Dissertations / Theses on the topic 'MEDICAL DECISION MAKING'

The Constitutional Court judgments of Teddy Bear Clinic for Abused Children and Another v Minister of Justice and Constitutional Development and Another 2014 (1) SACR 327 (CC) and Centre for Child Law and Others v Media 24 Ltd and Others 2020 (1) SACR 469 (CC) have set important precedents for a child’s autonomy and privacy. Two requirements are put forth in the Children’s Act 38 of 2005 for when a child may consent to his or her own medical treatment. The first requirement is the age of consent. A child aged 14 and older was allowed to consent to his or her own medical treatment and his or her surgery at 18 years without parental consent under the now repealed Child Care Act 74 of 1983. The Children’s Act however reduced this age of consent for both medical treatment and surgery and section 129 of the Children’s Act states that a child can consent to his or her own medical treatment without parental assistance at the age of 12. The second requirement is the maturity of the child which entails his or her ability to understand the nature of the medical procedure and the risk and consequence of giving consent to it. If one of the two requirements is not met, then consent may be obtained from the parent or guardian or caregiver of the child, the Superintendent of the hospital or the person in charge of the hospital, the Minister of Social Development or a High Court or Children’s Court.
Mini Dissertation (LLM)--University of Pretoria, 2020.
Centre for Child Law
LLM
Unrestricted

This study examines the decision-making activities and communicative activities of two groups participating in a simulated medical emergency activity: the control group (CG) using a traditional whiteboard and the experimental group (EG) using a structured interactive whiteboard. The two groups differ in that the EG has a structured template to annotate and share their arguments with each other. Data analysis of the decision-making activities focused on planning, data collecting, managing, and interpreting patient data. Data analysis of the communicative activities focused on informative, argumentative, elicitative, responsive, and directive acts. In the early stage of decision-making the EG spent significantly more time interpreting the situation and less time managing the patient than the CG; in the later stage the EG spent significantly more time managing the patient but less time interpreting the situation. No significant results were found in communicative activities due to low cell frequencies of the utterances. Qualitative results indicated that shared visualizations can disambiguate and clarify verbal interactions and promote productive argumentation and negotiation activities. Shared cognition facilitates the construction of shared situation models and joint problem spaces which lead to better decision making and problem solving.

Background: Stratified medicine aims to use a patient's genotype and other individual characteristics to predict their treatment outcomes. Several treatments have been developed which may potentially offer patients an increased response to treatment. For instance 5% of patients with cystic fibrosis can be prescribed Ivacaftor based on a specific genetic mutation. However, it is unclear about how a patient's genotype may influence particular aspects of medical decision-making, despite the relevance that this may have in routine clinical practice. Methods: Medical decision-making was investigated using a series of discrete-choice experiments (DCEs) in which participants were asked to consider and choose one of the presented scenarios. Regarding profession decision-making, in particular, the PhD research investigated extent to which a patient's genotype influenced the treatment judgements and recommendations of psychiatrists (n=68). Patient decision-making was investigated by using DCEs to assess how people with cystic fibrosis (n=80) 'traded-off the risks and benefits that were associated with each treatment option. In the final study of the thesis, I investigated whether or not members of the public (n=2804) would be willing to incur an increase in tax to help fund stratified medicine treatments. Results: The main findings of these studies suggest that clinicians may be unduly influenced by a patient's genotype when judging a patient's response to treatment and in their treatment recommendations. Cystic fibrosis patients may not be willing to tolerate some of the increased risks associated with their treatment options. Thus clinicians should discuss the risks and benefits associated with treatments with their patients. The PhD research highlighted that members of the public may not be willing to pay an increase in taxation unless the majority of people were eligible for the stratified medicine treatment, a result that poses a challenge for stratified medicine because only few people are eligible for potentially more effective treatments. Conclusions: Clinicians need to be cautious about being unduly influenced by a patient's genotype and should discuss the risks and benefits associated with different treatment options. Further research is needed to understand how a patient's genotype may influence the decisions that are made at the clinician, patient and policy level.

In this dissertation, we investigate three topics: predictive models for disease diagnosis and patient behavior, optimization for cancer treatment planning, and public health decision making for infectious disease prevention. In the first topic, we propose a multi-stage classification framework that incorporates Particle Swarm Optimization (PSO) for feature selection and discriminant analysis via mixed integer programming (DAMIP) for classification. By utilizing the reserved judgment region, it allows the classifier to delay making decisions on ‘difficult-to-classify’ observations and develop new classification rules in later stage. We apply the framework to four real-life medical problems: 1) Patient readmissions: identifies the patients in emergency department who return within 72 hours using patient’s demographic information, complaints, diagnosis, tests, and hospital real-time utility. 2) Flu vaccine responder: predicts high/low responders of flu vaccine on subjects in 5 years using gene signatures. 3) Knee reinjection: predicts whether a patient needs to take a second surgery within 3 years of his/her first knee injection and tackles with missing data. 4) Alzheimer’s disease: distinguishes subjects in normal, mild cognitive impairment (MCI), and Alzheimer’s disease (AD) groups using neuropsychological tests. In the second topic, we first investigate multi-objective optimization approaches to determine the optimal dose configuration and radiation seed locations in brachytherapy treatment planning. Tumor dose escalation and dose-volume constraints on critical organs are incorporated to kill the tumor while preserving the functionality of organs. Based on the optimization framework, we propose a non-linear optimization model that optimizes the tumor control probability (TCP). The model is solved by a solution strategy that incorporates piecewise linear approximation and local search. In the third topic, we study optimal strategies for public health emergencies under limited resources. First we investigate the vaccination strategies against a pandemic flu to find the optimal strategy when limited vaccines are available by constructing a mathematical model for the course of the 2009 H1N1 pandemic flu and the process of the vaccination. Second, we analyze the cost-effectiveness of emergency response strategies again a large-scale anthrax attack to protect the entire regional population.

