PubMed Health⌕ Search

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 145 records · Page 8Linked to original sources
PubMed1991

Why study treatment outcome?

Concern about the spiraling cost of mental health care has increased the need for reliable data about the outcomes of such care. Treatment outcome studies, although difficult to design and carry out, are essential in demonstrating the efficacy of psychiatric treatment, rationalizing clinical decision making, and encouraging public support for the availability of appropriate, cost-effective care for the mentally ill. Ideally, outcome studies should focus not only on clinical symptomatology but also on patients' social, interpersonal, and occupational adjustment as well as on factors that, taken together, shape the quality of life. The authors discuss these issues and some of the impediments to collecting useful outcome data, including the complexity of the mental health service delivery system and problems related to patient selection, study design, and how treatment is defined.

Cost-Benefit Analysis↗
PubMed1993

The treatment perspectives of physicians, citizens, and state legislators.

This study addresses the dilemma of physicians to act both as an agent of their patients and as an agent of society. We contrasted the perceptions of physicians, citizens at large, and state legislators about 11 topics related to physician decision making regarding the management of care for seriously ill patients. Significant and interpretable differences were found between physicians and citizens, although there were no differences between these two groups and the state legislators. However, even the obtained differences were fewer and smaller than expected. These results suggest that lay, legislative, and medical viewpoints may be less at odds with each other than the literature would suggest, and reaching an accord on at least some aspects of health policy may not be as difficult as generally is assumed.

Adult↗
PubMed2006

[Health economics of psychological diseases].

This article provides an overview of the characteristics and problems of the economic evaluation of mental health care. At first, the problems and methods of measuring direct and indirect costs of mental illness are discussed using cost of illness studies for depression and schizophrenia from the literature as examples. It is shown that, due to methodological problems of measuring costs of the wide range of mental health services as well as productivity losses, various cost of illness studies rendered very different results. Thereafter, the measurement of effects in the economic evaluation of mental health services is discussed whereby the problems of measuring quality-adjusted life years (QALYs) are addressed in particular. Despite the subjectivity of symptoms, preference-based valuation of health-related quality of life has rarely been attempted in psychiatric patients. Finally, frequent flaws of published cost-effectiveness analyses of mental health care are presented. These flaws make the interpretation and comparison of study results difficult. As there are hardly any German cost-effectiveness analyses of mental health care, more research efforts in this field seem to be necessary in Germany.

Cost-Benefit Analysis↗
PubMedDate not supplied

Using geographic information systems to design population-based interventions.

Geographic information systems (GIS) offer public health nurses a new technology to plan and implement interventions within communities. The present article gives a brief overview of GIS, describes a project designed to pilot-test the use of GIS for developing population-based interventions, and discusses lessons learned from the project that need to be applied to any future work. Using GIS to map the incidence and prevalence of disease, locate risk factors, and identify access to health care services is not difficult. Trying to move beyond that and use the technology to depict community networks and develop and implement population-based interventions is more problematic. The project identified specific questions that anyone involved in a planning or decision-making project in which GIS are used should ask.

Community Health Planning↗
PubMed2001

Too few or too many dermatologists? Difficulties in assessing optimal workforce size.

Discussions of the dermatology workforce have been dominated in the last 3 decades by concerns of an impending surplus. The aim of this article is to provide new data on the supply of dermatologists and to reassess estimates of future demand in light of growing anecdotal evidence suggesting a shortage. The US supply of dermatologists has risen to 3.3 per 100 000 population, and this growing workforce continues to be geographically maldistributed. A number of factors, including a possible increase in the number of surgical and cosmetic procedures being performed, might make this growing supply less available for the care of medical dermatology patients, complicating any supply projections. Precise estimates of future demand are also difficult because changes in disease prevalence, medical technology, and the health care delivery system are not always predictable. In an era when regulatory bodies are making more centralized decisions about residency training, the field must attempt to estimate and anticipate future needs. Simply allowing others to make decisions about the future size of the workforce based on outdated data risks an oversupply or undersupply, either of which will have detrimental effects on dermatologists and their patients.

Dermatology↗
PubMedDate not supplied

[Ethical and clinical decisions on artificial hydration and feeding via tube in the terminally ill].

