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PubMed2006

Supportive and palliative care in end stage renal failure: the need for further research.

In the UK, government guidelines related to chronic illness are being used to enhance supportive care of renal patients. Good practice includes ensuring the views of patients and carers are taken into account when developing and evaluating palliative care services. The literature relating to a renal patient's decision not to dialyse is sparse and the evidence base upon which to support effective nursing practice is currently weak. Much can be drawn from the discipline of cancer nursing, however, further research needs to be undertaken to develop new knowledge within the realm of supportive renal care. Having a fuller understanding of how, and when, renal patients finally make difficult end-of-life decisions is crucial in order to offer effective support and deliver an efficient and valuable renal supportive care service.

Advance Directives↗
PubMed2003

Transport and land-use policies in Delhi.

Current transportation policies in mega-cities worldwide lead to major threats to health through traffic injuries, air pollution, noise, reduction in physical activities, and adverse impact on urban quality of life. In addition, a large section of the population in cities in low-income countries has to live in informal-sector, substandard housing. Many transportation policies fail to take enough account of their impacts on poverty and social exclusion, and they neglect the access and transportation demands of the more economically disadvantaged groups of society, who rely mostly on public transportation, walking, and cycling. Delhi, the capital city of India, is an interesting case because failure to consider the broad spectrum of health effects that may result from transport and land-use policies and investments has resulted in decisions that penalize the least affluent groups of the population and make it more difficult for them to get to jobs, education, health care, amenities, and services.

Accidents, Traffic↗
PubMed1996

[Headache in general medicine: status and clinical evaluation].

Headache is one of the most frequent population health problems. It is also one of the most frequent complaints during an encounter in general practice. The family doctor is confronted with a difficult way of getting action, either diagnostic or therapeutic, which has to take into account the specificity of decision making in primary health care. A pragmatic and efficient proposal is built up, step by step.

Adolescent↗
PubMed2003

Understanding the role of "the hidden curriculum" in resource allocation--the case of the UK NHS.

In this paper we want to briefly illustrate the ways in which technical, ethical and political judgements of various kinds are interwoven in the processes of healthcare decision-making in the UK. Drawing upon the research for the "Choices in Health Care" project we will borrow the notion of the hidden curriculum from education to illuminate the nature of resource allocation decision processes. In particular we will indicate some of the fundamental but largely hidden political factors in play in these processes and the importance of the inchoate and implicit notion of "NHS values" in shaping UK resource allocation policies. We suggest that these more diffuse, holistic and system level value judgements are both central to understanding priority setting and at the same time difficult to reduce or abstract out into lists of single values/principles.

Costs and Cost Analysis↗
PubMed1999

Allocating scarce resources in a publicly funded health system: ethical considerations of a Canadian managed care proposal.

In the Canadian health care system, the Government is responsible for allocating scarce resources in a fair and equitable manner. A proposal to implement managed care as a method of reimbursing physicians in Alberta, Canada, needs careful ethical consideration, because physicians are not well prepared, and should not be asked, to make the resulting difficult allocation decisions. The Government must continue to be held responsible for ensuring that all citizens have equal access to necessary medical services, and we must find ways to encourage the public to become more involved in deciding how resources are best allocated. Health professionals other than physicians must take an interest and enter into this debate.

Alberta↗
PubMed2006

Difficult commissioning choices: lessons from English primary care trusts.

OBJECTIVE: In England, primary care organizations (primary care trusts, PCTs) have scope to influence the provision of health care at the margin. However, when faced with difficult commissioning choices, restriction of services potentially leaves them vulnerable to legal challenge. PCTs are developing different approaches to priority setting but there is a need to develop processes that lead to more consistent, accountable and fair decision-making. Our objective was to describe recent local developments on prioritization decision-making. METHODS: Rationing policies in PCTs in West Yorkshire and North & East Yorkshire and North Lincolnshire (NEYNL) Strategic Health Authority areas in 2003 were examined. To evaluate priority setting, we compared the descriptive findings with an internationally recognized ethical framework for priority setting, 'accountability for reasonableness' (AFR). RESULTS: PCTs varied as regards the stage of policy development they had reached. Rationing by exclusion was the most common approach to prioritization, but in general PCTs failed to make the rationale for their decisions explicit and accessible. The importance of an appeals process was recognized by the majority of PCTs. Those that had developed a formal process to address difficult commissioning decisions were an exception. CONCLUSIONS: Adopting AFR as a prioritization framework can serve to improve the fairness and consistency of the decision-making process, reducing the vulnerability of PCTs to legal challenge. Characteristics of rationing policies already in place fulfil some of the AFR conditions but there remains scope for further improvements in their design and dissemination.