Background: The Current Procedural Terminology (CPT) coding system for office visits, which has been in use since 1995, has not been well studied, but it is generally agreed that the system contains much room for error. In fact, the available literature suggests that only slightly more than half of physicians will agree on the same CPT code for a given visit, and only 60% of professional coders will agree on the same code for a particular visit. In addition, the criteria used to assign a code are often related to the amount of written documentation. The goal of this study was to evaluate two novel methods to assess if the most appropriate CPT code is used: the level of medical decision making, or the sum of all problems mentioned by the patient during the visit. Methods: The authors–a professional coder, a residency faculty member, and a PGY-3 family medicine resident–reviewed 351 randomly selected visit notes from two residency programs in the Northeast Tennessee region for the level of documentation, the level of medical decision making, and the total number of problems addressed. The authors assigned appropriate CPT codes at each of those three levels. Results: Substantial undercoding occurred at each of the three levels. Approximately 33% of visits were undercoded based on the written documentation. Approximately 50% of the visits were undercoded based on the level of documented medical decision making. Approximately 80% of the visits were undercoded based on the total number of problems which the patient presented during the visit. Interrater agreement was fair, and similar to that noted in other coding studies. Conclusions: Undercoding is not only common in a family medicine residency program but it also occurs at levels that would not be evident from a simple audit of the documentation on the visit note. Undercoding also occurs from not exploring problems mentioned by the patient and not documenting additional work that was performed. Family physicians may benefit from minor alterations in their documentation of office visit notes. Key Points: * All previous studies of CPT coding have audited the written encounter note. * Medical decision making (MDM) is the most appropriate basis for selecting the CPT code for an office visit, as long as the history or the physical exam documentation also support that level. * Using MDM to retrospectively audit office visit notes showed that 50% of visits were undercoded. A small amount of additional documentation would allow the higher code. * Addressing all patient-mentioned problems during the visit, although clearly more time-consuming, would allow a higher CPT code to be used for 80% of the audited visits.

Medical research on children is necessary to achieve progress in paediatric medicine for two reasons: firstly, certain diseases are unique to childhood and therefore medical research must be conducted on children to find out more about these childhood diseases, and secondly, adults and children respond differently to drugs and treatment, particularly when it comes to dealing with metabolism and disease. Due to findings that adults and children differ significantly in both pharmacodynamics (the way a drug affects the body) and pharmacokinetics (the way the body responds to the drug), results obtained in adults cannot easily be transposed in minors. To help ensure that children are prescribed safe and effective medicines, it is necessary to reduce widespread use of unlicensed and “off-label” medicines in children, because such medicines have neither been tested nor authorised for use in the paediatric population. Tensions in the legal and ethical frameworks that regulate decision-making about child participation in medical research are an obstacle to research being conducted with children because the existing frameworks cannot effectively inform the decision-making of parents and their children about research participation when they fail to give due attention to the family context in which decisions about child research participation tend to be made. For research and experimental or innovative treatment that falls within the remit of the common law, narrow definitions and interpretations of the best interests test, that do not sufficiently take account of all the different interests that will be involved when making a decision about a child, fail to adequately justify child participation in medical research and the administration of experimental or innovative treatment. The principal objective of this thesis is to highlight how more attention needs to be given to a child in the context of his or her caring relationships and the responsibilities that arise within these caring relationships to enhance existing decision-making frameworks that regulate child participation in medical research and strike an appropriate balance between protecting research participants and facilitating sound research.

The goal of this thesis project was to investigate cross-cultural differences in preferences for shared medical decision-making (SDM) by studying adults from the UK and Saudi Arabia. The aim of Study 1 was to gauge preferences for SDM in nonclinical samples from the UK and Saudi Arabia. Results show that there were indeed differences in SDM between Saudi and UK participants. Saudi participants tended to prefer stronger involvement from their doctor, whereas UK participants preferred to make choices themselves. The aim of Study 2 was to investigate in how far Saudi patients with Type 1 diabetes would be interested to be involved in a medical decision. The results of this qualitative study showed that, in general, physicians were reported to often have poor communication skills, which makes patients feel uncomfortable. Participants reported that their physician gave them medication without any discussion over the reasoning behind the prescription provided. Study 3 investigated parents’ preferences regarding their involvement in medical decisions when making decisions for themselves or their child, to record parents’ emotional reaction to shared medical decision-making, and to identify cultural differences on these topics in parents from Saudi Arabia and the UK. The results showed that parents were more likely to take an active role in the decision-making process when making the decision for themselves rather than their child. Decision confidence was higher in the non-informed choice condition. Emotional reaction and decision confidence were higher in the informed choice condition. A number of important recommendations for policy and practice that aim to increase shared decision-making and highlight the importance of culture. While European health-care professionals are increasingly encouraged to involve patients in decisions about their care, this study indicates that preferences for such shared medical decision making vary by culture and the recipient of the decision. This should be taken into account when health care professional involves patients in medical decisions.

Most of the current medical diagnosis support systems are based on a textual design. In this thesis we present a model that uses a different design. It uses visualization to aid home diagnosis of common diseases in a user-friendly way. The model clearly displays the diagnostic results on the screen. A way of organizing the information into a picture of all symptoms, diseases, and the complex relationships between them (especially the combination of symptoms onto a single screen to give a global view) is presented. The purpose of designing this model is to bring complicated medical knowledge to the ordinary user. We believe that the simplified and economic display can demystify medicine, and empower the user to take better care of himself. By this convenient software tool people can discover quickly at home whether their symptom is serious or not, and then decide whether it is necessary to see the doctor; also people can compare the diagnosis the model makes with the doctors'. This model does not recommend treatment or therapy.

Thesis (M.S. in Operations Research)--Naval Postgraduate School, September 2005.
Thesis Advisor(s): Moshe Kress, Matt Boensel. Includes bibliographical references (p. 95-99). Also available online.