Tube feeding is a widely used medical treatment for providing nutrition to terminally ill patients. Long term nutritional support in these patients or patients with irreversible neurological deterioration create a host of ethical and legal conflicts with difficult solutions. This work looks at the cultural and ethical-legal basis of these decisions and gives simple suggestions that might help the health care provider in making a viable clinical decision. However, each case should be treated in an individualized manner taking into consideration the rights and desires of each patient and their families.

Cognition Disorders↗
PubMed2004

Withholding and withdrawing life prolonging treatment in the intensive care unit: a current European perspective.

BACKGROUND: Many deaths are now preceded by an end of life decision, particularly in the intensive care unit (ICU), but such practices vary considerably between countries, ICUs and individuals, depending on many factors including cultural and religious background, family and peer pressure and local practice. AIMS: In this review, we will discuss the application of the four key ethical principles--beneficence, nonmaleficence, autonomy and distributive justice--to withdrawing/withholding decisions. METHODS: Drawing data from several national and international studies, we then summarize the current situation across Europe regarding such practices before making some suggestions as to how we could facilitate the often difficult decision making process by improved communication between staff, patient and relatives.

Attitude of Health Personnel↗
PubMedDate not supplied

Ethics for regional boards.

When regional health boards choose how to allocate limited resources on the public's behalf, they are exercising ethical judgment. When board members are familiar with the study of ethics and the tools it has produced, they are able to make informed and consistent ethical choices. One board in P.E.I. drew upon ethical principles to first codify its core values, and then develop a process for making decisions which conformed to those values. As boards across Canada assume greater authority and responsibility for public health, a clear understanding of ethical principles can guide their difficult choices.

Decision Making, Organizational↗
PubMed2001

Decision making by emergency physicians when assessing cardiac arrest patients on arrival at hospital.

OBJECTIVE: To investigate the factors which influence decision making by experienced emergency physicians when they decide whether to (a) pronounce 'life extinct' in adult patients with non traumatic cardiac arrest while in the ambulance, or (b) bring them into the resuscitation room in the Emergency Department for further assessment/management. DESIGN: Qualitative study involving semi structured interviews and a focus group. SETTING: Accident & Emergency (A&E) departments in the Yorkshire region. PARTICIPANTS: Fifteen emergency physicians (two clinical fellows, nine specialist registrars and four consultants) working in the Yorkshire region. RESULTS: Six main themes were identified that impacted upon the decision making process: the doctor's past experience, ambulance service issues, prehospital care, patient characteristics, presence and views of relatives, and organisational issues. CONCLUSION: The reasoning behind decisions made when a patient arrives at the Emergency Department in cardiac arrest is multifactorial. Strict guidelines would be difficult to construct since individuals vary in the importance they attach to different factors.

Adult↗
PubMed2003

Resource allocation in health care: health economics and beyond.

As resources in health care are scarce, managers and clinicians must make difficult choices about what to fund and what not to fund. At the level of a regional health authority, limited approaches to aid decision makers in shifting resources across major service portfolios exist. A participatory action research project was conducted in the Calgary Health Region. Throughfive phases of action, including observation of senior management meetings, as well as two sets of one-on-one interviews and two focus groups, an approach to priority setting at the macro level within the health region was developed and implemented. The resulting macro level approach builds on the program budgeting and marginal analysis (PBMA)framework. Using a multi-disciplinary expert panel, about dollar 45M (CAN) was released for the 2002/03 fiscal year and made available for re-allocation to service growth areas and the deficit. Important qualitative themes from the managers and clinicians informed both process development and refinement. The approach developed here not only facilitated re-allocation of resources, but also drew in both clinicians and managers to work together on this challenging task. The approach is pragmatic, transparent and evidence based, and should have application elsewhere.

Alberta↗
PubMed2005

[End-of-life decisions and reluctant treatment of newborns on the borderline of viability in the Netherlands].

End-of-life decisions are taken in the majority of deaths below one year of age, especially in neonatal intensive-care units. In the Netherlands, the frequency of such decisions has not increased in recent years. Intentional termination of life occurred in 1% of the deaths, which would be about 10 cases each year. However, only 3 such cases are reported to the public prosecutor for review by the responsible physician. Proposals from the government to facilitate reporting of such cases are awaited. Dutch neonatologists are reluctant to administer full neonatal intensive care to extremely preterm infants. Currently, the policy regarding antenatal referral and treatment of extremely preterm infants is being re-evaluated by obstetricians and neonatologists. Behind the stable frequency of end-of-life decisions, difficult ethical issues remain to be solved.

