism offers an appropriate framework and examples from clinical practice are described to support this argument.

Decision Making↗

PubMed1999

Strategic decision making on shifting sands.

Strategic decision making in today's health care marketplace is very challenging. In the past, strategic plans were written for five to ten years. With the rapidly changing environment, planning for more than two years is difficult. It is critical for organizations to set a pathway for success. However, the organization needs to be able to respond quickly to environmental changes and take advantage of opportunities. The article presents a case study on a relatively new organization that has ambitious strategic goals. It discusses the decision-making process on the ways to enter a new marketplace, including the key factors assessed by the organization and their implications.

Decision Making, Organizational↗

PubMedDate not supplied

Psychological androgyny and preference for intubation in a hypothetical case of end-stage lung disease.

Psychological androgyny theory (PAT) was employed as a model of the interpersonal (social) and task activities required of physicians for care of their patients. According to PAT, individuals with a large repertoire of task and social skills ("androgynous" individuals) should be optimally adaptable to contingencies reflecting varying combinations of task and social challenges. The authors examined the relationship between androgyny and preference for intubation on a patient management problem involving end-stage lung disease for 67 general internists and internal medicine housestaff from two hospitals. Results revealed a negative relationship between androgyny and preference for intubation, suggesting that androgynous and nonandrogynous physicians respond differently to complex and difficult decision-making tasks. Indirect evidence is offered to suggest that this response reflects a general tendency to utilize fewer health care resources. Discussion focuses on the need to improve the precision of measurement of these latent constructs.

Extraversion, Psychological↗

PubMed1997

Economic evaluation of medical technologies in Sweden.

This paper reviews the use of economic evaluations in the Swedish health care system. The most important actors are defined and examples are given how economic evaluations have played a role in the decision making process. The introduction of extracorporal shock-wave lithotripsy (ESWL) is used as an example on how economic evaluation was used for recommendations to the county councils to adopt this technology. Mammography is used as an example of how the evaluation is used in the political process following an initiative in the parliament. A study of the cost-effectiveness of hypertension treatment illustrates how economic evaluations are included as part of a medical technology assessment by SBU, the Swedish Council on Technology Assessment in Health Care. The role of economic evaluations for drug reimbursement and pricing is also reviewed. The main conclusions are that economic evaluations are one of several factors influencing a decision making process that have a strong strive for consensus. It is thus difficult to make a definitive statement of the contribution of such study to the outcome of the decision making process, and there is no evidence that the evaluation was the decisive factor. However, a number of changes in the way resources are allocated in the Swedish health care system speaks for an increasing role for such studies in the future. The county councils are identified as the main target for economic evaluations, and SBU has a key role in supplying the county councils with high quality assessment of new and old technologies.

Cost-Benefit Analysis↗

PubMed2002

In the patient's best interest--a call to action, a call to balance.

Nurses, physicians, and other healthcare professionals often complain that a loss of freedom or other obstacles hinder their ability to act in the best interest of the patient. These barriers cause professional burnout and moral outrage, and may contribute to a migration away from medicine or, more broadly, healthcare. Understanding the historical underpinnings of the phrase "in the patient's best interest," and realizing that healthcare, which is fundamentally a moral enterprise must be built on sound business principles can help healthcare professionals reframe the issue, and reclaim their original commitment to a difficult path.

Burnout, Professional↗

PubMed1990

Health services and decentralized government: the case of primary health services in Norway.

Decentralized forms of government are becoming more common in Western European countries. The effects of decentralization of public health services are explored in this article. In 1984 the Norwegian Municipal Health Act allocated the responsibility for primary health care to the municipalities. Based on data from a sample of 70 municipalities, the author shows that the number of primary health service personnel has expanded considerably during 1984-88, but the distribution of services has not become more equitable. Though the formal role of local politicians in the decision-making process has increased, the health sector officers and the Municipal Executives have in practice controlled the evolution of the municipal health services. The author concludes that decentralization does not necessarily lead to more democracy, and that an equitable distribution of public health services becomes more difficult to attain.

Decision Making, Organizational↗

PubMed1998

Pathway leadership: a mature framework for teams.

Shared Governance has been a successful organizational design for Central Baptist Hospital. We are addressing critical issues that impact our success, with involvement and facilitation of the employees who make up the organization. It will continue to change as our environment and system evolve. The movement from a traditional organizational structure and culture to one of embracing shared decision making gives leaders today an additional stressor. It is difficult to critically analyze your organization when you are faced daily with the external pressures of health care competition and the internal daily pressures of operations. It takes extra effort and introspection to recognize that you and your management team must undertake new and different behaviors to lead your organization into the next millennium. One thing is clear: If you do not create an environment that is flexible and able to accommodate change, your competitor will!

Communication↗

PubMed1992

When weaning from mechanical ventilation fails.

