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Medical Decisions (medical + decision)

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Medical Sciences	86%

Terms modified by Medical Decisions

medical decision making

Selected Abstracts

Which parameters differ in very old patients with chronic atrial fibrillation treated by anticoagulant or aspirin?

FUNDAMENTAL & CLINICAL PHARMACOLOGY, Issue 5 2008
Antithrombotic treatment of atrial fibrillation in the elderly
Abstract The objective was to determine the main parameters taken into account for the decision of antithrombotic treatment of atrial fibrillation (AF) by vitamin K antagonist or aspirin. This was a prospective clinical study of four clinical services of geriatric medicine. Two hundred and nine inpatients, 84.7 ± 7 years (women 60.8%), with chronic AF were included. The patients were distributed into two groups (anticoagulant or aspirin) according to medical decision. All the decision criteria for treatment were recorded: cardiopathy, conditions of life, clinical examination (nutrition and autonomy, mini-mental state examination (MMSE), walking evaluation, comorbidity), subjective evaluation of risk of falls and glomerular filtration rate. The thromboembolic risk and the bleeding risk, evaluated subjectively for each patient, were compared with two scores of thrombo-embolic risk and bleeding risk. The evolution of the patients was recorded after 3 months. Student's t -test and chi-squared tests were used for statistical analysis. One hundred and two patients (48.8%) received anticoagulant and 107 patients received aspirin. Patients in the aspirin group were significantly older (86.5 ± 6.5 vs. 82.9 ± 7.1 years), with more frequent social isolation, higher systolic blood pressure, and had more important subjective bleeding risk and risk of falls. Patients in the anticoagulant group had significantly more valvulopathies and a more important subjective thromboembolic risk. Thrombo-phlebitis antecedents, dementia, denutrition and walking alterations were only slightly more frequent in patients in the aspirin group. Physicians underestimated thromboembolic risk (one-third of patients) and they overestimated bleeding risk (half of the patients). After 3 months, the two groups did not significantly differ for death, bleeding or ischaemic events. In common practice, the decision of antithrombotic treatment for AF should take into account not only cardiovascular but also geriatric criteria. [source]

Asking fathers: a study of psychosocial adaptation

HAEMOPHILIA, Issue 5 2004
E. K. Herrick
Summary., Although few contemporary studies specifically address paternal adaptation, the theme of paternal estrangement from medical care and from family relationships is pervasive in the psychosocial literature on haemophilia. This estrangement has been shown to have a negative effect on fathers' psychological well-being, marital relationships and the adaptive outcome of their sons who have haemophilia. The goals of this study were to provide contemporary data on the psychosocial adaptation of fathers of boys with haemophilia and to examine specific variables that might influence their adjustment. Eighty-three eligible fathers returned a survey instrument that collected demographic and medical information, as well as scores on self-measures of adaptation in marital and parenting roles. Statistically significant direct correlations (P < 0.01) were found between fathers' scores on the Marital Adjustment Test and the Parenting Sense of Competence subscales (parenting efficacy and satisfaction). Variables specific to rearing a son with haemophilia that negatively affected fathers' marital adjustment scores included: feeling left out of medical decision making by their wives or partners, worry about their sons' having limited activity, and the presence of a secondary diagnosis in the affected child. Scores on the parenting efficacy subscale of the PSOC were statistically significantly reduced (i.e. fathers felt less effective in the parenting role) in men who ,rarely' or ,never' infused their sons (42/80, 53%). Variables that negatively affected scores on the parenting satisfaction subscale included frustrating interactions with medical staff and concern about their sons' potential to contract an infection or secondary diagnosis. This paper presents a model to examine the interrelationships among the data and discusses the clinical implications. [source]

The medical visit context of treatment decision-making and the therapeutic relationship