Attitude of Health Personnel↗
PubMed1998

Futility considerations in the neonatal intensive care unit.

The purpose of this article is to summarize and comment on the history of medical decision making in the neonatal intensive care nursery, emphasizing considerations of futility. Several epochs will be described, with shifting roles of health care providers, the infant's family, and proxies for society at large. Futility has been an issue in the intensive care of newborn infants throughout the last 35 years. Long before the Baby Doe regulations and the formation of ethics committees, neonatologists tried to determine which care measures were indicated. Given the frequency of severe malformations, birth asphyxia, and extreme prematurity, it has been a common event for the responsible physician to ask himself: will this treatment be beneficial or merely futile? As the therapeutic armamentarium became more powerful and complex, the choices from among a possible array of interventions became increasingly difficult. The autonomy of parents as decision makers was increasingly affirmed. In the 1980s, the federal government, the courts, and frequent malpractice suits set boundaries on medical decision making. In the 1990s, third party payors became increasingly assertive in limiting resource expenditure. These legal and societal mandates are frequently at variance with one another. Thus the issue of medical futility, as it applies to neonates in the United States, must be considered unresolved.

Decision Making↗
PubMedDate not supplied

Comparing cost-effectiveness analyses of anti-hypertensive drug therapy for decision making: mission impossible?

The purpose of this literature review was to compare the methodology used in the most recently published cost-effectiveness studies of antihypertensive treatments, and to identify methodological strengths and weaknesses that indicate the study's potential as a useful, decision-making tool. Based on the results of a search of several databases, spanning the years 1995 to 2000, 10 cost-effectiveness studies were identified. Although the majority of the studies reported their cost-effectiveness ratio in "costs per year of life gained," the studies also considered a varying range of components including additional end points. The methodology used to measure effectiveness, the cost variables included, and the characteristics of the patient population varied significantly across studies. Due to this lack of conformity, it would be difficult, if not impossible, to compare the results and draw conclusions about the relative cost-effectiveness of different types of antihypertensive drug therapies. This lack of uniform comparison across studies is likely to draw criticism from both the clinical and health-care decision-making communities. Future studies within this field should be thorough and useful for decision making. It is suggested that short-term outcomes should include systolic and diastolic blood pressure measurements and long-term outcomes should include end points such as myocardial infarction, stroke, congestive heart failure and renal events. Other positive outcomes such as a more favorable side-effect profile, should be used to enhance the primary outcomes. Additionally, when subpopulations are considered in submodels, studies should address the issue of generalizability. Cost calculations should be transparent and related to the perspective of the study. Modeling the cost-effectiveness of a drug may be an acceptable method provided that data sources and assumptions are valid and transparent.

Adult↗
PubMed2003

[End-of-life decision-making process].

Since time immemorial the attitude toward the dying patient has been one of the most difficult issues in medical ethics. The diversity of philosophical, religious, social and legal approaches does not enable one to reach a universal consensus to solve the many problems involved in end-of-life decisions. Within the health care system in Israel there is currently no consensual practice concerning the dying patient. Moreover, there is no published information on the actual decision-making processes within hospitals, hospices and geriatric facilities in Israel concerning the dying patient. A group of investigators in Shaare Zedek Medical Center in Jerusalem recently performed a prospective study to explore the decision-making process concerning DNR orders within this hospital. The results of this study demonstrated that the terminally-ill patients never take part in the decision-making process, they are never consulted about their wishes, and there is no effort to discover their previous wishes concerning their treatment at the terminal stages. Moreover, in many instances even the family was not consulted and did not take part in the decision-making process. In a significant minority, the final decision of a DNR order was undertaken by a single physician. This approach represents an extreme form of unethical paternalism, and it requires an urgent societal intervention to establish an ethically sound decision-making process. Recently, a national committee ("Steinberg Committee") formulated a widely agreed upon legislative proposal organizing all the fundamental and practical issues related to the dying patient. This proposal is based upon a balance between opposing values such as autonomy, life, quality-of-life, beneficence, non-maleficence and "slippery-slope" concerns. It relates to various treatment modalities, such as resuscitation, ventilation, dialysis, medication and sustenance. It establishes a clear position on euthanasia, physician-assisted suicide, withdrawing treatment and withholding treatment. It establishes a hierarchy of decision-making agents, and it validates advanced medical directives. It also promotes a legally-binding requirement of modern palliative care.