In an emergency, cognitive ability, skill performance, and decision making skills of medical personnel are often impaired due to the physical and psychological effects of stress created by the emergency event itself. Computerized human patient simulators hold the potential of enabling personnel to recreate the cognitive, psychomotor, and affective demands of a real life medical emergency without putting patients or personnel at risk. While previous research has demonstrated the potential of simulation-based instruction to improve cognitive and psychomotor learning outcomes, there has been no attention focused on affective learning domains and performance outcomes. Repeated practice in a realistic simulation training environment has the potential to decrease the stress response of personnel in an emergency, blunt the effects of skill degradation due to stress, and increase the performance capacity of medical personnel in an actual emergency. In this study, senior anesthesiology nursing residents participated in a series of computerized patient simulation scenarios in which overall medical performance and physiological and psychological indicators of stress were assessed. Physiological measures included noninvasive measures of heart rate, blood pressure, and salivary cortisol level. Psychological measurements included the State-Trait Anxiety Inventory (STAT) and two Likert-scale responses to the subject's perceived level of stress and level of confidence. Because of the individual variation in response to stress, each subject served as their own control. Fifty-four subjects participated in the study. A random sample of 16 subjects participated in a baseline nonemergency simulation scenario. All 54 subjects then participated in a pre- and post-intervention simulated emergency scenario. Between the two scenarios, each subject received 16 hours of simulation-based instruction in the management of anesthesia emergencies and stress inoculation training. Subjects showed a significant increase in all parameters in the pre-intervention emergency scenario when compared to the nonemergency baseline scenario. Equally, all subjects showed a significant increase in parameters during the pre-intervention scenario when compared to that during post-intervention scenario. However, all of the parameters during the post-intervention scenario showed significantly less response to stress than during the pre-intervention scenario. Additionally, ratings for performance showed a significant increase in the post-intervention scenario when compared to performance during the pre-intervention scenario. The research demonstrates that computerized human patient simulation is capable of replicating the demands of a real emergency. The study was able to validate an improvement in medical performance and decrease in responsiveness to stress. The research appears to be the first to confirm the utility of simulation-based instruction in mitigating the physical and psychological effects of stress, created by an emergency event itself. Equally important, the participants reported a decreased perception of stress and an increased level of confidence following the intervention. The combination of stress inoculation training and simulation-based instruction appears to an effective strategy for improving cognitive, psychomotor and affective learning and performance outcomes. Further study in a wider population and evaluation of the duration of the intervention is warranted.

Life-expectancy and Life-years lost are frequently used and analyzed indices of survival. Life tables and Markov models are two exact approaches to calculate these indices; however cumbersome calculation limits their usage in real situations. Some simple approximation approaches have therefore been developed since a convenient and accurate approximation is critical both to develop a treatment plan of a patient by physicians and to assess health policies by health policy makers. These approximation approaches include the DEALE (Declining Exponential Approximation of Life Expectancy), new DEALEs, the IPH method (A method developed at Institute of Population Health, University of Ottawa) and the Keyfitz approach. A new approach has been developed to achieve better accuracy and maintain ease of application by extending the Keyfitz approach. To make the new approach less dependent on age-stratified tabulations, a convenient formula for the EME (Established market economics) region is developed. Its accuracy, robustness, and ease of application are demonstrated.

Financial toxicity (FT) is the impact that out of pocket (OOP) costs of cancer care have on patients' well-being, leading to lower quality of life, less compliance with prescribed therapy, and poorer outcomes, including increased mortality. The purpose of this study was to understand the impact of FT on advanced cancer patients' lives and their health care decision-making. Fuzzy trace theory provided the framework for examining how patients use gist and verbatim when making health care decisions while experiencing FT. Gist refers to main ideas that are often infused with emotional overlays that people use to make risky decisions, while verbatim thinking involves the recall of precise facts and figures to make decisions. The research method was case study that included conducting 13 in-depth interviews, collecting artifacts, and scoring of FT using the Comprehensive Score for Financial Toxicity tool. Findings from two-cycle coding and cross-case analysis indicated that FT and OOP costs have significant impacts on patients' lives and how they make decisions about their cancer care. Participants considered cost as a risk in cancer treatment decisions and encoded this information using verbatim rather than gist, which they used for other dimension of risk in these decisions. Participants reported they would decline care if OOP costs were high and FT was present. When OOP costs were low, participants relied on gist decision-making and generally followed their physicians' recommendations. Findings may assist cancer experts who are investigating FT and its impact on cancer care as well as those who are developing support programs for patients who experience FT.

This research investigated the influence of patient gender as a nonclinical variable on treatment decisions made in general practice. Responses to exploratory interviews carried out with 34 GPs supported the relevance of decisional stress in general practice. Decisional conflict theory therefore provided a theoretical basis for predicting that gender differences in management would be most likely to occur under conditions of decisional stress. This is because GPs are likely to rely on gender stereotypes to simplify decision tasks as this allows them to selectively search and appraise information. Responses to interview questions regarding the influence of patient gender on decision making were analysed in order to establish a set of collective GP expectations about the characteristics and behaviour of male and female patients. Following the interview study, a subset of 23 GPs supplied information for each patient seen over approximately six surgeries, providing data for 1380 consultations in all. GPs recorded information about presenting complaints, management decisions, a range of patient characteristics, three measures of decisional stress and a measure of feeling towards patients. Log-linear analysis of these data suggested that when not feeling positively towards patients, GPs managed male and female patients presenting with certain complaints differently. Women were more likely to be prescribed drugs while men were more likely to be given advice or referral. This disparity only occurred for patients presenting with psychological and musculo-skeletal complaints. In order to identify whether consultation processes mediated these differences, corresponding audio-taped consultations also collected from the 23 GPs were analysed. Verbal interaction between GP and patient was coded according to the functional style and content of communication. However, no significant differences in either of these aspects of the consultation process emerged to explain differences in management outcome. This may be because treatment differences are mediated by implicit processes rather than by observable consultation behaviour. Research carried out in the thesis furthers the understanding of medical decision making by recognising that non-clinical factors such as patient gender and feeling towards patients, as well as medical factors influence the way that GPs manage their patients.