HEALTH EXPECTATIONS, Issue 1 2000
Debra Roter Dr (Phil)
The ascendance of the autonomy paradigm in treatment decision-making has evolved over the past several decades to the point where few bioethicists would question that it is the guiding value driving health-care provider behaviour. In achieving quasi-legal status, decision-making has come to be regarded as a formality largely removed from the broader context of medical communication and the therapeutic relationship within which care is delivered. Moreover, disregard for individual patient preference, resistance, reluctance, or incompetence has at times produced pro forma and useless autonomy rituals. Failures of this kind, have been largely attributed to the psychological dynamics of the patients, physicians, illnesses, and contexts that characterize the medical decision. There has been little attempt to provide a framework for accommodating or understanding the larger social context and social influences that contribute to this variation. Applying Paulo Freire's participatory social orientation model to the context of the medical visit suggests a framework for viewing the impact of physicians' communication behaviours on patients' capacity for treatment decision-making. Physicians' use of communication strategies can act to reinforce an experience of patient dependence or self-reliance in regard to the patient-physician relationship generally and treatment decision-making, in particular. Certain communications enhance patient participation in the medical visit's dialogue, contribute to patient engagement in problem posing and problem-solving, and finally, facilitate patient confidence and competence to undertake autonomous action. The purpose of this essay is to place treatment decision-making within the broader context of the therapeutic relationship, and to describe ways in which routine medical visit communication can accommodate individual patient preferences and help develop and further patient capacity for autonomous decision-making. [source]

Healthcare Proxies of Nursing Home Residents with Advanced Dementia: Decisions They Confront and Their Satisfaction with Decision-Making

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 7 2009
Jane L. Givens MD
OBJECTIVES: To describe the medical decisions confronting healthcare proxies (HCPs) of nursing home (NH) residents with advanced dementia and to identify factors associated with greater decision-making satisfaction. DESIGN: Prospective cohort study. SETTING: Twenty-two Boston-area NHs. PARTICIPANTS: Three hundred twenty-three NH residents with advanced dementia and their HCPs. MEASUREMENTS: Decisions made by HCPs over 18 months were ascertained quarterly. After making a decision, HCPs completed the Decision Satisfaction Inventory (DSI) (range 0,100). Independent variables included HCP and resident sociodemographic characteristics, health status, and advance care planning. Multivariable linear regression identified factors associated with higher DSI scores (greater satisfaction). RESULTS: Of 323 HCPs, 123 (38.1%) recalled making at least one medical decision; 232 decisions were made, concerning feeding problems (27.2%), infections (20.7%), pain (12.9%), dyspnea (8.2%), behavior problems (6.9%), hospitalizations (3.9%), cancer (3.0%), and other complications (17.2%). Mean DSI score±standard deviation was 78.4±19.5, indicating high overall satisfaction. NH provider involvement in shared decision-making was the area of least satisfaction. In adjusted analysis, greater decision-making satisfaction was associated with the resident living on a special care dementia unit (P=.002), greater resident comfort (P=.004), and the HCP not being the resident's child (P=.02). CONCLUSION: HCPs of NH patients with advanced dementia can most commonly expect to encounter medical decisions relating to feeding problems, infections, and pain. Inadequate support from NH providers is the greatest source of HCP dissatisfaction with decision-making. Greater resident comfort and care in a special care dementia unit are potentially modifiable factors associated with greater decision-making satisfaction. [source]

Integrating evidence into clinical practice: an alternative to evidence-based approaches

JOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 3 2006
Mark R. Tonelli MD MA
Abstract Evidence-based medicine (EBM) has thus far failed to adequately account for the appropriate incorporation of other potential warrants for medical decision making into clinical practice. In particular, EBM has struggled with the value and integration of other kinds of medical knowledge, such as those derived from clinical experience or based on pathophysiologic rationale. The general priority given to empirical evidence derived from clinical research in all EBM approaches is not epistemically tenable. A casuistic alternative to EBM approaches recognizes that five distinct topics, 1) empirical evidence, 2) experiential evidence, 3) pathophysiologic rationale, 4) patient goals and values, and 5) system features are potentially relevant to any clinical decision. No single topic has a general priority over any other and the relative importance of a topic will depend upon the circumstances of the particular case. The skilled clinician must weigh these potentially conflicting evidentiary and non-evidentiary warrants for action, employing both practical and theoretical reasoning, in order to arrive at the best choice for an individual patient. [source]