Attitude to Death↗
PubMed2002

What do you do when they grow up? Approaches to seizures in developmentally delayed adults.

Epilepsy and developmental disabilities (DD) often occur together but affect individuals differently and have a complex causal relationship. Most epilepsy in the population with DD is partial or symptomatic generalized. Seizures and antiepileptic drugs (AEDs) can further delay development, and the DD can complicate treatment and adjustment to epilepsy. Medical care and decision making require careful coordination of health care providers and the family, especially because of the trend for the patients to live in group homes. Behavioral and psychiatric disorders are difficult to diagnose but common in those with DD and epilepsy; psychiatric disorders are perhaps up to sevenfold higher in this group than in the general population. Psychotropic medications-antidepressants, anxiolytics (but use caution with benzodiazepines), antipsychotics, and stimulants-are appropriate for those with psychiatric disorders. Diagnostic difficulties may lead to undertreatment, and the motivation to lessen certain behaviors may lead to overtreatment. Because those with DD may be unusually sensitive to adverse effects of both seizures and AEDs, cognitive and behavioral side effects must be carefully monitored. Few relevant studies exist. For some patients, comorbid psychiatric disorders may be treated with one AED, such as carbamazepine, lamotrigine, or valproate. Phenobarbital and phenytoin may be inappropriate for those with epilepsy and DD. Studies have shown some success with oxcarbazepine (for partial and generalized epilepsy) and with adjunctive lamotrigine. For those on medication regimens, perhaps taking combinations of drugs for numerous years, queries about earlier attempts to reduce AEDs and gradual efforts to substitute less toxic mediations are worthwhile. Vagus nerve stimulation and epilepsy surgery for those with medically refractory epilepsy may be options after careful evaluation.

Adult↗
PubMed2002

Legislative connection: summary on the nursing shortage--March 6, 2002.

The panel was very well received and very informative to the legislators. The nursing shortage crisis in Colorado was succinctly identified. No single solution will fix the nursing shortage. Replacement of registered nurses by unlicensed assistive personnel, or using licensed personnel with less education, will add to increased patient safety issues, provide fewer learning experiences for nursing students, and decrease job satisfaction for current nurses. If a practice that decreases quality of care is put into law as a "quick fix," that standard is very difficult to change. Legislators must listen to experienced nurses so that the decisions they make on health policy will positively influence the nursing shortage issues.

Colorado↗
PubMed2006

Why do patients choose chemotherapy near the end of life? A review of the perspective of those facing death from cancer.

PURPOSE: The number of patients receiving chemotherapy near the end of life is increasing, as are concerns about goals of treatment, toxicity, and costs. We sought to determine the available sources of knowledge, the choices, and concerns of actual patients, and how patients balanced competing issues. METHODS: We used a literature search from 1980 to present. RESULTS: Available patient sources provide little information about prognosis, choices, alternatives, consequences, or how to choose. Many patients would choose chemotherapy for a small benefit in health outcomes, and for a smaller benefit than perceived by their health care providers for their own treatment. Adverse effects are less a concern for patients than for their well health care providers. There are no decision aids to assist patients with metastatic disease in making their choices, such as there are for adjuvant breast therapy. CONCLUSION: The perspective of the patient is different from that of a well person. Patients are willing to undergo treatments that have small benefits with major toxicity. Receiving realistic information about the different options of care and the likelihood of successful treatment or adverse effects is difficult. These factors may explain some of the increased use of chemotherapy near the end of life. Decision aids and honest, unbiased sources to inform patients of their prognosis, choices, consequences, typical outcomes, and ways to make decisions are needed. More prospective information about how patients make their choices, and what they would consider a good choice, would assist informed decision making.

Antineoplastic Agents↗