England↗
PubMed2006

Fruitful or futile: intensive care nurses' experiences and perceptions of medical futility.

The study sought to investigate the perceptions and experiences of nurses practising in adult intensive care units (ICUs) with regard to medical futility. A qualitative exploratory descriptive design was used, providing a framework which enabled information to be gathered on a relatively undefined phenomena. Data were gathered via semi-structured interviews with seven intensive care nurses. Findings concluded that there is no 'one size fits all' definition of medical futility. To arrive at the decision whether treatment is futile, participants want to understand patients' views on treatment limitation. In some ICUs, 'the decision' about whether to cease or continue treatment is unilaterally made by medical staff, raising concerns about value laden judgement. Nurses experience frustration with having to administer treatment with which they do not agree and may actually leave intensive care nursing because of their moral conflict. There are opportunities for nurses to have input into 'the decision', but they must have a cogent and articulate approach to be heard. Once treatment is deemed to be futile, nurses play a key role in treatment withdrawal and can have a significant impact on the patient and family experience if they manage the situation well; this nursing role in medically futile situations and treatment withdrawal is detailed. 'Medical futility' is not easily defined. Understanding patients' views about treatment limitation is important in deciding whether treatment is medically futile. To do this, an inclusive decision making process should be developed by ICUs which incorporates nursing and family input. Experienced ICU nurses can have a significant impact on the management of futile cases; they need to share their understanding of the processes surrounding medical futility and assist junior nurses in negotiating the difficult challenges encountered in decision making and treatment withdrawal.

Adult↗
PubMedDate not supplied

Residential alcohol detoxification: new role for mental health nurses.

This article discusses the philosophy and practice of a community-based residential detoxification service for people with alcohol problems. The service is provided on a direct-access basis and has a team of 19 nurses who are supported by a GP practice. The article highlights issues relevant to nursing in this community facility by referring to three case studies. The case studies demonstrate that this client group finds it difficult to access other forms of health and social care. The case examples emphasize both the qualitative aspects of nursing care and the decision-making involved in this type of service. The authors suggest that large populations with complex needs can be served by nursing-led services adopting a 'direct access' approach.

Adult↗
PubMed2005

Advanced cancer in children: how parents decide on final place of care for their dying child.

AIM: to explore retrospectively the decisions made by parents regarding their choice of place of care at time of death for their child with advanced cancer. DESIGN: cross-sectional descriptive study. ANALYSIS: interpretive phenomenological analysis. SAMPLE: parents of five children who had died of advanced cancer, whose care was overseen by the participating paediatric oncology centre in the southeast of England. Three children died at home and two in hospital. RESULTS: seven themes were identified, four of which will be discussed: valuing time left; needing to feel safe and secure; we didn't know what to expect; and the difference between specialist and non-specialist staff. Families' decisions were instinctive or intuitive rather than a calculated weighing up of options. Families identified aspects of care that were both valuable and could be improved. CONCLUSION: parents value the time that their children have to live when they know that their child's disease is incurable. Decisions around place of care are just that, decisions around place of care not place of death. Families valued the same types of support from staff regardless of the setting in which care was provided and found the same deficiencies difficult.

Adolescent↗
PubMed2001

Getting evidence into practice: the work of the Cochrane Effective Practice and Organization of care Group (EPOC).