OBJECTIVE: To describe the etiologies and indicators of weaning failure and to provide a framework for planning interventions to facilitate weaning of long-term ventilation patients. DATA SOURCE: A Medline search of human studies in English on weaning from mechanical ventilation. ARTICLE SELECTION: Articles were selected if they pertained to the assessment and management of weaning failure. Both research and review articles were included. DATA EXTRACTION: All pertinent articles were described, along with their limitations. DATA SYNTHESIS: Weaning from mechanical ventilation is an emerging science. Caring for patients who are difficult to wean requires expert clinical decision making so patients do not feel defeated and have the best chances for success. Combining the limited research on weaning intervention with clinical expertise helps to build a scientific basis for care and can assist clinicians in tailoring interventions to specific problems that precipitate weaning failure. CONCLUSION: A scientific approach to care may promote weaning in difficult cases and provide directions for future research into the etiologies of weaning failure.

Attitude to Health↗

PubMed2001

Using health outcomes data to inform decision-making: formulary committee perspective.

When healthcare resources are limited, decisions about the treatments to fund can be complex and difficult to make, involving the careful balancing of multiple factors. The decisions taken may have far-reaching consequences affecting many people. Clearly, decisions such as the choice of products on a formulary must be taken using a selection process that is fully transparent and that can be justified to all parties concerned. Although everyone would agree that drug selection should be a rational process that follows the guidelines of evidence-based medicine, many other factors may play a role in decision-making. Although some of these are explicit and rational, others are less clearly defined, and decision-makers may be unaware of the influence exerted by some of these factors. In order to facilitate transparent decision-making that makes rational use of health outcomes information, the System of Objectified Judgement Analysis (SOJA) has been developed by the author. SOJA includes interactive software that combines the quality advantages of the 'top-down' approach to drug selection, based on a thorough literature review, with the compliance advantages of a 'bottom-up' approach, where the final decision is made by the individual formulary committee and not by the authors of the review. The SOJA method, based on decision-making processes in economics, ensures that health outcomes information is given appropriate weight. Such approaches are valuable tools in discussions about product selection for formularies.

Decision Making↗

PubMed2006

Cost effectiveness of revision total knee arthroplasty.

UNLABELLED: Total knee arthroplasty now exceeds total hip arthroplasty as the most commonly performed joint replacement. Projections suggest the need for revision knee arthroplasty in the future will produce an immense economic burden. The excellent cost effectiveness of primary knee arthroplasty has been well established. This article explores the cost effectiveness of revision knee arthroplasty, and makes a comparison of costs between different international health care systems. While revision knee arthroplasty is more costly, technically difficult, and complicated than primary knee arthroplasty, it is still a cost effective means of improving function, pain relief, and quality of life. The role of national arthroplasty registries will be important in guiding decision making toward reducing the requirements for revision surgery. LEVEL OF EVIDENCE: Prognostic study, level II-1 (prospective study). See Guidelines for Authors for complete description of levels of evidence.

Arthroplasty, Replacement, Knee↗

PubMed1988

Guide to ethical decision-making for the critically ill: the three R's and Q.C.

Ethical decision-making for the care of the critically ill and injured has never been more difficult than it is today. Major technologic advances prolong life but often provide questionable benefit in human terms. Both the ethical commitment to the individual patient and the competition for access to expensive and scarce health resources prompt the search for clinically useful and operationally appropriate criteria for decision-making. The mnemonic 3 R's and Q.C. was evolved as a practical tool by which the ethical basis for interventions may be tested. The first tier, the 3 R's, is likely to resolve the vast majority of ethical issues. These are appropriately addressed at the bedside by clinicians who determine whether a proposed intervention is Rational, Redeeming, and Respectful. When the ethical issues cannot be resolved at the bedside on the basis of the 3 R's, a second tier of testing of Quality of Life and Cost (Q.C.) is triggered. This addresses decision-making which is not exclusively or even primarily in the skill domain or authority of most physicians. It calls for assistance by those who represent a broader base of societal involvement including multidisciplinary experts in ethics and law who serve as consultants or who are organized into medical center-wide ethics committees.

Critical Care↗

PubMed2005

Health-related decision-making by older adults and their families: how clinicians can help.

Helping frail and vulnerable individuals and their families to make the best health-related decision is difficult even in the best of circumstances. Decision-making as a discrete action is often discussed in the health care literature, but the concept that decision-making is a process is largely ignored. Understanding the basic elements of the decision-making process used by older adults and their family, or support individual(s) may help health care team members offer more substantial and meaningful assistance to the individuals who are trying to make tough health-related decisions. Full information needs to be available so all participants involved in the process can make reasonable decisions. The decision-making process is highly contextual and is based on how realistic the decision-making goals are and how congruent the experiences versus perceived expectations are, as well as the quality of options available.

Aged↗

PubMed1998

Medical knowledge, quality of life and accreditation of quality in health care. The perspective of the clinical nephrologist.