Introduction Family members (FM) often attend cancer consultations with patients and may be involved in medical decision-making (DM). However, limited research, theory, and practical strategies include the family. This thesis aimed to examine the existing evidence base, explore health professional (HP), patient, and family experiences of, and actual behaviours in cancer consultations involving family. It aimed to utilise this research to propose an initial conceptual framework and draft physician communication strategies. Method A systematic review of 52 triadic consultation studies was conducted. Interviews with 10 nurses, 11 oncologists, 30 patients, and 34 FMs examined their attitudes and experiences. An interaction analysis coding system capturing family-relevant behaviours was developed and applied to 72 audiotaped cancer consultations. An initial conceptual framework of triadic DM and communication strategies were developed. Results HPs, patients, and FMs held positive attitudes towards family involvement. However, challenges such as conflicting patient-family wishes were reported. HPs reported inclusive behaviours, however consultation analyses revealed HPs rarely initiated interaction with FMs and regularly interrupted them. In light of study results, practical strategies for HPs to manage and enhance family involvement were proposed. Additionally, triadic (physician-patient-family) DM may rest on a spectrum from passive to dominant, is variable and dynamic, and may be influenced by a number of clinical and contextual factors. An initial conceptual framework was proposed, using a triangle to graphically represent triadic dynamics. Conclusion This thesis improves our understanding of patient, FM, and HP experiences of, and actual behaviours in, cancer consultations and raises a number of conceptual, ethical, and practical issues regarding the accommodation of family. Continued refinement of the framework and strategies will follow completion of this thesis.

This thesis contains the findings of a study undertaken in the field of medical decision-making. The Glaserian approach to grounded theory (Glaser and Strauss, 1967; Glaser, 1978) was used in order to build a theoretical representation of this area. Four phases of data collection were used, the first to develop initial theoretical sampling points and obtaining permission to approach medical practitioners. Following this, 12 personal in-depth interviews were performed to collect the primary data. A period of secondary data collection was then performed and finally an appraisal of the draft theory. Trading Off emerged from the constant comparative method as the core category explaining how pharmaceutical decision-making (as a form of medical decisionmaking) is performed. Sub core categories that were integrated within the Trading Off process included Focusing as the initial period of analysis, Self-Referencing and Surrogating reflecting sources and use of information and the Shiftin g that occurs as physicians develop expertise. In order to develop and frame the contribution of this theory within relevant literature, an number of areas of decision-making and medical decision-making research were reviewed. Expertise and its development were also examined. The main conclusions and recommendations of this research are that physicians Trade Off levels of confidence held in behaviours and aspects of the behaviour in order to decide on a course of action. Trading Off can used to direct the efforts of pharmaceutical companies and healthcare providers in order to modify pharmaceutical decision-making and reduce the large volume of prescribing errors. These efforts should be based on an accurate analysis of the individual decision environment and involve a wide view of possible influencing factors. It is recommended that actual patient case studies supplied from clinical trials are used in these efforts and that an opinion leader should perform the delivery where possible.

The principle of autonomy allows each person control over his or her body, and, consequently, to decide what medical treatment he or she will accept or refuse. However, where the individual does not have the ability, or capacity, to make such a decision, they may be subjected to medical treatment carried out in what a substitute decision-maker perceives to be their "best interests", which may not conform to their previous wishes that were reached autonomously. In order to preserve autonomy in the anticipation of a lack of capacity, individuals can formalise their health care plans in documents known as advance care directives. In many common law jurisdictions, the use of these types of documents is provided for by legislation. In this thesis I aim to review the legality of these directives where there is no legislation providing for their use, using Ireland as a case study, as the statutory law in Ireland is currently silent on this issue.I propose that the principle of autonomy which is protected under Irish law allows for the use of advance care directives without the need for legislation. I set out the criteria, as I see them, of a lawful advance care directive under Irish legal jurisdiction. I will address this issue by reviewing the Irish law in relation to the right to autonomy, the criteria for assessment of capacity, and health care decision-making, drawing on relevant examples from other common law jurisdictions.
Le principe d'autonomie permet à chacun de prendre les décisions relatives à son corps, et par conséquent, permet à l'individu de décider quel traitement médical accepter ou refuser. Toutefois, lorsque l'individu n'a pas la capacité de décider, il ou elle peut être soumis à des traitements médicaux qu'un décideur substitut considère être en son « meilleur intérêt ». Cette décision n'est pas nécessairement conforme aux désirs exprimés par la personne traitée alors qu'elle en avait la capacité. Pour préserver leur autonomie alors qu'ils en ont encore la capacité, certains rédigent un document appelé directive préalable de traitement. Dans plusieurs juridictions de « common law », ces directives font l'objet d'un cadre législatif. Cette thèse considère la légalité de telles directives dans les juridictions dépourvues d'un tel cadre législatif et utilise l'Irlande comme étude de cas parce que le droit statutaire irlandais ne se prononce pas sur les directives préalables de traitement.