Policy makers and continuing educators often face difficult decisions about which educational and quality assurance interventions to provide. Where possible, such decisions are best informed by rigorous evidence, such as that provided by systematic reviews. The Cochrane Collaboration is an international organization that aims to help people make well-informed decisions about health care by preparing, maintaining, and ensuring the accessibility of systematic reviews of the benefits and risks of health care interventions. International collaborative review groups prepare Cochrane reviews for publication in The Cochrane Library, a collection of databases available on CD-ROM and the World Wide Web and updated quarterly. The Cochrane Effective Practice and Organization of Care Group (EPOC) aims to prepare and maintain systematic reviews of professional, financial, organizational, and regulatory interventions that are designed to improve professional practice and the delivery of effective health services. EPOC has 17 reviews and 20 protocols published in Issue 3, 2000, of the Cochrane Library, with further protocols in development. We also have undertaken an overview of previously published systematic reviews of professional behavior change strategies. Our specialized register contains details of over 1,800 studies that fall within the group's scope. Systematic reviews provide a valuable source of information for policy makers and educators involved in planning continuing education and quality assurance initiatives and organizational change. EPOC will attempt to keep the Journal of Continuing Education in the Health Professions informed on an ongoing basis about new systematic reviews that it produces in the area of continuing medical education and quality assurance.

CD-ROM↗
PubMed2001

Balancing rights and duties in 'life and death' decision making involving children: a role for nurses?

In recent years, increasing pressures have been brought to bear upon nurses and others more closely to inform, involve and support the rights of parents or guardians when crucial 'life and death' ethical decisions are made on behalf of their seriously ill child. Such decisions can be very painful for all involved, and may easily become deadlocked when there is an apparent clash of moral ideals or values between the medical team and the parents or guardians. This article examines a growing number of such cases in New Zealand and analyses the moral parameters, processes, outcomes and ethical responses that must be considered when life and death ethical decisions involving children are made. The article concludes with a recommendation that nurses should be recognized as perhaps the most suitable of all health care personnel when careful mediation is needed to produce an acceptable moral outcome in difficult ethical situations.

Child↗
PubMed2005

"Saying no is no easy matter" a qualitative study of competing concerns in rationing decisions in general practice.

BACKGROUND: The general practitioner in Norway is expected to ensure equity and effectiveness through fair rationing. At the same time, due to recent reforms of the Norwegian health care sector, both the role of economic incentives and patient autonomy have been strengthened. Studies indicate that modern general practitioners, both in Norway and in other countries are uncomfortable with the gatekeeper role, but there is little knowledge about how general practitioners experience rationing in practice. METHODS: Through focus group interviews with Norwegian general practitioners, we explore physicians' attitudes toward factors of influence on medical decision making and how rationing dilemmas are experienced in everyday practice. RESULTS: Four major concerns appeared in the group discussions: The obligation to ration health care, professional autonomy, patient autonomy, and competition. A central finding was that the physicians find rationing difficult because saying no in face to face relations often is felt uncomfortable and in conflict with other important objectives for the general practitioner. CONCLUSION: It is important to understand the association between using economic incentives in the management of health care, increasing patient autonomy, and the willingness among physicians to contribute to efficient, fair and legitimate resource allocation.

Attitude of Health Personnel↗
PubMed2001

The advantages of prenatal consultation by a neonatologist.

The neonatologist can be a valuable source of information for the pregnant woman and her partner faced with making difficult decisions. In specific clinical situations, a focused, thorough consultation by a neonatologist provides benefits for the parents, their child, the physicians, and the health care delivery system as a whole. Members of the perinatal team should act to facilitate early neonatal consultation in order to ease the transition from the obstetric to the neonatal team after delivery.

Congenital Abnormalities↗
PubMed2001

Cost-effectiveness analysis of changing from live oral poliovirus vaccine to inactivated poliovirus vaccine in Australia.

OBJECTIVE: Estimate the economic impact of introducing inactivated poliovirus vaccine (IPV) into the Australian childhood immunisation schedule to eliminate vaccine-associated paralytic poliomyelitis (VAPP). METHODS: Cost-effectiveness of two different four-dose IPV schedules (monovalent vaccine and IPV-containing combination vaccine) compared with the current four-dose oral poliovirus vaccine (OPV) schedule for Australian children through age six years. Model used estimates of VAPP incidence, costs, and vaccine utilisation and price obtained from published and unpublished sources. Main outcome measures were total costs, outcomes prevented, and incremental cost-effectiveness, expressed as net cost per case of VAPP prevented. RESULTS: Changing to an IPV-based schedule would prevent 0.395 VAPP cases annually. At $20 per dose for monovalent vaccine and $14 per dose for the IPV component in a combination vaccine, the change would incur incremental, annual costs of $19.5 million ($49.3 million per VAPP case prevented) and $6.7 million ($17.0 million per VAPP case prevented), respectively. Threshold analysis identified break-even prices per dose of $1 for monovalent and $7 for combination vaccines. CONCLUSIONS: Introducing IPV into the Australian childhood immunisation schedule is not likely to be cost-effective unless it comes in a combined vaccine with the IPV-component price below $10. IMPLICATIONS: More precise estimates of VAPP incidence in Australia and IPV price are needed. However, poor cost-effectiveness will make the decision about switching from OPV to IPV in the childhood schedule difficult.