The problem of Quality has three dimensions: the dimension of quality of life (the patients, perspective), the dimension of quality of medical knowledge and of the appropriate use of medical technology (i.e. the "evidence based" medical approach to clinical decision making) and the dimension of accreditation of health care providers. The problem of keeping clinicians well updated is a difficult one but there are solutions. The medical literature can be selectively but thoroughly analysed and on the basis of high quality studies specific recommendations (i.e. guidelines) can be produced. Scientific societies are now making major efforts to produce high quality guidelines for the treatment of patients with chronic renal failure and for those on chronic dialysis. The DOQI and the Standards Document by the Renal Association offer first class examples of how scientific knowledge can be translated into clear practice guidelines. As far as the dimension of quality of medical knowledge is concerned, there is now increasing evidence that the taking into full account of quality of life issues such as those regarding the physical, psychic and social dimensions of health improves substantially patient's satisfaction and the patient-doctor relationship. Quality of life considerations are now fully considered when evaluating the efficacy erythropoietin in the treatment of uraemic anemia. If we accept the perspective that health care organisations should aim at excellence, the performance of a given provider can be evaluated on the basis of various indicators and its performance made transparent to the potential users. The internet has become the most accessible source of such kind of information and it can be easily forecasted that the performances of all major hospitals and health care organisations will soon be in the public domain.

Accreditation↗

PubMed2001

Ethical issues in the critically ill patient.

Ethical issues have emerged in recent years as a significant component of care in the critically ill patient. Recently, the primary emphasis has been directed to care at the end-of-life. The factor that has been identified as the most important to patients and families and the one that is accomplished the least often is successful communication with the physicians. When communication does not take place or is inadequate physicians are left to try to determine what their patient's wishes would have been regarding end-of-life decisions. This leads to tremendous potential for conflict between the physician and the family, as the patients are often incapable of participating in any discussion regarding end-of-life care. Advance planning on the part of the patient in terms of making their wishes known and education of the health care professionals is essential in promoting effective communication, thereby avoiding conflict in these difficult end-of-life decisions.

Advance Directives↗

PubMed1996

The evolution of the intensivist: from health care provider to economic rationalist and ethicist.

In contrast to many open intensive care units (ICUs) in the United State, where "parent" units (sometimes with few intensive care skills) admit and manage their own patients, Australia has closed units in which the intensivist has primary control of patient care while the patient remains in the ICU. This difference is important because in Australia, by virtue of having control of the ICU, the intensivist can be made responsible not only for patients care, but for resource allocation and financial constraint. Australian intensivists are called upon daily to make difficult decisions about who will be admitted, prematurely discharged or transferred from ICUs, and when treatment will be restricted or withdrawn.

Australia↗

PubMedDate not supplied

In their own voices: families discuss end-of-life decision making--part 2.

This two part series of articles presents poignant narratives based on interviews done with two mothers who suffered the worst pain imaginable--the pain of losing a child. Each woman describes an insensitive health care system with providers unaware of parental views and needs when confronted with difficult decisions during their children's illnesses and subsequent deaths. Each woman also hoped that telling her story might help nurses and other health care providers better understand how to help. Part 1 of the series is the story of a professional, highly educated mother who experienced periods of extreme distress while she tried to give her premature daughter an identity and meaningful life in the neonatal intensive care unit and the difficulties faced when she was transferred to another unit as she became more ill Part 2 of the series is the story of a highly devoted working mother who tried to understand the information that was rarely offered to her as she lived through the extreme surgical and uncertain medical interventions given her toddler daughter with a fast-growing brain tumor. Both women faced hard decisions along their daughters' illness trajectories. Both hoped for support from their health care providers in being active in decision-making. These narratives are in their own voices, from their own points of view.

Adaptation, Psychological↗

PubMed2003

Disclosure of HIV infection: how do women decide to tell?

This descriptive study explores the phenomenon of disclosure of HIV infection by women. Specifically, we examined women's level of disclosure to various groups and how these disclosure decisions are made. The sample consisted of 322 HIV-infected women residing in the southern US. Participants were predominantly African-American, single women of reproductive age with yearly incomes less than $10,000. Data were collected at the first interview of a longitudinal study of reproductive decision making. Findings showed that the majority of the women had disclosed to some sex partners, close family and friends, and health care professionals. However, for a group of women, disclosure of HIV infection is a difficult issue supporting the need for health education and counseling. Qualitative data were analyzed using content analysis and revealed three major categories describing how women make disclosure decisions: full disclosure, criteria for disclosure and emotional disclosure. Quantitative analysis revealed few demographic differences among women in the three disclosure categories. These findings provide insight that can assist those working with HIV-infected women in helping them decide not only to whom they disclose, but how best to disclose.

Adolescent↗

PubMed1985

Ethical dilemmas in caring for patients with the acquired immunodeficiency syndrome.

Caring for patients with the acquired immunodeficiency syndrome (AIDS) raises ethical dilemmas about when to provide life-sustaining treatments such as mechanical ventilation and cardiopulmonary resuscitation. In addition, many patients become mentally incompetent and unable to participate in decisions. Homosexual men may want their lover or a friend to make decisions for them, but the patient's partner or friend cannot make these decisions unless he is legally designated. Decision-making guidelines may be hard to implement because caring for patients with AIDS is stressful. We describe three cases that illustrate the difficult ethical dilemmas and stresses of caring for these patients.

Acquired Immunodeficiency Syndrome↗