Stability of decisional role preference over the course of cancer therapy

PSYCHO-ONCOLOGY, Issue 4 2006
Julie B. Mallinger
Abstract Cancer patients vary in their preferred level of involvement in medical decision making, and responding to patients' desired level of involvement is a key element of good medical care. While the literature has clearly demonstrated heterogeneity among cancer patients' preferences, less is known about how the preferences of any given patient may change over time. This longitudinal study compared cancer patients' preferences for involvement in medical decision making from the time of diagnosis to the time of completion of therapy. Data from 729 cancer patients with mixed diagnoses were analyzed. Most patients reported a change in preferred level of involvement over time, and multivariate analysis demonstrated that patients tend to prefer a decreasing level of involvement over time (p<0.0001). Stability of patients' preferences was also associated with type of cancer, but not with other sociodemographic characteristics. The results from this study highlight the importance of reevaluating patients' preferences for involvement in medical decision making throughout the course of cancer therapy, as such preferences are likely to change. Copyright © 2005 John Wiley & Sons, Ltd. [source]

ORIGINAL ARTICLE: Urgent Termination of Pregnancy in Pre-eclampsia and Panel of Antiphospholipid Antibodies

AMERICAN JOURNAL OF REPRODUCTIVE IMMUNOLOGY, Issue 6 2009
Libor Hradecky
Problem, The present work was undertaken to investigate the occurence of autoantibodies to eight various phospholipids in time of urgent termination of the pregnancy (sectio caesarea) in patients in reproductive age with severe preeclamptic symptoms. Method of study, Autoantibodies against annexin V, ph-serine, ph-ethanolamine, ph-inositol, ph-DL-glycerol, cardiolipin, beta2-glycoprotein I (beta2-GPI), and phosphatidic acid were studied by ELISA methods. Results, Increased levels of IgA-beta2-glycoprotein I, IgG-beta2-glycoprotein I, IgG- anti-ph-serine, and IgG-anticardiolipin were found in sera of preeclamptic women in the time of urgent sectio caesarea when compared to the control group with physiological pregnancy. Conclusion, Supposed increase in various antiphospholipid antibodies (aPLs) levels due to the stress during the short time of admission and a need for a quick medical decision to terminate the pregnancy was not unambiguously proven, but our results are evidently influenced by the current urgent life-saving treatment. [source]

Healthcare Proxies of Nursing Home Residents with Advanced Dementia: Decisions They Confront and Their Satisfaction with Decision-Making

End-of-Life Decision-Making, Decisional Conflict, and Enhanced Information: Race Effects

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 10 2008
Rebecca S. Allen PhD
OBJECTIVES: To examine the effect of enhanced information regarding the risks, benefits, and life-sustaining treatment alternatives on hypothetical medical decisions and decisional conflict in older, community-dwelling Caucasian and African-American adults. DESIGN: Two-group (enhanced information; no information) between-subjects design. SETTING: Community-based dwellings, two assisted living facilities, and one senior citizen center. PARTICIPANTS: Seventy-eight adults (aged 74.5±7.18) with a mean Telephone Interview for Cognitive Status,Modified (TICS-m) score of 31.5±4.7 were recruited through personal contacts and informational talks held at the recruitment sites. MEASUREMENTS: Measures included the Life Support Preferences/Predictions Questionnaire,modified (LSPQ-m); the Decisional Conflict Scale; and enhanced information, including detailed descriptions of life-sustaining treatment options for each LSPQ-m illness scenario, risks of the treatment, benefits of the treatment, and alternatives for each treatment (called medical information stimuli). RESULTS: Enhanced information (e.g., medical information stimuli) reduced decisional conflict (P=.049, d=0.47) for hypothetical life-sustaining treatment decisions. A mixed analysis of variance with group and race as between-subjects variables and illness and treatment as within-subjects variables revealed significant main effects of race, illness, and treatment, as well as a significant race-by-illness-by-group interaction (Wilk's lambda=0.923, F(2, 73)=3.05, P=.05, partial ,2=0.08). Enhanced information produced different patterns of desire for life-sustaining treatments in African Americans and Caucasians. CONCLUSION: Physicians and other healthcare professionals can reduce decisional conflict in patients by providing enhanced information regarding treatment risks, benefits, and alternatives. Such decision aids may provide new information or knowledge and thus reduce desire for treatment in African Americans. [source]