Australia↗
PubMed1988

Selectivity within primary health care.

While great strides have been made in improving socioeconomic conditions in the developing world, prospects for health for all remain remote. Resources are few, and difficult decisions must be made concerning the priorities for their use. This paper addresses several topics involved in making these choices including the methods for determining priorities and ensuring effectiveness of resource use. First, prioritizing. Information is needed concerning the prevalence, mortality, morbidity, feasibility and cost of control for each disease of importance in the area under consideration. Second, the use of technology. In discussion of health care some have denigrated the concentration many programs have placed on specific methods and technologies. Nevertheless, technological advances, while some have had detrimental results, have often led to improved living conditions; for example, improved seed and fertilizer use, improved water pumps, family planning efforts. These technologies required a larger investment in management, financial and communication systems. Health interventions are frequently more various and complex than these and need a similar support system for impact. However there are many shortcomings in health services; the paper looks at some of these learnt through experience, and concludes that the lack of impact on health of large scale health programs that have provided selective interventions is probably related to an inadequate recognition of the importance of community and political involvement and of the necessary social, cultural, financial, management and administrative underpinnings.

Developing Countries↗
PubMed1992

Decision analysis for periodontal therapy.

Current decision-making approaches in clinical medicine and dentistry are based on principles developed when diagnostic and therapeutic options were few. The rapid pace of new technology development and the role of third-party payment systems are increasingly requiring that health-care providers and patients confront very complex decisions. These decisions typically involve significant uncertainty (e.g., How will a specific patient respond to each possible treatment?) and difficult tradeoffs (e.g., How much are patients willing to pay in money, time, and treatment effectiveness to avoid pain and discomfort?). This paper discusses high-quality decision-making. High-quality diagnostic and therapeutic decisions result from a well-developed decision basis that represents the alternatives, information, and preferences pertaining to the decision at hand. An effective decision basis is framed to address patients' and clinicians' key concerns. The resulting recommendation for action is based on an understanding of what factors are most sensitive in determining the best course of action. Moreover, the value of additional information-gathering efforts (e.g., further diagnosis) can be measured before the information is obtained to determine whether it is worth more than it costs. The paper illustrates the need for better decision-making methods with a sample patient case, discusses key decision analysis principles and methods, identifies specific areas where periodontal decision-making can be improved by decision analysis, and presents a periodontal decision analysis case. It then discusses how intelligent decision system technology can make decision analysis widely available in a clinical setting and concludes by exploring how a future dental office might use this technology on a routine basis.

Decision Making↗
PubMedDate not supplied

Reform, change, and continuity in Finnish health care.

This article describes some essential aspects of the Finnish political and governmental system and the evolution of the basic institutional elements of the health care system. We examine the developments that gave rise to a series of health care reforms and reform proposals in the late 1980s and early 1990s and relate them to changes in health care expenditure, structure, and performance. Finally, we discuss the relationship between policy changes, reforms, and health system changes and the strength of neo-institutional theory in explaining both continuity and change. Much of the change in Finnish health care can be explained by institutional path dependency. The tradition of strong but small local authorities and the lack of legitimate democratic regional authorities as well as the coexistence of a dominant Beveridge-style health system with a marginal Bismarckian element explain the specific path of Finnish health care reform. Public responsibility for health care has been decentralized to smaller local authorities (known as municipalities) more than in any other country. Even an exceptionally deep economic recession in the early 1990s did not lead to systems change; rather, the economic imperative was met by the traditional centralized policy pattern. Some of the developments of the 1990s are, however, difficult to explain by institutional theory. Thus, there is a need for testing alternative theories as well.

Decision Making, Organizational↗