Decision making is pervasive in our daily life. Sometimes we face decisions that are very important, such as the decision about what medical treatment to undergo. But how can we be sure that we are making the right decision? Or even more subtly, how can we be sure that our decision would be the same, no matter what the circumstances? The answer from the research that has been conducted in the field of medical judgment and decision making is “you can’t be sure.” Indeed, the context has a great impact on what patients decide. In this dissertation, I show some examples of the effects of contextual information on decision making. Specifically, three studies address the effect of different variables that influence judgments and decisions without the decision maker being aware of them. In the first study, I examine the role played by three factors on the decision between a risky and a safe alternative: the decision domain (the medical vs. financial domain); the decision maker’s purpose (utilitarian vs. hedonic); and the type of information provided (generic vs. detailed). The results suggest that when the information is generic and the purpose is hedonic (i.e., not essential), the risk attitude is opposite in the two domains, thus suggesting that when people’s life or health is at stake, they are more cautious, whereas they are more willing to play with their money for hedonic purposes. The second study investigates several potential explanations for an unusual finding. Indeed, while people generally prefer harms of omission to harms of commission (i.e., omission bias), for cancer they prefer active treatments over undergoing regular check-ups without treatment. On one hand, the results highlight that this finding depends on how the inactive option is conceived and described. On the other hand, they also point out that the instance of a malignant tumor which has already been diagnosed is a peculiar case relative to other kinds of illnesses. Finally, the third study is a demonstration that physicians are also affected by context factors that should not affect their choices. Specifically, they are influenced both by how many options are available and by information about patients that is irrelevant to the decision. Thus, when we as patients or physicians are making decisions which impact either our own health or someone else’s health, we are subject to biases and we are affected by contextual information. But what if we were health communicators? How would we use this knowledge? Knowing that patients may make differing choices depending on the way information is presented is certainly important, but how health communicators and policy decision makers apply this knowledge is just as central to medical decision making. Possible approaches that can be taken can be visualized along a continuum. At one extreme, the paternalist approach sees the doctor as an apprehensive father, and, thus, it is the doctor who makes the decision with little or no input from the patient. At the other extreme, with the informed decision making approach, it is the patient who, after being fully informed about all the options available and their consequences, makes the decision with little or no input from the doctor. Depending on the approach that is chosen, health messages also can take different forms. When they are aimed at persuading people to engage in a given behavior, such as dieting or undergoing a screening test. When informing a patient about the options available (in the informed or shared approach), the message should not be designed to influence the patient’s decision other than providing information, i.e., it should be neutral relative to the decision. The other three studies presented in the dissertation investigate cancer screening decision making within these two approaches. The first two of these studies investigate the effect of the way in which information is presented on participants’ prostate cancer screening decisions. The first study takes an informed approach, while the second one considers the same topic from the paternalistic approach, by using prospect theory as reference. The last study, also using a paternalistic approach, but applied to the decision whether or not to undergo colon cancer screening, assesses the real screening behavior of patients. Our findings allow us to discuss in a critical manner the results of a recent meta-analysis that disconfirmed the effect of framing, as proposed and interpreted in prospect theory. Indeed, we have tested and confirmed one possible reason for this result, not considered in the meta-analysis and which could have, therefore, biased its conclusion. Specifically, the lexical valence of the terms used to describe the consequences seems to be a relevant factor in the effectiveness of the message. To our knowledge, this factor was considered neither in previous studies nor in the more recent meta-analysis. To summarize, I first investigated some of the contextual factors that affect medical judgments and decisions from an experimental perspective. Then, I studied more specifically context effects in messages promoting cancer screening behaviors, highlighting some practical implications and theoretical consequences.
Le decisioni sono molto comuni nella nostra vita quotidiana. Spesso si tratta di decisioni banali, altre volte ci confrontiamo con scelte molto importanti, come ad esempio quelle che coinvolgono la nostra salute. Potremmo, ad esempio, essere chiamati a decidere se sottoporci o meno ad un certo trattamento medico, oppure potremmo trovarci a dover scegliere tra due o più alternative di trattamento. Ma come potremmo essere sicuri che la nostra scelta sia davvero la scelta giusta, o comunque la migliore per noi? E, ancora, come potremmo essere sicuri che quella sarebbe in qualsiasi caso la nostra decisione? La risposta della ricerca condotta nell’ambito delle decisioni mediche è “non possiamo esserne sicuri”. Numerosi effetti di contesto influenzano, infatti, le decisioni dei pazienti. In questa tesi illustro alcuni esempi che mostrano come le informazioni contestuali possano avere un effetto sulla presa di decisione. Nello specifico, tre studi indagano l’effetto di diverse variabili che influenzano i giudizi e le decisioni senza che i decisori stessi ne siano consapevoli. Nel primo studio mostro come la scelta tra un’alternativa rischiosa e un’alternativa sicura possa essere influenzata da tre fattori: l’ambito della decisione (medico vs. finanziario); l’obiettivo del decisore (necessario vs. futile); e l’informazione fornita (generica vs. dettagliata). I risultati suggeriscono che quando l’informazione è generica e l’obiettivo è futile, l’atteggiamento nei confronti del rischio è l’opposto nei due ambiti, suggerendo quindi che quando è la vita delle persone ad essere in gioco, esse si mostrano più caute, mentre risultano maggiormente disposte ad azzardare con il denaro, quando l’obiettivo è futile. Il secondo studio indaga numerose potenziali spiegazioni per un risultato riportato recentemente in letteratura che sembra andare in direzione opposta a quelli riportati negli studi che lo hanno preceduto. Infatti, sebbene generalmente le persone preferiscano opzioni i cui danni derivanti dalla mancata azione sono maggiori rispetto ai danni provocati dalla commissione di un’azione (“omission bias”), nel caso di una diagnosi di cancro sembra preferiscano trattamenti attivi rispetto alla possibilità di effettuare controlli regolari, senza trattamenti. Da una parte, i risultati del mio studio evidenziano che questo risultato dipende da come è concepita e descritta l’opzione di omissione dell’azione. Dall’altra, evidenziano anche che una diagnosi di tumore maligno è un caso particolare, rispetto ad altri tipi di diagnosi. ll terzo studio, infine, è una dimostrazione del fatto che anche gli studenti di medicina sono influenzati da fattori di contesto che, auspicabilmente, non dovrebbero invece influire sulle loro scelte. In particolare, sono influenzati sia dal numero di alternative a disposizione, sia da informazioni che, pur essendo relative alla storia clinica del paziente, dovrebbero essere irrilevanti per la decisione. Quindi, l’essere pazienti o medici che decidono per la propria o l’altrui salute non ci esime dall’essere soggetti a distorsioni e, tutti, siamo vittime di trappole cognitve e siamo influenzati da informazioni contestuali. Ma cosa succederebbe se fossimo esperti in comunicazione sulla salute? Come useremmo questa conoscenza? Sapere che i pazienti possono prendere decisioni diverse a seconda del modo in cui le informazioni sono presentate loro è certamente importante, ma anche l’uso che gli esperti in comunicazione sulla salute e coloro che attuano le decisioni a livello comunitario fanno di questa conoscenza è centrale nella presa di decisione in ambito medico. I diversi approcci possono essere collocati lungo un continuum. Ad un estremo, l’approccio paternalistico vede il medico come un padre apprensivo: in questo caso, è il medico a prendere la decisione, con poche o nessuna indicazione da parte del paziente. All’altro estremo, secondo l’approccio informato alle decisioni mediche, è il paziente che, dopo essere completamente informato su tutte le opzioni disponibili e sulle loro conseguenze, prende la decisione, con poche o nessuna indicazione da parte del medico. A seconda dell’approccio adottato, gli stessi messaggi per la salute possono avere forme diverse. Quando si promuove un comportamento salutista usando un approccio paternalistico, il messaggio dovrebbe cercare di convincere le persone ad attuare il comportamento desiderato, come ad esempio mettersi a dieta o effettuare un test di screening. Quando invece si informa il paziente sulle opzioni disponibili (approccio informato o condiviso), il messaggio non dovrebbe essere formulato in modo da influenzare la decisione del paziente, dovrebbe cioè essere neutro rispetto alla decisione. Gli altri tre studi presentati nella tesi indagano la decisione di sottoporsi a screening oncologici nell’ottica di questi due approcci. I primi due di questi studi indagano l’effetto del modo in cui sono presentate le informazioni relativamente allo screening per il cancro alla prostata. Il primo studio assume un approccio informato, mentre il secondo considera lo stesso argomento con un approccio paternalistico, prendendo la teoria del prospetto come riferimento. L’ultimo studio, anch’esso in una prospettiva paternalista, ma applicata allo screening per il cancro del colon, confronta diversi tipi di messaggio e valuta, anziché le intenzioni dei pazienti, il comportamento effettivo di adesione dei pazienti all’esame proposto. I dati ottenuti ci consentono di discutere in modo critico i risultati di una recente meta-analisi che ha confutato l’effetto framing, così come proposto dalla teoria del prospetto. Abbiamo preso in considerazione e testato un possibile aspetto, non valutato nella meta-analisi, che potrebbe aver contribuito a distorcere i risultati e la conclusione. In particolare, la nostra ipotesi è che la valenza lessicale dei termini usati per descrivere le conseguenze del comportamento sia un fattore rilevante nel determinare l’efficacia del messaggio. Per quanto ne sappiamo, questo fattore non è stato considerato né negli studi precedenti, né nella più recente meta-analisi. Per riassumere, i primi studi presentati in questa tesi hanno indagato alcuni dei fattori di contesto che influenzano i giudizi e le decisioni da una prospettiva sperimentale. Nelle ricerche successive, ho studiato più specificamente gli effetti del contesto nei messaggi che promuovono comportamenti di screening per tumori, mettendo in luce possibili approfondimenti teorici e alcune implicazioni pratiche.

