The adolescent perspective on participation in treatment decision making: a pilot study.

Few research studies have obtained data directly from the adolescent with cancer regarding decision making. The developmental stage of these patients focuses on developing independence, yet the health care decisions required for cancer treatment preclude independent decision making. The purpose of this pilot, or exploratory, study was to determine whether the research question is appropriate and whether participants between 13 and 15 years of age were capable of providing rigorous data. The results suggest that treatment decision making was not a concern for these patients and that they were capable and appropriate study participants. Semistructured interviews were performed with 3 adolescents diagnosed with cancer within the previous 3 to 6 months. These data were qualitatively analyzed using Colaizzi's technique, which identified themes perceived as critical by these participants. Independent behavior, such as decision making, is not relevant at this health care juncture. However, support, information, and education are desired. These should be routinely available using means appropriate for adolescents. Infusing information and education into the health care plan from time of diagnosis may allow the adolescent to become knowledgeable about the disease process. This may enable him or her to participate in health care treatment decisions, when appropriate.     

Ethical decision making for high-risk infants. The parents' perspective

The experiences of 32 families with high-risk infants provide the foundation for a discussion of the parents' perception of the ethical dimension of intensive newborn care. The families' focus on the need for support in the NICU crisis rather than a plea for rights, justice, and autonomous decision making leads to a suggested professional response guided by an ethic of care. Through a caring professional, ethical decision making in the NICU can be implemented to encompass a shared moral responsibility for the high-risk infant during this process.     

Nurses' roles in discharge decision making in an adult high dependency unit.

An ethnographic approach was used to investigate the roles which nurses take in the discharge decision making process in an adult High Dependency Unit (HDU). Participant observation and unstructured interviews were the data collection methods used. Four themes were identified. The first theme encompassed the relationship of nurses with medical staff. Tension was felt between nursing and medical staff, although this was not demonstrated in direct communication between the two professions. Nurses took a submissive role in order to avoid conflict, but this also enabled them to manipulate doctors. Another theme was the unique value of the nurse which was defined as the 'holistic' view which nurses took towards patients which was different to that taken by other health care professionals. Nurses undertook an important administrative role. They had substantial responsibility for bed management and became more proactive in decision-making when there was pressure on HDU beds. Issues associated with decision making were highlighted, as although nurses wanted to contribute to discharge decision making, they were often uncomfortable with this role. There is scope for further investigation into the working relationship of nurses and medical staff, how administrative roles of nurses influence their ability to provide patient care and whether the opinions expressed with regard to decision making are widespread within the nursing community.     

Ethical decision making.

Members of the health care profession have a responsibility to identify and regulate their practice to protect consumers and assure the delivery of quality service. In this case study in which a patient wakes up during surgery, the nurse's code of ethics, standards of care, and ethical decision-making models provide guidance toward the resolution of this clinical dilemma. Such resolution requires sound nursing knowledge, knowledge of the facts of the situation, knowledge of the law, and application of critical thinking skills to facilitate positive outcomes for all parties involved.     

Purchasing medical equipment: a protocol for decision making.

In light of today's tight hospital financial picture caused by Medicare's prospective payment system and local constraints, capital expenditures must be made with great care and forethought. The process for purchase decision making should assess the need for the device; specifically identify what is required; carefully evaluate the product via technical, clinical, and user studies; collate the results for committee decision making; and plan for the introduction and support of the product through its lifetime. A case study of the acquisition of a neonatal monitoring system is presented.     

Multi-ontology sense making: a new simplicity in decision making

Imagine organising a birthday party for a group of young children. Would you agree a set of learning objectives with their parents in advance of the party? Would those objectives be aligned with the mission statement for education in the society to which you belong? Would you create a project plan for the party with clear milestones associated with empirical measures of achievement? Would you start the party with a motivational video so that the children did not waste time in play not aligned with the learning objectives? Would you use PowerPoint to demonstrate to the children that their pocket money is linked to achievement of the empirical measures at each milestone? Would you conduct an after-action review at the end of the party, update your best practice database and revise standard operating procedures for party management? No! Instead, like most parents, you would create barriers to prevent certain types of behaviour, you would use attractors (party games, a football, a videotape) to encourage the formation of beneficial largely self-organising identities; you would disrupt negative patterns early, to prevent the party becoming chaotic, or necessitating the draconian imposition of authority. At the end of the party you would know whether it had been a success, but you could not have defined (in other than the most general terms) what that success would look like in advance.     

Breast restoration decision making.

Women diagnosed with breast cancer have many physiological and psychological adjustments to make following mastectomy. The present study described in this article sought to determine the decision-making patterns used by two groups of women. Nurses need to be well informed and professionally confident to provide the individualized care and support deserved by women throughout the breast cancer trajectory. A major outcome of such professional care is confident women who understand their disease, treatments, and methods to manage stresses as they occur.     