Research Issues in Genetic Testing of Adolescents for Obesity

NUTRITION REVIEWS, Issue 8 2004
Mary E. Segal Ph.D.
Obesity is often established in adolescence, and advances are being made in identifying its genetic underpinnings. We examine issues related to the eventual likelihood of genetic tests for obesity targeted to adolescents: family involvement; comprehension of the test's meaning; how knowledge of genetic status may affect psychological adaptation; minors' ability to control events; parental/child autonomy; ability to make informed medical decisions; self-esteem; unclear distinctions between early/late onset for this condition; and social stigmatization. The public health arena will be important in educating families about possible future genetic tests for obesity. [source]

All in the family: Evaluation of the process and content of sisters' communication about BRCA1 and BRCA2 genetic test results,

AMERICAN JOURNAL OF MEDICAL GENETICS, Issue 2 2002
Chanita Hughes
Abstract Despite the potential importance of family communication, little is known about the process and content of communicating BRCA1/2 test results to relatives. The objectives of this observational study were to describe the process and content of communicating BRCA1/2 test results to sisters, and to evaluate whether the proband's carrier status influenced communication outcomes. Participants were 43 women who were the first family member to have genetic testing (probands). Probands reported on communication outcomes for 81 sisters. Process and content variables were evaluated 1-month after receipt of BRCA1/2 test results using the Family Communication Questionnaire (FCQ). Overall, BRCA1/2 test results were communicated to 85% of sisters, and carriers communicated their results to significantly more sisters compared to uninformative (96% vs. 76%, FET,=,0.02). The most important reason for communicating results was to provide genetic risk information; however, compared to uninformatives, carriers communicated their results to significantly more sisters to obtain emotional support (74%) and to get advice about medical decisions (42%) (FET,=,0.001). Carriers also discussed the possibility of discrimination and recommendations for cancer management with significantly more sisters. Among sisters to whom BRCA1/2 test results were not communicated, the most important reason for not sharing test results was because of emotionally distant relationships. The results of this study suggest that probands are likely to quickly communicate their BRCA1/2 test results to relatives and that although needs for social support may motivate family communication, emotionally distant relationships may be a barrier to communication with relatives. © 2001 Wiley-Liss, Inc. [source]

The counsellees' view of an unclassified variant in BRCA1/2: recall, interpretation, and impact on life

PSYCHO-ONCOLOGY, Issue 8 2008
Joël Vos
Abstract Objective: Unclassified variants (UVs, variants of uncertain clinical significance) are found in 13% of all BRCA1/2 mutation analyses. Little is known about the counsellees' recall and interpretation of a UV, and its psychosocial/medical impact. Method: Retrospective semi-structured interviews with open questions and five-point Likert scales were carried out in 24 counsellees who received a UV result 3 years before (sd=1.9). Results: Sixty-seven percent (16/24) recalled the UV result as a non-informative DNA result; 29% recalled a pathogenic result. However, 79% of all counsellees interpreted the UV result as a genetic predisposition for cancer. Variations in recall and interpretation were unexplained by demographics, cancer history of themselves and relatives, and communication aspects of UV disclosure. Sixty-seven percent perceived genetic counselling as completed, whereas 71% expected to receive new DNA information. Although most counsellees reported that UV disclosure had changed their lives in general little, one in three counsellees reported large changes in specific life domains, especially in surveillance behavior and medical decisions. Ten out of 19 participants who interpreted the UV as pathogenic had undergone preventive surgery against none of the 5 counsellees who interpreted the UV as non-informative. Conclusion: Counsellors and researchers need to address discrepancies between the counsellees' factual recall and their subjective interpretation of non-informative BRCA1/2-test results. Copyright © 2007 John Wiley & Sons, Ltd. [source]