Background: In research, patient participation in medical decision-making has been shown to be associated with higher patient satisfaction and improvement of treatment outcomes. But when it comes to patient participation when being old and frail there are pitfalls and the research in this area is sparse. The aim of this thesis is to explore participation in medical decision making of the frail elderly patient in hospital from the perspectives of patients themselves and the health care staff. In this thesis frail, elderly patients is defined as individuals 75 years old or older, who during the past 12 months have received inpatient hospital care three or more times and who have three or more diagnoses in three or more diagnostic groups according to the classification system ICD-10. The participants were frail patients’ in hospital or newly discharged and it was health care personnel working with frail elderly patients. In three of the studies the method was mainly qualitative (Paper I, III, IV) and in one (Paper II) quantitative. The qualitative methods were one-to-one tape-recorded interviews of 25 patients (Paper I and IV), 18 personnel (III and IV), 5 focus group interviews of physicians (Paper III) and 26 days of observations in hospital wards (IV). Chosen methodologies of analysis were content analysis and Grounded Theory. The quantitative study (II) was a cross-sectional survey using telephone interviews with patients (n= 156). This material was descriptively analysed and examined using weighted kappa statistics. Results: The results reported in Paper II show that elderly patients generally want to participate more in medical decision making than they do, though preferences for degree of participation are highly individualized – both findings important to consider in clinical practice. According to the patients important key concepts of patient participation in medical decision making are to be listened to and to be informed (Paper I). The main reasons for not being able to participate included having many illnesses and generally, overall bad medical condition (Paper II). Also, cited as a problem was difficulty in understanding medical information, for example when given by a foreign-speaking physician (Paper I, II and IV). Frail, elderly patients complained that they were less informed than was their preference (Paper I, II and IV). Moderate agreement was obtained between patient’s preferred and actual roles in medical decision making. Patients often expressed gratitude and confidence in their health care (Paper I and IV), but also, sympathy for stressed health care personnel who had so much to do. The frail elderly patients do sometimes feel like a burden to the health care (Paper I and IV). The professionals gave expressions of trying to avoid taking care of frail elderly patients and at the same time expressions of frustration and bad conscience not being able to take good care of them due to lack of time and lack of beds (Paper III, IV). Especially the physicians felt they were trapped between the needs of the patients’ and the remunerations system rewarding time-constricted health care production (number of investigations, operations, easy accessibility) – not a time-consuming holistic view on all illnesses and medications including communication with the patients and all caregivers involved (Paper III). Both patients and the professionals perceive the hospital as some kind of “institution of power”, difficult to challenge, and the decisions of which one has to accept. Conclusion: In this thesis there are shown a number of challenges to participation in medical decision making by frail, elderly patients, which thus limits quality of care for this patient group. Health care is revealed as not well adapted to meet these patients’ complex needs. A model is presented that explains how the organisation of health care, and the reimbursement system, does not facilitate a holistic view. The health care professionals appear to adapt to the organisation and the remuneration system, which leads to practices, such as, rapid discharges and a tendency to examine the patient for only one or a few problems. Finally a suggestion for a model to improve care of frail elderly patients is presented. This model includes the need of more hospital wards being able to work with a holistic view, better skills in gerontology and geriatrics and a more adapted remuneration system for the frail, elderly patients.