RXPERT: a prototype expert system for formulary decision making.

OBJECTIVE: RXPERT, a prototype, computer-based, expert system that models the decision-making processes for an ambulatory (non-hospital) formulary, is described as an example of how expert systems may be used to support pharmacy decision making. Basic information about expert-system technology is provided through this example. BACKGROUND: Computer-assisted decision making is becoming an important and accepted aspect of complex, health-related decisions. Because expert-system support may become an integral component of future, complex, pharmacy decision making, it is important for pharmacists to become familiar with this technology and its possibilities for supporting pharmacy decisions. METHOD: Expert systems offer the potential advantages of making the human decision-making process explicit, more consistent, easily duplicated in many locations simultaneously, and easy to update and document. Although an expert system is seldom intended to replace human decision makers, it can provide valuable support for complex, multivariable decisions. Typical knowledge-acquisition and knowledge-engineering techniques, as well as the characteristics and structure of expert systems, are described, relative to the development of the RXPERT prototype. CONCLUSIONS: Although RXPERT is not yet in use, the process for using an expert system to support an individual committee member's personal assessment of a drug product is described. Decision-support expert systems are potentially useful to pharmacists in complex decision-making tasks.     

Demystifying ethical decision making.

Ethical dilemmas frequently occur in the practice of orthopaedic nursing. Nurses, however, are often unsure about how to resolve these dilemmas. The language of ethics remains elusive. Yet, because nurses have a central role in patient care, they need to become more comfortable making ethical decisions related to their practice. This article briefly describes the dialectical process of ethical decision making and demonstrates this process by using a case presentation. Readers are encouraged to put themselves into the role of the bedside nurse in the case, determine what they believe to be the right action, and provide a well-grounded rationale for that decision.     

Classifying clinical decision making: a unifying approach

This is the first of two linked papers exploring decision making in nursing which integrate research evidence from different clinical and academic disciplines. Currently there are many decision-making theories, each with their own distinctive concepts and terminology, and there is a tendency for separate disciplines to view their own decision-making processes as unique. Identifying good nursing decisions and where improvements can be made is therefore problematic, and this can undermine clinical and organizational effectiveness, as well as nurses' professional status. Within the unifying framework of psychological classification, the overall aim of the two papers is to clarify and compare terms, concepts and processes identified in a diversity of decision-making theories, and to demonstrate their underlying similarities. It is argued that the range of explanations used across disciplines can usefully be re-conceptualized as classification behaviour. This paper explores problems arising from multiple theories of decision making being applied to separate clinical disciplines. Attention is given to detrimental effects on nursing practice within the context of multidisciplinary health-care organizations and the changing role of nurses. The different theories are outlined and difficulties in applying them to nursing decisions highlighted. An alternative approach based on a general model of classification is then presented in detail to introduce its terminology and the unifying framework for interpreting all types of decisions. The classification model is used to provide the context for relating alternative philosophical approaches and to define decision-making activities common to all clinical domains. This may benefit nurses by improving multidisciplinary collaboration and weakening clinical elitism.     

The ethical decision making process: a demonstration

Two issues identified from the scenario have been explored using the Ethical Decision Making Tree. Now look at some of the other issues identified earlier in this article work through the decision-making process using the Ethical Decision Making Tree. In looking at the use of experimental or futile care, what information would you need to gather and analyze? What personal values and moral positions need to be considered? Based on the previous two steps, what are the options? What is your decision and course of action? How are you going to evaluate the action taken to see if it worked or if other actions need to be taken? Remember, the solution is not what is best for you but what is best for the patient at this point of time.     

Efficacy of multidisciplinary treatment in a tertiary referral headache centre

Despite the high prevalence of headaches, multidisciplinary headache clinics are few and their efficacy still needs validation. We set out to describe the procedures, characterize the patients and evaluate the treatment results in Danish Headache Centre. All clinical records for patients discharged in 2002 were systematically reviewed. Diagnoses were classified in accordance with ICHD-II. Outcome results were analysed with respect to headache diagnoses, frequency, intensity, absence from work and medication use. Five hundred and five patients were included and 336 were eligible for the study. Mean age was 46 years and male/female ratio 1:2.4. For patients without medication overuse headache (MOH) a reduction in headache frequency (P<0.01) and intensity (P<0.05) was seen for frequent episodic and chronic tension-type headache (TTH), migraine, cluster and other headaches. No reduction was seen in post-traumatic headache. Absence from work decreased significantly for migraine (P<0.001) and frequent episodic TTH (P<0.05). For patients with MOH a reduction in headache frequency was seen for TTH and migraine (P<0.001). A specialized headache centre is valuable in treatment of patients with complex headache disorders.