An ethical hierarchy for decision making during medical emergencies

ANNALS OF NEUROLOGY, Issue 4 2010
Patrick D. Lyden MD
Evidence from well-designed clinical trials may guide clinicians, reduce regional variation, and lead to improved outcomes. Many physicians choose to ignore evidence-based practice guidelines. Using unproven therapies outside of a randomized trial slows recruitment in clinical trials that could yield information on clinical and economic efficacy. Using acute stroke therapy as an illustration, we present an ethical hierarchy for therapeutic decision making during medical emergencies. First, physicians should offer standard care. If no standard care option exists, the physician should consider enrollment in a randomized clinical trial. If no trial is appropriate, the physician should consider a nonrandomized registry, or consensus-based guidelines. Finally, only after considering the first 3 options, the physician should use best judgment based on previous personal experience and any published case series or anecdotes. Given the paucity of quality randomized clinical trial data for most medical decisions, the "best judgment" option will be used most frequently. Nevertheless, such a hierarchy is needed because of the limited time during medical emergencies for consideration of general principles of clinical decision making. There should be general agreement in advance as to the hierarchy to follow in selecting treatment for critically ill patients. Were more clinicians to follow this hierarchy, and choose to participate in clinical trials, the generation of new knowledge would accelerate, yielding rigorous data supporting or refuting the efficacy and safety of new interventions more quickly, thus benefiting far more patients over time. ANN NEUROL 2010;67:434-440 [source]

Decision making about pre-medication to children

CHILD: CARE, HEALTH AND DEVELOPMENT, Issue 6 2008
M. Proczkowska-Björklund
Abstract Background Inviting the child to participate in medical decisions regarding common medical procedures might influence the child's behaviour during the procedures. We wanted to study nurse decision-making communication regarding pre-medication before ear, nose and throat (ENT) surgery. Method In total, 102 children (3,6 years) signed for ENT surgery were video-filmed during the pre-medication process. The nurse decision-making communication was identified, transcribed and grouped in six main categories dependent on the level of participation (self-determination, compromise, negotiation, questioning, information, lack of communication). Associations between child factors (age, gender, verbal communication and non-verbal communication) and different nurse decision-making communication were studied. Associations between the decision-making communication and verbal hesitation and/or the child's compliance in taking pre-medication were also studied. Results Totally, information was the most frequently used category of decision making communication followed by negotiation and questioning. To the children showing signs of shyness, the nurse used more negotiation, questions and self-determination communication and less information. The nurse used more compromise, negotiation and gave less information to children with less compliance. No specific type of nurse decision-making communication was associated with verbal hesitation. The most important predictors for verbal hesitation were none or hesitant eye contact with nurse (OR = 4.5) and placement nearby or in parent's lap (OR = 4.7). Predictors for less compliance in taking pre-medication were verbal hesitation from the child (OR = 22.7) and children who did not give any verbal answer to nurse initial questions (OR = 5.5). Conclusion Decision-making communication could not predict the child's compliance during pre-medication. Although negotiation, questioning and self-determination communication were associated with more unwillingness to take pre-medication. More knowledge is needed about communication to children in medical settings and how it influences the child's behaviours. [source]

Diagnosing infections,,current and anticipated technologies for point-of-care diagnostics and home-based testing

CLINICAL MICROBIOLOGY AND INFECTION, Issue 8 2010
L. Bissonnette
Clin Microbiol Infect 2010; 16: 1044,1053 Abstract In recent years, we have witnessed many transitions in healthcare systems around the globe. For example, population expansion and ageing, and the human immunodeficiency virus (HIV)-AIDS epidemics, have exerted pressure to decentralize the practice of healthcare outside of traditional settings to bring care to those in need. Upstream of patient management, diagnosis is aimed at adequately orienting medical decisions, and considerable efforts have been made to make this process faster and more efficient. However, there are several diseases and medical conditions that may/will benefit from technologies and tests that can be performed closer to the patient, at the point of care or even in the home. In this review, and in light of the paradox that technology and assay developers and healthcare officials must take into consideration for advancing human health in developed and developing countries, we present an overview of rapid diagnosis of infectious diseases at the point of care and of technologies that may contribute to enhancement of the worldwide point-of-care testing market. [source]