The subject of this thesis is the investigation and critical evaluation of how Canadian legal institutions approach substitute decision-making in the particular context of making medical choices for incompetent elderly persons. Underlying the inquiry is an acknowledgment of the right of competent persons to have their autonomy recognized and the duty to protect from harm those with reduced competence. Statutes, case law and custom are examined to determine how well they serve older persons when choices concerning medical treatment and participation in research protocols are required. The adequacy of current Canadian law relating to informed consent to medical treatment and competency assessment is evaluated in light of the special characteristics of elderly persons. Recent and proposed law reforms are examined for their appropriateness in addressing the questions of who should make substitute decisions for incompetent persons and how these decisions should be made. The three foremost criteria used as the basis for making substitute decisions--best interests, substituted judgment and advance directives--are analyzed. A final proposal is made that would redefine the notion of a person's "interests", allowing us to view the criteria for substitute decision-making not as competing, but as complementary, the appropriateness of each varying with the situation in question. Ethical principles have been employed both as a critical framework for assessing the fairness and acceptability of particular laws and as complementary to these laws, since law by its nature can never be crafted to address adequately every question we may pose.
The statutes, case law and legal literature referenced in this thesis are up to date as of December 25, 1991.

This doctoral thesis considers the family’s role in the process of making medical treatment decisions for one of its members. Chapter 1 explores the meaning of family in the context of illness and disability. It is suggested that membership is not defined by biological or marital status but by interdependence, which also provides the moral and logical claim for a role of influence in treatment decisions. Chapter 2 considers various ethical frameworks for development of an inclusive decision-making framework, using fictional case studies. Chapter 3 examines the historical development of the legal framework for the resolution of treatment disputes revealing the ‘invention’ of a common law jurisdiction in respect of adults lacking capacity in order to meet perceived social need. Chapter 4 examines the unifying concept of the various jurisdictions in respect of adults and children, namely the patient’s ‘best interests’. Decided cases are categorised by their principal issue to demonstrate that the judicial concept of best interests has been shaped by core values intrinsic to those issues, leaving consideration of the interdependence inherent in the family context side-lined. That such disregard is not a necessary corollary of the mechanisms adopted for decision-making is shown by comparison with later cases of paternity testing disputes. Chapter 5 traces the last throes of the inherent jurisdiction through political engagement and the Bournewood litigation. Finally chapter 6 assesses the provisions of the Mental Capacity Act 2005. It is argued that, although the statutory test of ‘best interests’ is susceptible to familyfriendly considerations, the general authority limits involvement of families to trivial matters.

This thesis seeks to examine how healthcare decisions are made for children, with a particular focus on situations where medical interventions that (1) are not intended to advance the medical welfare of the individual child (eg bone marrow donation and research without therapeutic intent involving young children), or (2) are contrary to the expressed will of the child (e.g. the imposition of life-saving treatment on adolescents who have refused it), are authorised by parents or the state. The authorisation of these procedures is contentious because they breach the child’s bodily integrity while either (a) lacking a clear therapeutic purpose with regard to that child, or (b) being imposed even though refused by a possibly competent adolescent. Their controversial nature has lead to attempts to justify these procedures, generally by the application of ideal-type adult-child relationship theories. The four papers at the core of this thesis examine these legitimising propositions, but demonstrate that they are insufficiently robust to legitimise the acts in question. Instead, this thesis raises questions about inequality; about why it is deemed acceptable to take the tissue of the vulnerable incompetent but not the capable adult; or why it is appropriate to impose different tests of mental capacity on the adolescent and the adult, or of competence on the ‘criminal’ child and ‘innocent’ teenager. It is proposed that the reason that inequitable treatment can occur is because adults sit in a position of power and authority relative to children. The common themes in all four papers are thus the issues of power, inequality and fairness. There is also a focus on the use of language, and it is argued that terms are used in academic debate about children’s healthcare issues that lead to a lack of clarity and transparency in discussions about the imposition of unchosen healthcare burdens on vulnerable populations. If we hold that children are morally relevant beings deserving of respect then debates about matters that concern them should take place using language that avoids obfuscation and the cloaking of adult interests.

Thesis (Ph. D.)--West Virginia University, 2001.
Title from document title page. Document formatted into pages; contains viii, 71 p. Includes abstract. Includes bibliographical references (p. 43-47).

Progressive Neuromuscular Diseases (PNDs) are relentless, debilitating, incurable diseases that cause nerves and muscles to atrophy. A large portion of the population who experience PNDs are adolescents. These adolescents progressively lose physical abilities and increasingly rely on caregivers at a time in their life when, paradoxically, normative adolescent development prescribes a move towards independence and autonomy. There is little research examining this experience from the adolescents’ perspectives. The purpose of this interpretive phenomenology study was to understand the experience of adolescents with PNDs when making decisions in relation to their health. Data collection consisted of 10 semi-structured interviews with 5 adolescents, 16-19 years of age, who were living with a PND (two interviews with each of the 5 participants). These interviews lasted an average of 60 minutes. Data were analysed using interpretive strategies, including the development of themes using exemplars, and paradigm cases. Findings revealed that the adolescents separated health decisions into two distinct categories, Big and Small, based upon level of perceived risk and physician involvement. Big referred to high-risk decisions, included physicians, and involved a medical/surgical procedure or intervention. Small referred to lower risk decisions, did not include physicians, and involved personal care. An expert emerged with each category of decision. In Big Decisions, the physician was perceived as the expert who made recommendations, provided information, and introduced the decision. In Small Decisions, the adolescent perceived himself as the expert. With Big Decisions, the physician expertise was typically respected, and the recommendations were followed. With Small Decisions, parents typically respected adolescent expertise. However, the adolescents commonly experienced not having their expertise respected by health professionals. In the context of Big and Small decisions, the theme Joint Ownership captured the sense that with the progressive loss of abilities and resulting dependence, the physical disability and illness were not experienced solely by the adolescent but by the adolescent and his parent(s). As the parent(s) and adolescent shared these experiences, the decisions, ownership of the physical body, and the responsibility for the care of the body also became shared. The findings suggest that health care professionals need to include the adolescents in the Small Decisions, and also acknowledge that adolescents may desire parental involvement in Big Decisions.

The prevalence of medical misdiagnosis has remained high despite the adoption of diagnostic software. This ongoing controversy about the role of technology in mitigating the problem of misdiagnosis centers on the question of whether diagnostic software does reduce the incidence of misdiagnosis if properly relied upon by physicians. The purpose of this quantitative, cross-sectional study based on planned behavior theory was to measure doctors' opinions of diagnostic technology's medical utility. Recruitment e-mails were sent to 3,100 AMA-accredited physicians through their database that yielded a sample of 99 physicians for the study. One-sample t tests and, where appropriate because of non-normal data, one-sample Wilcoxon signed-rank tests were conducted on the data to address the following key research questions on whether diagnostic software decreases misdiagnosis in healthcare versus unassisted human diagnostic method, if physicians use diagnostic software frequently enough to decrease misdiagnosis in healthcare, and if liability concerns prevent physicians from using diagnostic software. It was found that in the opinion of those surveyed (a) diagnostic software was likely to result in fewer misdiagnoses in healthcare than unassisted human diagnostic methods, (b) when speaking for themselves, physicians thought they used diagnostic software frequently enough to decrease misdiagnoses, and (c) physicians agreed they were not prevented from using diagnostic software because of liability concerns. The study's social significance is the affirmation of diagnostic software's usefulness: Policy and technology stakeholders can use this finding to speed the adoption of diagnostic software, leading to a reduction in the socially costly problem of misdiagnosis.

At least 11 million Americans are diagnosed with chronic obstructive pulmonary disease (COPD), and there is a high likelihood millions more suffer from the disease but are undiagnosed. Spirometry is a medical test to determine how well a patient’s lungs work, and is used to diagnosis COPD. Despite this test’s utility, resident providers may be uneducated about or uncomfortable with administering spirometry. Past research has demonstrated that brief educational interventions can lead to clinically significant improvements in knowledge of spirometry. The purpose of this study is to compare family medicine residents’ responses regarding the use of spirometry in a rural Family Medicine Residency clinic before and after an educational program on the topic. Researchers will administer a survey to resident physicians at the Family Physicians of Bristol clinic about their knowledge regarding spirometry; residents will then be resurveyed after an educational program. It is expected that resident providers will show significant gains in their knowledge of spirometry after the completion of the educational program. Results of this project will be useful in identifying methods to increase medical providers’ awareness and comfort with spirometry, which will hopefully lead to increased accurate diagnosis of airway diseases.

Thesis (Ph. D.)--Johns Hopkins University, 2009.
Includes Vita. Title from PDF title page (viewed on May 21, 2010) Available through UMI ProQuest Digital Dissertations. Includes bibliographical references (leaves 144-152). Also issued in print.

Since the beginning of the Revolutionary government in Cuba, a comprehensive foreign policy involving medical personal and equipment has been implemented worldwide. Known as medical internationalism, thousands of doctors have been sent to developed and less developed nations in the spirit of solidarity and humanitarian aid. Even more, thousands of students have been given free medical education in Cuba at its world renowned university, the Latin American School of Medicine (ELAM). Often, no monetary or direct political gain is made by Cuba and the doctors simply receive their normal government salary. While the success of Cuba's medical internationalism is well documented (Feinsilver 1993, Kirk & Erisman 2009), the reasons and guiding forces behind it are much less understood. Based on a Cultural/Political Foreign Policy model created by Marijke Breuning to study foreign policy, this study aims to show that the concept of proletarian internationalism is the guiding principle in Cuba's medical internationalism programs.

This thesis aims to illuminate how paediatricians in the United Kingdom (UK) make difficult medical decisions when treating severely disabled children with complex health conditions. In particular, it examines the part played, if any, by law, rights, and ethics in those decisions. After drawing on jurisprudence of the English and European Human Rights Court, together with existing scholarship, to analyse the doctors' decision making, this thesis adopts a legal consciousness theoretical approach. Using this it looks at how the paediatricians make sense of and conceptualise law when making these decisions. It examines how decisions are, by the paediatricians' own accounts, commonly made at present and what the paediatricians say about how they and their colleagues make such decisions. This thesis addresses the following research questions: i) Which decisions do UK paediatricians find particularly difficult when working with disabled children and what makes those decisions particularly difficult? ii) What factors do UK paediatricians take into consideration when making difficult decisions for disabled children and what weight do they put on those factors? iii) What formal education in law, rights, and ethics have the doctors received and to what extent, if any, can we discern how this education impacts on their difficult decisions for disabled children? iv) How do UK paediatricians construct and understand the law, rights, and ethics when making their difficult decisions? This thesis makes an original contribution, being the first in-depth socio-legal study examining UK paediatricians' medical decision-making for severely disabled children, by identifying two distinct styles paediatricians adopt when approaching best interest decisions, and by recommending a new category of legal consciousness. It concludes by recommending research and changes both in doctors' training and approach to best interest decision-making to address the current challenges paediatricians describe facing when deciding for severely disabled children.

Urban Bioethics
M.A.
In the setting of the health care field, multiple decisions must be made on each patient’s care from a variety of viewpoints on the medical team. In these settings, Interprofessional Decision Making is becoming a tool that can incorporate shared decision making with the patients and multiple care team members’ goals in order to optimize and keep an ethical focus on clinical outcomes. By reviewing a patient case below and evaluating the body of literature at the present, it can be determined that a disassembly of the current medical hierarchical structure and the barriers to team based interaction it creates, with a move toward open and ethical interactions, collaborations, and discussions will result in shared consensus on a patients management and care. While this may be difficult to achieve, interventions such as multidisciplinary team building and medical training, prior to matriculation, may provide a foundation for improved Interprofessional Decision Making and overall collaboration.
Temple University--Theses